tality from all operations, by whomsoever performed, is not more than one in twelve, while in the practised hands of my young friends, Dr. George Macleod, Dr. Eben. Watson, and Dr. George Buchanan, a still higher degree of security has been attained. These are surely recommendations that might induce even a surgeon to a metropolitan hospital to try the operation, although I am aware that it has to contend with the good old English prejudice against everything which comes from the country of John Hunter.-Lancet, June 27, 1868, p. 831.

68.-ON CYSTITIS AND PROSTATITIS.

By Sir HENRY THOMPSON.

[The chronic form of cystitis is that which most requires our attention, and in treatment most care and judgment. In the simpler, there is little else than some increase of the natural mucus from the bladder mixed with the urine. In the other form the mucus is very tenacious, and acquires a thick viscid character on standing. The most common cause of this is inability of the bladder, either from atony of its coats or from prostatic obstruction, to empty its contents; yet it does by no means necessarily occur in these circumstances.] With regard to the treatment, the first thing is to take care that the bladder is emptied by a catheter once, twice, or three times a day, in the easiest manner possible, of which I treated in the fourth lecture. And this is necessary because decomposing urine is a great source of irritation to the mucous membrane. The urea contained in the secretion which enters by the ureters in a healthy state is soon decomposed into carbonate of ainmonia, and the ammoniacal salt is an acrid and irritating substance. You explain to your patient that his bladder, not having been emptied for many months perhaps, has acquired somewhat the condition which a badly washed utensil would have done in like circumstances-a useful and sufficiently accurate illustration for the lay understanding, and he will appreciate it when he finds, as he probably will, that the inucus diminishes considerably after a few days of this treatment. But suppose it does not do so, or does so but slightly, what then? I will tell you what sometimes happens, and I am not sure that the fact I am about to ask your attention to has been observed or recorded. It is this: you cannot completely empty every bladder with the catheter. When the prostate is irregular in shape and throws out protuberances into the bladder, there are sinuses or spaces between them, which retain one, two, or even more drachms of urine. Again, there are not unfrequently numerous small sacculi in the coats of the bladder which act in the same way. When obstruction at the neck has existed some time, the daily straining, although not considerable, necessary to expel the urine produces hypertrophy of the muscular bands which form that coat of the bladder. Now you know hydraulic pressure is equal in every direction, and in course of time the expulsive act gradually forces the mucous lining between the interlacing muscular bands, and little pouches result. In these it is not uncommon for calculi to be secreted, and thus in time encysted calculus is formed. In any case, however, those pouches become receptacles of urine, which become stale, and irritating in consequence. Now the mere withdrawal of the urine by catheter by no means empties the reservoir in these circumstances, and enough of noxious fluid is left therein to maintain the unhealthy condition of its lining membrane. What you have to do is to wash out the bladder at least once a day with a little warm water before you remove the catheter. I am very particular indeed as to the manner of doing this. Washing out the bladder may be a very valuable mode of treatment, or a mere contrivance for seriously irritating that organ, according to the mode in which it is performed. A common mode, indeed that which I always saw employed some years ago, was to attach to the catheter (which was often of silver, and it is unnecessary to repeat my views about that) a large metal syringe, and to throw in with considerable force six or eight ounces of water. I wish you to cherish a wholesome horror of that proceeding; and in no case can it be necessary. A healthy bladder, and

much more a tender one, can only be disturbed and pained by such a process. This sensitive organ is only accustomed to be distended gradually by the continued percolation into it of urine from the kidneys. Let your washing-out at least conform in some respect to that process. Never, under any circumstances, throw in more than two ounces; and even this quantity, for efficient washing, is better avoided. Proceed then as follows:-You have a flexible catheter in the bladder; have ready a four-ounce india-rubber bottle with a brass nozzle and stop-cock, the nozzle long and tapering so as to fit a catheter of any size between Nos. 5 and 10, filled with warm water-say at 100° Fahr. Attach the nozzle gently to the catheter, and throw in slowly a fourth of its contents; let that run out, and it will be thick and dirty, no doubt; then inject another fourth, which will be less so; again another, which will return clearer than the preceding; and the fourth portion will probably come away nearly clear. Now these four separate washings, of an ounce each, will have been really more efficient than two washings of four ounces each; and you will, in obedience to my never-failing injunction, have reduced the amount of instrumental irritation to a minimum. Ten to one but the patient will regard your performance as soothing to his feelings. There are other methods of effecting the object, but this is the principle I want you to understand; and the mode of carrying it out which I have described is one of the simplest.

