CYSTITIS IN WOMEN.
It is -impossible at present to estimate the frequency with which cystitis occurs in women. Severer grades of cystitis are not infre quently met with, and milder degrees of the affection seem to become more frequent as cases are examined by the new cystoscopic method.
All grades of inflammation of the bladder mucosa are found, from a slight hyperemia well localized, through hyperemic conditions distributed in patches over the surface of the bladder, to an intense inflammatory state involving the whole surface of the mucosa. While we cannot properly speak of the hyperfemias as inflammatory clinically, we observe all grades of them from a mild congestion to a well-defined inflammation.
The cause of the inflammation is one of the pus-producing organ isms, or it may be a diphtheritic affection, or tuberculosis. Affections of the latter class have proven, in my experience, to be quite com mon. In several instances, the tubercular cystitis was associated with a tubercular ureteritis. In another case a tubercular inflammation was localized near the right posterior cornu of the bladder. I was . able here to discover by a cystoscopic examination that the focus of the bladder trouble was about a small orifice which a careful biman nal pelvic examination showed to be connected with a densely adhe rent right tube and ovary, undoubtedly tubercular, and pouring pus through a sinus under the broad ligament into the bladder.
Morbid Anatomy.—The changes in cystitis are quite characteristic, the most marked being the reddening of the surface, more or less in tense according to the grade of inflammation, and varying in degree with the extent of contraction of the bladder. As the inflammation becomes more marked the larger vessels, so characteristic of the nor mal background, disappear from view. Sometimes a network of in numerable capillaries may be seen, at others nothing more than an intense red blush on the surface. In a graver class of cases the mucous membrane breaks down in places and discharges in flabby shreds mixed with pus. These can be seen hanging from the sides of the bladder, overlying areas of granulation tissue, floating in a little bloody urine, accumulating in the vault (when the patient is examined in the knee-breast position), and hanging from superior to inferior wall like beans. In these cases, to get a clear picture of the actual state of the bladder, it will be necessary to introduce a two way catheter and to give it a thorough washing out. Oftentimes the bladder walls are so coated with a deposit of dark blood as to be in visible. This may come down from the kidneys and settle on the mucous membrane, or may arise from hemorrhage of the bladder wall. It is usually found in those parts of the bladder which are most dependent when the patient is lying down or sitting. A little
pledget of cotton introduced on the mousetooth-forceps will remove the thin layer of blood and expose the surface beneath it.
At the first examination of a case of cystitis, it is in the highest degree important to make a minute inspection of every part of the bladder, not forgetting the urethra, when the speculum is withdrawn at the conclusion of the examination. Particular attention must be paid to the ureteral areas. The results of the examination should also be entered upon the schemata which I have described in the section on the topography of the bladder.
The treatment of cystitis is general, systemic, and local. Patients thus afflicted should go to bed and keep as quiet as possible. The bowels must be kept thoroughly open, and a mild, non-stimulating diet prescribed. Sweet spirit of nitre given in half-teaspoonful doses, four to six times daily, often diminishes the pain. Hot vagi nal injections are serviceable as a counter-irritant, and benefit is often derived by the use of hot-water bags over the abdomen. The most direct and best form of local treatment is by injections of a few ounces of 1-100,000 bichloride solution repeated daily. While the patient at first is able to retain only a few ounces, she will often soon be able to hold four or five. The strength of the solution can be increased by taking off 5,000 each time, until it is equal to 1-20,000 or 1-30,000. Where the bichloride is not well tolerated, a good re sult may often be obtained by injections of a saturated solution of borax in water, once daily.
Where the cystitis is localized in patches, the improvement will often be hastened by applications once in five days, or once a week, of a three-, five-, or even ten-per-cent. solution of nitrate of silver, directly upon the affected area. This application must of course be made through the cystoscope, and be controlled by sight. It will not do good, but rather harm, where the inflammation is widespread and intense.
When the disease has existed a long time, and the patient is suf fering intensely, and the whole or almost all the bladder is found to be affected, immediate relief will be given and a cure more quickly realized, by making an opening an inch long into the vagina through the base of the bladder, and suturing the vesical to the vaginal mu cosa, to prevent the artificial fistula from closing too soon. The con stant, perfect drainage thus secured will give great relief, and in the course of from two to four months will bring about such a degree of improvement that the fistula may be closed and the rest of the cure effected by irrigation.