A simple spontaneous catarrh of urethra and bladder, such as occasion ally occurs in pregnancy from pressure upon the urethra and the vesical neck, or repeated catheterization, may give rise to this decomposition. Fischer and Traube, Olshausen and Kaltenbach, have fully demonstrated this fact. The latter proved Cult vesical catarrh during the puerperal period might be due to chemical or mechanical irritation from the cathe ter, or to spread of inflammatory affections from the sexual organs to the bladder, or from traumata during delivery. P. Dubelt proved by experi mentation upon dogs that the injection of air into the bladder had no effect; that decomposed urine injected into a healthy bladder caused but slight inflammation; but that it was much more effective as soon as the vesical mucosa was injured. Frequent introduction of the catheter he found to cause circumscribed redness at the place where the catheter touched, with loss of the epithelium there.
Besides these chief predisposing causes, certain general ones remain to be mentioned. These are: Cardiac lesions (Lowenson's case), typhus (cases of Cossy and Ebers), small pox (Cruveilhier's case), paraplegia, spinal diseases, extreme old age (case in Lancet, see above.) To these we may add diseases of vagina and uterus, especially cancer of these organs, perforating fcetal sacs, etc. In some of these cases the cystitis undoubtedly occurs spontaneously. Probably in all these cases a ferment is carried in from the vagina, which determines the alkaline decomposition of the urine. Klamann found on the vesical epithelium both bacteria and leptothrix. A healthy bladder with smooth walls and a vigorous muscular structure, soon expels the offending matter; not so one irritated by the presence of a foreign body, a catheter, or a ilew growth.
Prognosis. — Simple hypertemias, hemorrhages and catarrhal condi tions of the female bladder are of good prognosis. The entire inner surface of the bladder can be washed out easily and without much pain, and uncomplicated cases can usually be Cured in eight to fourteen days. It is otherwise with croupous, diphtheritic, or gangrenous processes, which are more serious. Of eleven recent cases 5 or 45 per cent. suc cumbed (cases of Bauer, Schatz, Spencer Wells, Krukenberg, and Schwartz); and six recovered, (cases of Spencer Wells, Wardell, Hausa mann, Kiwisch, Frankenhauser, and Madurovicz.) The earlier the cause of the trouble is recognized, the better the prognosis; and the longer the ammoniacal decomposition of the urine persists, the worse it is. High fever, considerable swelling of the urethra and the anterior abdominal wall, and acute cedema in the neighborhood of the bladder are unfavorable, being symptoms of threatening vesical perforation. Adhesion of the bladder to neighboring organs may have an unfavorable influence, since it favors retention of urine, the entrance of air during catheterization and recidives of the catarrh and inflammation.
It is very evident that the prognosis may depend to a considerable ex tent upon the matter coming from the mucosa; it being better in cases of simple croup, where only epithelium and exudate is demonstrable, than. in cases where portions of the muscularis or even gangrenous pieces are present.
It may also be mentioned tluit adhesions of the bladder to the intestine have subsequently caused a fatal Rens.
Tlierapy.—To prevent hyperiemia of the bladder, we must regulate diet and drink in those predisposed to it. We must see that gravid women keep the abdomen and feet warm, and preach especial caution in cases where there is the least difficulty in voiding urine, even if due to purely mechanical causes. If there be constipation, we must use lavements, mild cathartics like magnesia, rhubarb, sulphur, calomel, and cause moderate rectal and intestinal irritation, so as to exercise a derivative influence upon the bladder, and preventing straining at stool. It is of great im
portance in any case in which we have to use the catheter, not only to disinfect it with corrosive-sublimate (it should, if frequently used, be kept in a 1 per cent. sublimate solution), but also to be careful that no air enters the bladder while it is being used. In Rutenberg's method we do, it is true, distend the bladder with air; but it immediately escapes through the dilated urethra, and we always use antiseptic injections there after. Nevertheless we have twice observed a teniporary vesical catarrh after its use. In all maternity hospitals every puerperal woman whose urine requires drawing off, should have a new or a chemically cleansed catheter for her own use alone. This has long been the custom in the Dresden Institute, and to it I ascribe the extreme rarity of puerperal vesical catarrh there. I think it would be well if the same thing were done in private practice, and each patient required to buy a neNy instru ment for herself.
If, however, hyperxmia or cystitis has set in, it is my experience after many years that, whether it be in full-grown women or in little children, the lo(al treatment is of the most importance. I always begin by washing out the bladder with lukewarm water or linseed decoction or lime water; and to one of these I often add salicylic acid (1:1000) or 3 per cent. of ' boracic acid. The fluid must be at blood heat, and is best applied by means of a Hegar funnel, which should not be held too high up. An elastic catheter is attached to the tube and introduced into the bladder. The fluid is permitted to remain in the viscus a few minutes, and is then withdrawn by sinking the funnel. The amount to be used varies with the patient's age and the size of the bladder; from one to two pints should be thrown in, and the injections are to be repeated 1 to 3 times daily. This may be kept up for weeks. When it appears to be of no service, I have recourse to solutions of nitrate of silver 1-2-3:500, or tannin, 10 to 15 grains to 4 ounces. I have never been tempted to try the various other injections which have been recommended, since I have always ob tained the desired result by the above means. I order rest, in bed if there is much tenderness, warm abdominal applications, and a simple fluid diet of milk, tea, yolk of egg, bouillon, and lean meat; rectal injections, and the cathartics above recommended, may be used to regulate the bowels. I have never used balsam of copaiva in these cases, and I think wo can well do without it. Nor have I tried bromide of potassium, lately recom. mended by Meinhard for cysto-blenorrh(ca. But I can recommend the continuous use of chlorate of potash 0:175) in tablespoonful doses 4 to 6 times a day. A sornewhat different method of local treatment was reconnnended by Braxton-Hicks two years ago. During the acute stage he first washes out the bladder with two pints of fluid composed of two drops of hydrochloric acid to the ounce of water. Then he injects a solution of morphine, 1:600, which is to be retained as long as possible. Two repetitions, he says, are enough. If the urine is acid, mild carbonate of soda solutions are injected twice daily. After the acute symptoms have passed off, tannin or solutions of 3 to 4 drops of liquor ferri sesquichlorati to 6 drachms of water are injected. For ebronie vesical catarrh be uses nitrate of silver 1:60 to 1:40 and liquor ferri 3 times as strong as he used during the acute stage. He applies this same irritating treatment to the urethra also, as a means of counter-irritation, introducing sounds coated with nitrate of silver or tannin-covered elastic bougies. He also recom mends dilatation of the urethra and pencilling of its mucous membrane with a solution of sulphate of iron.