What if this washing-out has not accomplished all we wish? We may then, and often with great advantage, try medicated injections. Perhaps the best mild astringent, when the urine is alkaline and depositing phosphates, is the acetate of lead, in the proportion of one grain to four ounces of warm water, not stronger; to be used once a day. After this comes the dilute nitric acid; one or two minims to the ounce of water. Then you may try nitrate of silver in small quantity, certainly not more than one grain to four ounces to begin with, going up to about half a grain, or one grain at most, to the ounce. You may also use, especially where the urine is offensive, carbolic acid; one or two minims to four ounces is quite strong enough. Then there is a soothing injection well worth your remembering-viz., biborate of soda and glycerine. It may be used where there is no great indication for an astringent, or it may be combined with one. The value of this for sore mouth suggested to me its use for an irritable bladder, and experience has confirmed my expectation. Here is my formula: Two ounces of glycerine will hold in solution one ounce of biborate of soda; to this add two ounces of water. Let this be the solution, of which you add two or three teaspoonfuls to four ounces of warm water. I arrange all these solutions for four ounces because the four-ounce india-rubber injecting bottle already described is a convenient and portable instrument.

And

In circumstances of great pain you may inject anodynes into the bladder if you please; but they are of little value. And you need not be afraid of the quantity; for the mucous membrane of the bladder appears to have no absorbing power, unlike the neighbouring tissue which lines the rectum. there, indeed, is your place for action, if spasm and pain greatly disturb the patient; a suppository of cocoa-nut butter, containing from half a grain to a grain of morphia, is often of the greatest service. Counter-irritants play a small part among our remedies; perhaps the best and safest is a hot linseed poultice, well sprinkled with strong flour of mustard, above the pubes. I cannot say much for croton oil, nitrate of silver, &c., there. Hot fomentations, in the form of bran bags, hot flannels, &c., alleviate pain materially; so also hot hip-baths and the hot bidet.

Then there is a host of infusions and decoctions reputed to exercise a beneficial influence in cystitis. I will name some of them in what I think to be about the order of their value for the cases one commonly meets with:Buchu, Triticum repens, Alchimella arvensis, Pareira brava, and Uva ursi. Now, for the doses of these, your conventional tablespoon is a miserably inefficient measure. Of the first, fourth, and fifth give half a pint daily; of the second and third, a pint-that is of their infusions or decoctions, as the case may be.

LVIII.--12

The underground stem of the Triticum repens, or the common couch grass, was introduced some years ago by myself. Of this I will only say that it maintains its credit, and is undoubtedly very useful in many cases. For use, boil two ounces in one pint of water for a quarter of an hour; the strained liquor to be taken by the patient in four doses in the twenty-four hours. It was a favourite remedy in the old herbals; and it formed the staple medicine against what was called "strangury," which, a few centuries ago, meant everything like pain or difficulty in making water, no matter what the cause; for the art of diagnosis then was in its earliest infancy. The Alchimella arvensis, or "Parsley piert" (derived from "percer la pierre," and not a parsley or umbelliferous plant at all), has proved in my experience an admirable remedy in obscure cases. Use it as an infusion; one ounce to the pint. Besides these there are the resins, which have a certain amount of influence upon the mucous membrane of the bladder-such, for instance, as copaiba, Venice turpentine, &c. You should not, however, give the dose which you would give in gonorrhoea. Five minims of copaiba, three or four times a day in mucilage, often answers well. I may say the same of the oil of cubebs.

One word about alkalies. As a rule, no doubt, alkalies, in neutralising highly-acid urine, help to control chronic cystitis; and I like the liquor potassæ, as well as the bicarbonates, tartrates, and citrates, which appear to have more diuretic action, and to increase the quantity of urine, when you would rather avoid this action and lessen the frequency of micturition. The old combination of liquor potassæ and henbane, affirmed to be a union of incompatibles, nevertheless seems to me about the most valuable form in practice. I have no doubt that it is quite correct that both henbane and belladonna are deprived of their specific activities when mixed with liquor potass. Chemically I dare say that is so. But I am perfectly satisfied that this combination materially controls painful and frequent micturition in the complaint we are considering. Hence I have of late gone back to it, and for the reasons stated.

