Compliments 
W. L. RICH ARD S ON. 
SIIIUCUTE CYSTITIS FOLLOWS PARTURITION. 
W. L. RICHARDSON, M. D,, 
VISITING PHYSICIAN OF THE BOSTON LYING-IN HOSPITAL. 
[Reprinted prom The Boston Medical and Surgical Journal, February 3, 1876.] SUBACUTE CYSTITIS FOLLOWING PARTURITION.1 
Visiting Physician of the Boston Lying-Tn Hospital. 
W. L. RICHARDSON, M. D., 
No mention is made, in any of the works on obstetrics which I have 
been able to consult, of any inflammatory condition of the bladder follow- 
ing delivery. Holmes in his System of Surgery places among the causes 
of acute cystitis a protracted or difficult labor, but the disease as he 
describes it is a very severe affection, which runs a rapid and often 
fatal course, and which is always accompanied by a marked constitu- 
tional disturbance. 
During the past three years I have met with four instances of a 
marked inflammatory condition of the bladder following delivery. It 
is possible that many of the cases of metritis or circumscribed perito- 
nitis which have been reported by physicians may have been a similar 
temporary affection of the bladder, and it is with the view of calling the 
attention of the profession to this variety of cystitis that I venture to 
report the following cases. 
Case I. (with clinical chart). F. H., married, primipara, twenty- 
three years old, was taken in labor October 5,1873, about six o’clock in 
the morning. The os slowly dilated, and the first stage was completed 
at 2.30 p. m. The pains, which had been regular and of considerable 
intensity during the day, now began to occur at longer intervals, and, 
as but little progress if any was made during the next three hours, 
forceps were applied, and the patient was delivered at 6.30 of a male 
child which weighed eight and a quarter pounds. During the first 
seven days which followed the delivery nothing abnormal was noticed ; 
but in the evening of the eighth day the patient had a marked chill, 
followed during the next seven days by a very high evening temper- 
ature and pulse (the former being in the neighborhood of 102°, and the 
latter 120), while the morning examination showed a temperature and 
a pulse of only about 100. The morning after the chill, the patient 
complained of great pain and scalding on micturition, and there was 
very marked tenderness over the pubes. There, was more or less 
nausea, and two attacks of vomiting occurred during the day. The 
history of the milk and lochia was normal throughout the progress of 
the case. The bowels were moved on the third day, by a dose of cas- 
tor-oil, and subsequently the patient had, as a rule, one daily ((ejection. 
The dysuria was relieved temporarily by the occasional use of supposi- 
1 Eead before the Obstetrical Society of Boston, December 11, 1875. 4 
Subacute Cystitis following Parturition. 
Tories containing an eighth of a grain of the sulphate of morphia. 
Poultices of linseed meal and mustard were applied over the bladder. 
The tenderness over the pubic region still remaining, and the dysuria 
also being frequently complained of, an examination of the urine was 
made, and a considerable quantity of pus was found in it, together with 
a slight amount of blood. The bladder was accordingly washed out 
(October 20th) by means of a double silver catheter, with warm water, 
and afterwards with a weak solution of carbolic acid (six drops to the 
pint of water). The temperature and pulse at once fell, and the patient 
expressed herself as feeling decidedly better. The dysuria was greatly 
relieved. During the next five days the patient slowly improved, 
and the tenderness over the pubic region was very much less than 
before. 
On the morning of October 27th, however, she had a second chill. 
The temperature and pulse began again to show a high evening and a 
low morning range. The dysuria returned, although it was not so severe 
as before. The tenderness over the bladder was again noticeable. The 
urine was found (November 8d) to be very offensive, and to contain a 
large amount of pus. The bladder was again washed out, and the 
immediate relief from all the symptoms just described was even more 
marked than on the first occasion. The temperature and pulse at once 
fell, the dysuria disappeared, and in three days no tenderness over the 
bladder could be detected. The patient made a rapid recovery, and 
went out to ride November 12th. 
She was again confined May 3, 1875, but no deviation from a normal 
delivery or convalescence was noted. 
Case 11. M. L., married, primipara, nineteen years old, entered 
the Boston Lying-In Hospital November 6, 1875, to await her con- 
finement, Labor began early in the night of November 16th, although 
she had suffered considerably during the previous twenty-four hours 
from false pains. The os dilated rapidly, and the first stage of labor 
was completed about six o’clock. The pains now began to come on 
at longer intervals, and were less severe in character than before. 
The head, having reached the perinseum, made-but little if any prog- 
ress until eight o’clock in the morning, when, the os being fully dilated 
and the head low down in the perinseum, the membranes were rup- 
tured. The pains at once became stronger in character, and a male 
child of seven and a half pounds was born at 9.45. In the evening, the 
patient being unable to pass her water, it was drawn by a catheter. 
November 17th. The report was that the patient had slept well and 
was feeling nicely, although somewhat restless. 
November 18th. The water was again drawn by the catheter. The 
milk and lochia were normal, and continued so during the subsequent 
history of the case. The pulse and temperature were somewhat ele- 
vated, as is usually observed during the accession of the milk. The 
temperature was about 101° and the pulse 120. Subacute Cystitis following Parturition. 
