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 sit several times a day in a very hot hip-bath. When he has got back to bed, a fomentation under oil-silk, or some other waterproof material, should be placed over the lower part of the abdomen. The diet should be milk (diluted with hot or cold water), barley-water, and bread and butter; no alcoholic drink should be allowed. If the urine is acid, bicarbonate of soda may be given, or citrate of soda; if alkaline, urotropine—a derivative of formic aldehyde—may prove a useful urinary disinfectant. If the straining and distress are great, a suppository of or  a grain of morphia may be introduced into the rectum every two or three hours. The bowels must be kept freely open. If the urine is foul, the bladder should be frequently washed out by a soft catheter and two or three feet of india-rubber tubing with a funnel at the other end, weak and abundant hot lotions of Sanitas or Condy’s fluid being used.

Chronic cystitis is the condition left when the acute symptoms have passed away, but it is liable at any moment to resume the acute condition. If the cystitis is very intractable, refusing to yield to hot irrigations, and to washings with nitrate of silver lotion, it may be advisable to open the bladder from the front, and to explore, treat, drain and rest it.

In tuberculous cystitis there is added to the symptoms the discovery of the bacilli of tuberculosis in the urine, and cystoscopic examination may reveal the presence of tubercles of the mucous membrane or even of ulceration. The patient is probably losing weight, and he may present foci of tuberculosis at the back of the testicle, the lung or kidney, or in a joint or bone, or in a lymphatic gland. Treatment is rebellious and unpromising. Washings and lotions give but temporary relief, and if the bladder is opened for rest, and for a more direct treatment, the germs of suppuration may enter, and, working in conjunction with the bacilli, may cause great havoc. Koch’s tuberculin treatment should certainly be given a trial. This consists of the injection into the body of an emulsion of dead tubercle bacilli which have been sterilized by heat. As a result of this injection the blood sets to work to form an “opsonin”—a protective material which so modifies the disease-germs as to render them attractive to the white corpuscles of the patient’s blood (phagocytes), which then seize upon and destroy them. Sir A. E. Wright has devised a delicate method of examination of the blood (the calculation of the opsonic index) which tells when the tuberculin injections should be resorted to and when withheld (see ).

Calculi and Gravel.—Uric acid is deposited from the urine either as small crystals resembling cayenne pepper, or else, in combination with soda and ammonia, as an amorphous “brick-dust” deposit, which, on cooling, leaves a red stain on the bottom of the vessel, soluble in hot water. These substances

are derived from the disintegration of nitrogenized food taken in excess of demand, and from the breaking down of the human tissues. They occur therefore in fevers, in wasting diseases, and in the normal subject after excessive muscular exercises, especially if these exercises have been accompanied with so much perspiration that the excess of water from the blood has escaped by the skin rather than by the kidneys. The abundance of this deposit is in accordance with the amount of heat developed and work done in the body, and corresponds with the dust and ashes raked out of the fire-box of the locomotive after a long run. But supposing that the uric acid débris continues to be excessive, the risk of the formation of renal or vesical calculi becomes considerable, and it may be advisable to place the patient on a restricted nitrogenized diet, to induce him to drink large quantities of water, and to keep his bowels so loose with watery laxatives, such as Epsom salts or sulphate of soda, that the waste products of his body are made to escape by the bowels rather than by the kidneys. In addition to the salts just mentioned, an occasional dose of blue pill will prove helpful. A course of treatment at Contrexéville or Carlsbad may be taken with advantage.

Alkaline urine is unable to hold the phosphates of ammonia and magnesia in solution, so they are deposited in abundance either in the kidney or bladder. If the voided urine is allowed to stand in a tall glass they sink to the bottom with pus and mucus in a cloudy deposit. To remedy this condition it is necessary to treat the cystitis with which the bacterial decomposition of the urine is associated. It may be that a calculus of acid urine, such as one of uric acid or oxalate of lime, has been resting in the bladder and keeping up incessant irritation, and that the micro-organisms of decomposition or suppuration have found their way to the mucous lining of the bladder from either the bowel, the urethra or the blood-stream; undergoing cultivation there they break up the urea into carbonate of ammonia and so render the urine alkaline. This alkaline urine deposits its phosphates, which light upon the calculus and encrust it with a mortary shell, which may go on increasing in size until it may even fill the bladder. Sometimes the nucleus of a calculus is a chip of bone or a blood-clot, or some foreign substance which has been introduced into the bladder. Sooner or later the urine becomes alkaline and the calculus is encrusted with lime salts.

When urine contains a larger amount of chemical constituents than it can conveniently hold in solution, a certain quantity crystallizes out, and may be deposited in the kidney or in the bladder. If the crystals run together in the kidney the resulting concretion may either remain in that organ or may find its way into the bladder, where it may remain to form the nucleus of a larger vesical calculus, or, especially in the case of females, it may, while still small, escape from the bladder during micturition.

In children, in whom there is a rapid disintegration of nitrogenized tissues, a uric acid calculus in escaping from the bladder may block the urethra and give rise to sudden retention of urine. On introducing a metal “sound,” the surgeon may strike the stone, and if it happens to be near the bladder he may push it back and subsequently remove it by crushing. But if it has made its way some distance along the urethra, so that he can feel it from the outside, he should remove it by a clean incision.

A stone in the bladder worries the nerves of the mucous membrane, and, giving them the impression that the bladder contains much water, causes the desire and need for micturition to be constant. The irritation causes an excessive secretion of mucus, just as a piece of grit under the eyelid causes a constant running from the eye. So the urine, if allowed to stand, gives a copious deposit. During micturition the contracting bladder bruises its congested blood-vessels against the stone, so that towards the end of micturition blood appears in the urine. Lastly, cystitis occurs, and the urine contains fetid pus. A stone in the bladder gives rise to pain at the end of the penis, and it is apt suddenly to stop the flow of urine during micturition.

The association of any of these symptoms leads the surgeon to suspect the presence of a stone in the bladder, and he confirms his suspicions by introducing a slender steel rod, a “sound,” by which he strikes and feels the stone. Further confirmation may be obtained by the help of the X-rays, or, in the adult, by using a cystoscope. In a child the stone may often be felt by a finger in the rectum, the front of the bladder being pressed by a hand on the lower part of the abdomen. The cystoscope is a straight, hollow metal tube about the size of a long cedar pencil, which the surgeon introduces into the adult bladder, which has already been filled with warm boracic lotion. Down the tube run two fine wires which control a minute electric lamp at the bladder end of the instrument. At that end also is a small glass window which prevents the fluid escaping by the tube, and also a prism; at the other end of the tube is an eye-piece. By the use of this slender speculum the practised surgeon can recognize the presence of tubercle or tuberculous ulceration of the bladder, stone, or other foreign material, and innocent or malignant growths. He can also watch the urine entering the bladder by the openings of the ureters, and determine from which kidney blood or pus is coming.

The treatment of stone in the bladder is governed by various conditions. Speaking generally, the surgeon prefers to introduce a lithotrite and crush the stone into small fragments, and then to flush out the fragments by using a full-sized, hollow metal catheter and an india-rubber wash-bottle. Even in children this operation may generally be adopted with success, the stone being crushed to atoms and the fragments being washed out to