Now as to acids.

Remember that these are by no means the complement of alkalies in relation to the urine. Beware of the popular notion that it is possible to produce an acid reaction on urine by giving mineral acids by the mouth. By giving alkalies you can make the urine neutral or alkaline to any extent you please, but you cannot do the converse with these acids. Yet I constantly hear it said, "The patient's urine is very alkaline; had we not better order acids?" My reply is, "By all means; give an ounce or two daily if you like, but it will not change the reaction of the urine." I have given these quantities, greatly diluted, of course, without the slightest effect on alkaline urine. No doubt mineral acids are useful in giving tone, and so do good; but don't prescribe them with the view of acting on the urine. The acids that do act on the urine are benzoic acid and citric acid, but you have to give so much of these that I do not know whether the remedy is not mostly worse than the disease. The benzoic acid, having some balsamic character, may be useful in some cases of chronic cystitis. The best way to give it is in pills, as it is not soluble in water. Three or four grains, with one drop of glycerine, is a good form; and you must give as many as ten or twelve pills a day if you want to do any good. At all events, it is of no use giving less than six; that would be twenty-four grains in the day. Lemon-juice has also an acid influence on the urine, and if it agrees with the stomach, may be taken in large quantity. But here is the important fact for you to remember. Surplus of acid in the urine is a constitutional error, and it enters the urinary passages at the kidney. It requires constitutional treatment, of the digestive rather than of the excretory organs, and mere alkaline treatment does but mask the acid, does not cure it. You have to remodel the patient's habits, control his diet, and take care that his liver and bowels act healthily and freely. On the other hand persistent alkali in the urine is, in nineteen cases out of twenty, a local formation in the bladder. It requires local treatment, as by catheter and injecting-bottle, and not physic. Now and then you have alkaline urine, milky-looking, with amorphous phosphates, as

a constitutional condition; but this is rare, as compared with the cases I am now describing.

I shall close this lecture with some brief remarks on acute and chronic prostatitis.

Acute prostatitis occurs in different degrees of severity, and often comes first before the practitioner's notice when it causes retention of urine by obstructing the neck of the bladder. How this emergency is to be met I have described at some length in the fifth lecture. The organ is often considerably swollen and very tender, and the inflammation may give rise to abscess in the substance of the gland, or adjacent to it; and the matter may burst either into the urethra, its most common course, or into the rectum.

Chronic inflammation of the urethra passing through the prostate, and more or less affecting the prostate itself, is a condition less generally known or recognised. Nevertheless it is a common and important affection. We see it frequently, not always, as the result of obstinate gonorrhoea. I have already referred to it as the cause of symptoms resembling, more than any other malady, those of calculus in the bladder when mild in degree. Thus a patient of twenty or thirty years of age tells you that the following symptoms have rather gradually appeared:-under frequency of micturition; pain following the act, and felt in the end of the penis; occasionally a little blood seen with the last few drops of urine, which may be a little cloudy with muco-purulent deposit; a sense of heat and weight in the perineum and rectum; there is, perhaps, also some gleety discharge in the urethra; and all these conditions aggravated by exercise. You see he gives you a complete sketch of the symptoms of calculus; and how are you to distinguish them? By the history and by sounding. Thus, there is no history of the descent of calculus from the kidney, nor of gravel previously passed. But there is the fact of a chronic gonorrhoea resisting, perhaps, months of treatment. And if the patient shows no improvement you must not decline to sound him. You do so, and find nothing, but that the prostatic urethra was very sensitive; and you make him a little worse, perhaps, for a time.

What is to be done? First and foremost, as a rule, abjure all instruments, which, in most cases, can only do mischief. Treat it as you would a chronic inflammation of the ear or eye-i. e., blister an adjacent surface; make a small blister every four or five days on either side of the raphé of the perineum, by applying with a brush the lin. epispast. of the Pharmacopoeia, not so freely as to distress him or prevent locomotion, and keep it up for four or six weeks. I have found the best results from this method, combined with a tonic medicine and regimen, and you will find the patient himself gladly exchanging the dull, weary aching in the perineum for the smart of the blister, and cheerfully noticing how the former gradually subsides under the influence of the latter. In exceptional cases, where chronic gleet is a prominent symptom, the application of a solution of nitrate of silver, not more than five or ten grains to the ounce of water, to the prostatic urethra, may be very serviceable.—Lancet, June 20, 1868, p. 775.