5 
November 19th. At the morning visit the patient expressed herself as 
feeling very well. The temperature and pulse had both fallen to 98. 
In the afternoon, however, she complained of great distress in the ab- 
domen, which was not relieved by the application of poultices. One 
eighth of a grain of the sulphate of morphia was ordered, and the patient 
was soon quiet. An enema was given at the evening visit, as no dejec- 
tion had been had since the confinement; the effect of the injection 
was slight. 
November 20th. The skin was hot and dry, the abdomen somewhat 
tender over the region of the bladder. Half an ounce of castor-oil 
was ordered, and a good operation was obtained from the bowels. The 
temperature was 100.6°, the pulse 120. Poultices of linseed meal and 
mustard were applied to the abdomen. In the evening the temperature 
had risen to 103.6°. 
November 21st. The patient remained about the same, the temper- 
ature in the morning being 99°, and at night 104.2°. 
November 22d. The tenderness of the abdomen had nearly disap- 
peared. The patient reported herself as feeling well. The tempera- 
ture in the morning was 101°, at night 103°. 
D uring the next four days the patient’s condition remained about the 
same. She did not complain of any abdominal pain or tenderness. 
The temperature in the morning averaged about 98°, and at night 102° 
or 103°, with a corresponding variation in the pulse. She reported 
herself as feeling well, and complained only of loss of appetite. 
November 27th. She had a chill in the afternoon, and the next morn- 
ing was unable to pass her water, which was therefore drawn by a 
catheter. 
During the next three days no change was noticed, the temperature 
being, as before, normal in the morning, but quite high at night. Some 
tenderness on pressure over the bladder was present. 
November 30th. The patient had a second chill. 
December Ist. Two chills occurred. There were also two attacks of 
vomiting. The general condition of the patient was one of considera- 
ble nervousness, for which bromide of potassium was ordered. She now 
began to complain of great pain and scalding on urinating. Supposi- 
tories containing an eighth of a grain of the sulphate of morphia were 
ordered, pro re natd. 
December 2d. The patient had another attack of vomiting and com- 
plained of some abdominal pain. No tenderness, however, could be 
detected anywhere. 
December Bd. There was decidedly less pain on micturition. The 
temperature, as before, still remained low in the morning and high in 
the evening. An examination of the urine, drawn by catheter, showed 
the presence of considerable pus. 
December 4th. The bladder was washed out with a weak solution of 
carbolic acid (three drops to the pint), as in the previous case. The 6 
Suhacute Cystitis following Parturition. 
next day, December sth, the patient reported herself as feeling very much 
better. There was no dysuria. The evening temperature fell to '99.8°. 
December 6th. An examination of the urine showed decided diminu- 
tion in the amount of pus. The bladder was again washed out. From 
that time the temperature, morning and evening, remained nearly con- 
stant at a little over 98°. 
December 10th. The patient sat up. 
December 11th. She was about the ward, feeling as well as ever. 
She was discharged from the hospital, well, December 16th: 
Case 111. F. S., single, primipara, twenty-one years old, entered the 
Boston Lying-In Hospital April 16, 1874, to await her confinement. 
Labor began about eleven o’clock of the night of April 28th. The waters 
broke at five o’clock of the morning of the 29th, and the os was fully 
dilated at eleven o’clock. The pains having become very weak, and the 
labor making no further progress, forceps were applied, and the child 
(a female weighing six and a half pounds) was born about half past 
twelve. The first five days following the delivery, the urine was drawn 
by a catheter, the patient being unable to pass it herself. 
At the evening visit of May 4th, the patient complained of some 
pain over the region of the bladder, and the next morning there was 
marked dysuria. 
May sth. The pain over the bladder had considerably increased, 
and the catheter had to be used. A poultice of linseed meal and mus- 
tard was applied over the pubic region. 
Potassse bicarbonatis . . 3ij. 
Tincturae hyoscyami . . . . * . . . . Sj. 
Mucilaginis acacise ■. gv. M. 
S. Half an ounce every three hours. 
The scalding and pain on micturition gradually diminished, and the 
medicine was discontinued May"Bth. The tenderness oyer the bladder 
was noticeable for a day or two longer. 
May 11th. The patient sat up a short time, and the next day com- 
plained again of dysuria, and pain over the pubes. The recipe of the 
sth was resumed, and a poultice reapplied. 
May 14th. The pain and tenderness over the bladder had increased 
considerably, the former keeping the patient awake at night. There 
was some dysuria. The prescription of the sth was omitted, and one 
eighth of a grain of the sulphate of morphia was ordered, pro re natd. 
May 15th. The patient reported hei’self as feeling much better. The 
abdominal pain and tenderness were decidedly less. The evening 
temperature and pulse were from the outset higher than the morning. 
The dysuria still continuing, the urine was examined May 21st, and 
found to contain a large amount of pus. 
May 25th. The bladder was washed out with a weak solution of 
carbolic acid (six drops to the pint), and a drachm of the fluid extract 
of pareira brava was ordered three times a day. Subacute Cystitis following Parturition. 
