If the oils are used it is important to watch their effect on the stomach and kidney. If they disagree they may lead to pain after food and nausea, or to pain in the back of the loin and albuminuria.

Lavage is a most important element in treatment, as it can be made to act beneficially in several ways; first, by mechanical flushing and cleansing of the surface of the mucous membrane; secondly, as an antiseptic or astringent agent; thirdly, as an agent to distend the bladder and gradually increase its capacity for holding fluid in those cases where the bladder is contracted.

These are the methods in common use for flushing out the bladder: (1) The method of Janet, the sphincters being overcome by hydraulic pressure; (2) the common method by the passage of a catheter through the sphincters.

In chronic cases, where there is no other call for a catheter, we prefer the method of Janet, as it saves the passage of a catheter and helps to increase the size of the bladder.

In cases where a catheter has to be passed to relieve residual urine, as in cases of paralysis or enlarged prostate, then it is more convenient to proceed with the second method.

1. The method Janet.-Apparatus required: A douche-tin to hold at least three pints of fluid, six feet of rubber tubing and a clip, a urethral nozzle and shield, a stylo-filler, a sterilised 2 per cent. solution of novocain nitrate, some swabs, a bottle of lysol, a receiver.

The nozzle and stylo-filler should have been sterilised in boiling water. The douche-tin is filled with a suitable solution and is suspended from a nail five feet above the level of the bladder. The patient lies on his back with a receiver beneath the perinæum and thighs. The glans penis is cleansed with lysolised swabs. The stylo-filler is made to take up a supply of novocain, is inserted within the meatus, squeezed, and withdrawn, the solution being held in the urethra by means of compression of the tip of the penis with the other hand. The anterior urethra is now full of novocain solution. With a finger of the right hand on either side of the bulbous urethra, the solution is stroked backwards into the deep urethra. After a few minutes the spastic reflex of the compressor urethra will be found abolished. The urethral nozzle is now taken up by the fingers of the right hand, which simultaneously compress the rubber tubing just above the nozzle, and the clip is removed. The nozzle is

inserted into the urethra, and, after the anterior part of the urethra has been flushed with fluid, is made to block the meatus completely. The fluid now presses its way through the compressor urethræ and into the bladder, producing a thrill. As much fluid may be injected as the patient will stand without discomfort (ten to twenty ounces), the nozzle being then removed, and after a minute or so the patient asked to micturate into the receiver. The process may be repeated two or three times, and can be carried out once a day if necessary in chronic cases, but usually twice a week is sufficient. After a few trials the use of novocain can be dispensed with as the patient learns to relax the compressor voluntarily and with ease.

This method should only be performed by the surgeon himself, as it requires some skill and experience.

A

Lavage by means of a catheter.-A catheter is passed into the bladder in the ordinary way with full antiseptic ritual. The larger the catheter the better. A soft rubber catheter may be usefully employed if it can be passed with ease, but in many cases a gum-elastic catheter will have to be used. The best modern gum-elastic catheters can be boiled. two-way catheter should never be used, as the chief object of the wash is to distend the folds of the mucous membrane so as to flush them thoroughly. The urine is drawn off completely, and fluid is then injected. The temperature of the fluid should be 105° F., and the amount injected each time should be four ounces.

A metal or glass syringe to hold four ounces, with a snugly fitting metal or glass piston, can be obtained from the best instrument makers. The syringe must take to pieces easily for cleaning, it must be capable of being boiled, the piston should work smoothly and evenly and should not leak, and care should be taken not to inject air.

For routine work in hospital wards it is more convenient to use a douch tin with rubber tubing and clip, and a glass nozzle which can be inserted into the end of the catheter. An indiarubber ball syringe is convenient for a patient's own use. The old method of using a syphon funnel is quite

obsolete.

Lavage should be continued until the fluid comes away clear, and a few ounces of fluid may be left in the bladder with advantage if the fluid is unirritating.

Solutions for lavage.-Solutions may contain antiseptic agents, astringent agents, or agents having both actions.

The solution should be made up when possible with boiled, distilled water from which all foreign matter has been sedulously removed. Failing this, boiled tap-water poured through a fine muslin filter will suffice. The temperature of the solution should be 105° Fahr.