69.-ON HÆMATURIA AND RENAL CALCULUS.

By Sir HENRY THOMPSON, Surgeon to University College Hospital.

[Hæmaturia is the outflow of urine mixed with blood. Thus, bleeding from the penis at other times than at that of micturition is, of course, not hæmaturia. Hæmaturia, then, is a symptom, and it is a matter for diagnosis to determine what it is a symptom of.]

When you see a specimen of urine containing blood, you will, as a matter of course, make a rough mental note of the proportion of blood present, and you will mark the colour. And as you can count on your fingers the ordinary sources of blood, these will pass rapidly in review at the same time. Let us name them as follows:

1. The kidneys, where it may be from diseased action, more or less tem

porary, as inflammation; or from disease more or less persisting, as degeneration of structure; or from mechanical injury, as from calculus there, or by a strain, or a blow on the back. If the hæmaturia is the result of inflammation, there will be general fever denoting its presence; if produced by slow organic change, there will be the history of failing health, and probably urine changed in quality otherwise than by the mere admixture of blood. Where blood is in very small quantity, as it will naturally be at times, note the character of the urine proper-whether of low specific gravity, pale, with albumen in greater proportion than blood or pus will account for; perhaps renal casts may be found; and look out for dropsies in any degree. In both the preceding forms, if blood is present it will give the smoke tint to the secretion. Perhaps it may be affirmed that such urine, associated with very little if any local pain, is more likely to come from the kidney than elsewhere. In malignant renal tumour blood may be large in quantity at times: the rapidity of growth, and the size attained, are the marked characteristics of the disease. If mechanical injury be the origin of hæmaturia, there will be the history of a blow or strain; or there may be the signs and symptoms of renal calculus, of which more detail presently.

2. Then, putting aside the ureters, you will remember the bladder as the second source of hemorrhage; and here it may be due to some acute cystitis, stone, or tumour. The former is obvious enough from muco-pus in the urine, and through other signs; while the second may well be suspected by the symptoms, and its presence realised by the sound. Here the hemorrhage is usually florid, and in proportion to the patient's movements. But the third condition-namely, that the hemorrhage arises from tumour-is not always so readily to be affirmed. As rule, however, blood from such a source is larger in quantity than from stone, and may be associated with less of mucopus. If the tumour is malignant, it may be felt, and the pain is often severe; if villous, it gives an even pale-red tint for days together to the urine; and in both cases the blood is florid, unless it is long retained in the bladder, when dark sanies, like coffee-grounds, results.

3. In hemorrhage from the prostate, the third principal locality or source, the same thing occurs, if the organ is hypertrophied and the blood is retained; but here the age of the patient, and the ascertained condition of the organ from the bowel, aid the diagnosis. A slight appearance of blood mixed with the last few drops of urine is not a rare occurrence in chronic prostatitis.

4. When bleeding arises from stricture of the urethra, the patient's history and the cause of the bleeding, almost always instrumental, leave no room for doubt. From the use of instruments also in the bladder hemorrhage sometimes arises. Then it is not to be forgotten that occasionally blood is found in the urine as the result of violent diuretics, from purpura, in fevers, and in a hemorrhagic diathesis.

Now for the treatment of hemorrhage. When you have determined that its source is above the bladder-that is, in the kidney or in its pelvis, probably the first and most influential remedial agent is rest in the recumbent position. Whether from a lesion affecting the intimate structure, or from the mechanical irritation of a calculus in any part of the organ, rest is the first and the essential condition. The patient is, moreover, to be maintained in as cool and as tranquil a state as possible.

It is in renal more than in any other form of hæmaturia, perhaps, that direct or internal astringents or styptics are useful. I shall do no more than name those which are most commonly used-namely, gallic and tannic acids; lead and turpentine; equal to them is, I think, the infusion of matico, say in doses of two ounces every two or three hours. The tincture of iron and also sulphuric acid may sometimes be taken with advantage.

It is, however, in cases of severe hemorrhage from the bladder, or more commonly from an enlarged prostate, that active and judicious treatment is necessary. You will be called sometimes to a patient whose bladder is distended with coagulated blood, or who is passing frequently a quantity of fluid in which blood is the predominating element. Usually this has arisen