7 
May 27th. The tenderness over the bladder was decidedly less, 
although the patient still complained of great pain after passing water. 
The dysuria gradually diminished, and June 6th the patient declared 
herself entirely free from it. An examination of the urine showed an 
entire absence of pus. 
June 9th.- The patient was discharged from the hospital, well. 
The history of the lochia was normal throughout the course of the 
case. The variation between the record of the pulse and temperature, 
as taken in the evening, when compared with that observed in the 
morning, was not nearly so noticeable as in Cases I. and II.; but the 
variation was constant throughout the course of the case. No chill was 
observed, nor was the tenderness over the pubes so great as in the two 
previous cases. The dysuria however was, if anything, more marked, 
and less readily yielded to treatment. There was no loss of appetite, 
and but little if any constitutional disturbance. 
Case IV. M. 0., married, primipara, thirty-seven years old, entered 
the Boston Lying-In Hospital October 4th, during the service of Dr. 
Tuck, who has kindly allowed me to report the case. Labor had begun, 
but the pains were very weak, and occurred at long intervals. The 
waters broke very early in the morning of October 6th, the os at that 
time scarcely admitting the tip of the finger. During the next three 
days the pains were very weak, and occurred, as before, at long in- 
tervals, the os being very firm and rigid. Dilatation was very gradual. 
October 9th. Morphia was ordered, and the patient obtained some 
sleep. The water was frequently drawn by a catheter, the patient 
being unable to pass it herself. The urine on the 9th was reported as 
dark-colored and offensive. At seven o’clock in the evening the child 
(a female weighing seven and a quarter pounds), was born, dead. 
The placenta came away at once, and the uterus contracted well, but 
soon an alarming post-partum haemorrhage took place, which was pres- 
ently controlled by ice, ergot, brandy, and opium. 
The next morning the patient,, was very comfortable. During the 
next three days the history of the case was that which usually follows 
natural labor. 
October 17th. One week after her delivery, the patient complained 
of pain in micturition. The urine was very offensive and contained a 
large amount of pus. 
October 18th. The bladder was washed out with a solution of car- 
bolic acid (three drops to the pint), and the next day the patient re- 
ported decidedly less pain on passing water. 
October 20th. The bladder was again washed out. No further dys- 
uria. 
October 22d. The patient sat up for an hour. Her subsequent 
history was one of rapid convalescence, and she was discharged from 
the hospital, October 31st, well. 
Prior to the first washing out of the bladder the pulse had remained 8 
Subacute Cystitis following Parturition. 
over a hundred, but at once fell to about 80. The temperature, also, 
which had been high at night and low in the morning, although the 
variation was not so marked as in the other cases reported, fell to 98°, 
at which point it remained constant. 
Remarks. All these cases present certain points in common. In 
all, more or less protracted pressure was exerted, during the progress 
of the labor, by the child’s head upon the bladder. In two of the cases 
forceps were used to hasten the delivery. In the two cases (I. and II.) 
in which the cystitis was best marked from the outset, the invasion of 
the disease was announced by a chill. In the first case, where there 
was a relapse of the disease, a second chill preceded the rise in the 
temperature and pulse. In all the cases there was great dysuria, which 
in most of them was the chief symptom complained of by the patient, 
apart from the general constitutional disturbance. In three of the cases 
(I-, 11., and III.) there was marked tenderness over the region of the 
bladder, and the patients complained of more or less pain referred to 
the same spot. In one case (HI.), the pain was so great as to render 
the use of morphia necessary, in order that the patient might obtain 
any rest or sleep. In the severer cases (I. and II.) more or less nausea 
and vomiting were noticed during the progress of the disease. The 
clinical history of the lochia and milk was normal from first to last. 
In all the cases the urine contained a large amount of mucus and more 
or less pus. In only one case (I.) was blood found in the urine on a 
microscopical examination. In none of the cases was the constitu- 
tional disturbance as great as would naturally have been expected from 
the daily variation in the record of the temperature, pulse, and respira- 
tion. At the evening visits the patients complained of feeling feverish 
and sick, but in the mornings declared themselves almost well, except 
for the dysuria or the local pain and tenderness on pressure over the 
pubic region. The record of the pulse, temperature, and respiration 
was, in all these cases, very peculiar, being characterized by a low 
morning and a high evening range, and this peculiarity was especially 
marked in the first two cases. In the last two the same variation was 
noticed, but the differences recorded were not nearly so great as in the 
others. A clinical chart of the first case is published ; it illustrates very 
well the character of the daily variations observed in all the cases. 
The only treatment adopted was the application of poultices over the 
region of the bladder, until the pain and tenderness had in a great 
measure subsided ; the administration of morphia, either in suppositories 
or by the mouth, for the relief of the pain or dysuria ; and finally, after 
the more acute symptoms had subsided, the bladder was washed out 
with warm water, and later with a weak solution of carbolic acid and 
water. In all the cases the washing out of the bladder was followed 
by a general feeling of relief, and by a sudden disappearance of all the 
symptoms complained of, that was very striking.