Instillation is a very valuable method of treatment. especially for cases complicated by posterior urethritis, and can be performed with the syringe of Guyon or of Ultzmann, or when these are lacking by means of an ordinary syringe and catheter. The syringe is filled with thirty minims of solution, the patient passes water, the urethral tube, lubri cated with glycerine, is pushed down the urethra until the resistance of the compressor is felt at the depth of some six inches. The tube is then pushed onwards for another one or two inches through the compressor, so that the eye lies well within the deep urethra, the solution is injected and the tube withdrawn. In this way strong concentrated solutions can be applied to the deep urethra and bladder often with remarkable benefit. Pain after the injection is relieved by a hot bath, and it is better not to use cocaine, but if silver salts are being used the hydrochloride salts of cocaine, eucaine, novocaine, etc., will decompose the silver, so that special solution of the nitrates of these salts must be kept for this purpose.

If oil be used it prevents the antiseptic from getting at the wall of the bladder, whereas glycerine aids the process by prolonging the action of the drug.

The method of instillation can be applied with benefit immediately after an irrigation by the method of Janet.

Solutions used. Silver nitrate

Strength.

Protargol.

Potassium permanganate

Work up from gr. j to the ounce, to gr. xx,

xxx or even xl to the ounce.
5-10 per cent.
1: 200.

Surgical measures.-In obstinate cases, or where it seems impossible to keep the bladder free from residual urine and back-pressure, continuous drainage may be instituted either by a catheter á demeure or by supra-pubic or perinæal incision. The supra-pubic route is the better, and the application of an Irving's dressing keeps the bed dry and enables lavage to be most easily performed. Continuous irrigation can be instituted if two tubes are inserted, by the use of simple mechanical devices, a method that appears to be of especial value as a preliminary measure to enucleation in old men with enlarged prostates and a severe cystitis.

If a stricture be present it is far safer to divide it at once by internal urethrotomy and either tie a catheter into the bladder or instil thirty drops of silver nitrate solution (gr. v to the ounce). The establishment of free drainage carries with it far less risk than attempts to dilate a stricture gradually when the cystitis is at all severe.

In a few obstinate cases that present chronic ulceration of the walls, benefit may be obtained by painting the ulcers with stimulating lotions such as strong silver nitrate through an endoscopic tube or after supra-pubic cystotomy.

Vaccine treatment is seldom required for a pure cystitis, though in obstinate cases it should be given a prolonged trial. The patient's own bacteria should be isolated and prepared

as a vaccine.

SUMMARY OF PROCEDURE IN DEALING WITH A PATIENT SUFFERING 66 FROM SYMPTOMS OF CYSTITIS."

1. Never employ lavage or pass an instrument at the onset of such symptoms.

2. Put the patient to bed, take the temperature, and find out if the kidneys have been painful or are tender.

3. Examine the urine, and send it to a bacteriologist for an expert report.

4. In the meantime give urotropin.

Lavage should not be employed till the acute symptoms have abated, and then only if there has been no painful or tender kidney; if no tubercle bacilli have been found; if the pyuria does not disappear with the mitigation of symptoms.

If lavage cures the pyuria the diagnosis of cystitis as opposed to pyelitis is rendered complete,

CHAPTER IV.

TUBERCULOSIS OF THE BLADDER.

Ætiology.1

The disease is caused by infection of the walls of the bladder with the tubercle bacillus, which may reach that position by three different paths:

1. Along the walls of the vas deferens secondary to a tuberculous epididymitis.

2. Along the walls of the ureter secondary to a renal tuberculosis.

3. Direct from the blood-stream in the walls of the bladder (primary).

Primary tuberculosis of the bladder is seldom if ever seen in museum specimens, but there is cystoscopic evidence to show that the first deposit of tuberculosis in the genito-urinary tract may be from the blood direct into the submucous tissues of the posterior superior wall of the bladder (Fenwick).

In the usual course the tubercle bacilli are deposited primarily in the epididymis or the kidney and spread down in the wall of the vas deferens or the ureter until they reach the wall of the bladder just above and to the outer side of the mouth of the ureter. At this spot a submucous deposit of miliary tubercles is formed, which may break down and form a tuberculous ulcer. The bacilli are not carried to the bladder by the stream of urine and implanted on the walls, but work their way along in the submucous or peri-muscular coat of the ureter itself. Tuberculosis of the bladder is most frequently met with in adult males as the most prominent tuberculous lesion in the urinary tract.

Chronic gonorrhoea and excessive coitus are said to be predisposing causes, with how much truth is difficult to say. The disease is uncommon in females except as a late complication of advanced tuberculosis of the kidneys and ureters, 1 See Ch. VIII, Sect. I, "Tuberculosis of Kidney."