CI1RONIC INFLAMMATION OF TI1E BLADDER.—The treatment of this condition in the first instance as in the acute affection should consist in the removal of the cause when possible. The following are the chief causes usually met with: (i) Prostatic Enlargement, (2) Stone or Foreign Bodies, (3) Atony, (4) Tumour, (5) Stricture, (6) Spinal Paralysis, (7) Gout, (8) Abscess in the uterus or pelvis, (9) Parasites or their ova as bilharziosis, hydatids, &c., (so) Micro-organisms as in B. coli, tubercular and typhoid infections, chronic gonorrhoea, &c.
Prostatectomy by Freyer's suprapubic method should be resorted to before the bladder has become infected, when the enlargement has become a serious obstacle to the emptying of the bladder in micturition.
The treatment of cystitis caused by the presence of stone, foreign bodies, tumours, and stricture can only be met by dealing with the primary cause. Gouty cystitis yields to the constitutional treatment indicated for the uric acid diathesis. Typhoid cystitis, the colon bacillus, and chronic gonor rliceal cystitis yield to the disinfection of the urinary tract by Urotropin or Boric Acid administered by the mouth as in the acute affection. In obstinate gonorrhoeal cases there is always more or less prostatitis which may end in abscesses, and often some narrowing of the urethra. The treatment of these cases is often most tedious and disappointing; it con sists in the passage of a full-sized solid metal bougie to dilate the urethra, after which the urethroscope or cystoscope may he passed to investigate the condition of the prostatic urethral membrane and neck of the bladder. Janet's posterior irrigation after the urethral injection of Cocaine to re move spasm of the compressor urethrae is most valuable, a weak solution of Silver Nitrate, r gr. to i pint, being used, or a soft rubber catheter should be passed till its eye reaches the affected spot (the apex of the prostate), which is usually about 72 inches from the meatus; Guyon's method of instillation of the posterior urethra is then carried out by in jecting through a graduated syringe a strong (so per cent.) solution of Nitrate of Silver. Any abscesses about the prostate or Cowper's gland will require incision from the perineum. Massage of the gland through the rectum is of much value in inveterate cases, and Vaccine treatment by injection of killed gonococci should always lie resorted to; doses gradually increased to roo,000,000 organisms have been injected hypodermically without harm.
Chronic cystitis in which the tubercle bacilli are found in the urine is usually hut not invariably due to a local lesion in the genito-urinary tract or renal pelvis. When the cystoscope reveals evidence of tuber culous ulcers (these are generally found in the region of the trigone), no good can be expected from injection into the bladder of antiseptics like Iodoform Emulsion or Lactic Acid. In the large majority of these cases the bladder condition is secondary to tuberculous disease of one kidney. Treatment consists in determining (r) the site of the diseased organ, and (2) whether the other kidney is sound. When this has been demonstrated by the help of the catheterising cystoscope and a careful bacteriological examination of the urine from each kidney, the diseased organ must he removed at once. This will usually be rapidly followed by relief of symptoms, and after a period of constitutional treatment by complete cure.
In atony of the bladder when not dependent upon the obstruction of stricture or other removable cause the cystitis present must be treated as in paralytic cases, and a wide selection of agents and drugs is at the com mand of the practitioner. Since the use of these is indicated in all the chronic types of cystitis whose causes are beyond the reach of operative surgery, they may advantageously be considered seriatim.
First will come the discriminating use of the catheter; this will be indicated in all cases of atony and paralysis, and its use is imperative where great tenesmus and pain are present from inability of the bladder to expel its contents completely. Where there is a large amount of re sidual urine found upon the first passage of the instrument it is risky to empty the organ. When it is necessary for diagnostic purposes to com pletely evacuate the contents, a quantity of Boric Acid solution should be injected through the catheter and left in the bladder to prevent collapse from the altered pressure of the blood in the abdominal vessels.