A practical treatise on the diseases, injuries and malformations of the urinary bladder, the prostate gland, and the urethra

Front matter

22101803820

PRACTICAL TREATISE 44£2*S"

ON THE

Preface

A new edition of this work having been called for, after havino- been out of print for several years, I have entrusted its revision to my son, Dr. S. W. Gross, who has rewritten the greater portion of it, and brought it fully up to the existing state of our knowledge. As he has delivered several courses of lectures upon the affections of the urinary organs in the Jefferson Medical College, and has devoted much study and attention to their practical details, I felt satisfied that the task would be thoroughly executed. The chapters on Tumors of the Bladder and of the Prostate Gland, which add largely to the value of the work, are entirely due to his pen. It is proper to observe that the anatomy of the urinary organs, and the appendix in relation to the prevalence of stone in the bladder and calculous disorders in the United States, inserted into the former editions, have been omitted in this. To Dr. 0. H. Mastin, of Mobile, Alabama, I am indebted for the statistics of lithotomy as performed by American surgeons ; and I am also under obligations to Dr. Barnes, Surgeon-General U. S. Army, for several engravings illustrative of various topics discussed in these pages.

S. D. GROSS.

Jefferson Medical College,

Philadelphia, September, 187G.

Chapter I. Inflammation Of The Bladder And Its Results

PAGE

Sect. I. Acute Inflammation .18

II. Croupous Inflammation of the Bladder 27

III. Suppuration and Abscess of the Bladder 29

IV. Gangrene of the Bladder . . . . . . • .32

Y. Ulceration of the Bladder 35

Chapter II. Chronic Inflammation Of The Bladder And Its Results

Sect. L Catarrh of the Bladder .43

II. Hypertrophy of the Bladder 55

III. Sacculation of the Bladder 62

Chapter III. Functional Diseases Of The Bladder

Sect, I. Irritability of the Bladder . . . . . . ' . .68

II. Spasm of the Bladder ......... 78

HI. Neuralgia of the Bladder 80

IV. Paralysis and Atony of the Bladder 85

Chapter IX. Treatment Of Stone In The Bladder

Sect. I. Medical Treatment II. Litholysis .

III. Extraction of Calculi through the

IV. Lithotrity .

V. Lithotomy •

Art. I. Lateral Lithotomy .

II. Bilateral Lithotomy

III. Median Lithotomy

IV. Becto-Vesical Lithotomy V. Suprapubic Lithotomy

VI. Extrapelvic Lithotomy

Urethra

Part III. Chaper II

CONTENTS. xi CHAPTER III.

PAGE

INJURIOUS EFFECTS OF OPERATIONS ON THE URETHRA . 489

CHAPTER IV.

CHAPTER V.

CHAPTER VI.

CHAPTER VII.

CHAPTER VIII.

CHAPTER IX.

PROLAPSE OF THE MUCOUS MEMBRANE OF THE URETHRA . 526

CHAPTER X.

CHAPTER XI.

CHAPTER XII.

CHAPTER XIII.

MALFORMATIONS AND IMPERFECTIONS OF THE URETHRA . 554

CHAPTER XIV.

LESIONS OF THE GALLIN ACINOUS CREST

LIST OF ILLUSTRATIONS.

FIG. PAGE

1. Urinary deposits in cystorrhrea ..... 45

2. Keyes's apparatus for washing out the bladder . . .52

3. General hypertrophy of the bladder ..... 56

4. Columniforni bladder ....... 56

5. Interureteral bar . . . . . .58

6. Mercier's instrument for incising the bar at the neck of the bladder 61

7. Mercier's instrument for excising a portion of the bar at the neck of

8. Sacculated bladder ....... 62

9. Sacculated bladder ....... 63

10. Catheter syringe ....... 78

13. Gouley's tunnelled catheter ...... Ill

14. Tapping the urethra in the perineum . . . . .112

15. Over-curved flexible catheter ...... 114

16. Mercier's catheter ....... 114

17. 18. French gum-elastic catheters ..... 114

19. Gross's prostatic catheter ...... 115

22. Mode of securing the gum catheter in the bladder . . . 126

24. Mode of holding the female catheter ..... 128

25. Rectal puncture of the bladder ..... 130

26. Tube to be worn after suprapubic puncture of the bladder . . 132

28. Benign vesical papilla . . . ... . . 136

29. Papillary fibroma of the bladder ..... 137

30. Multiple papillary fibroma of the bladder .... 138

31. Carcinomatous vesical papilla ...... 143

32. Simon's urethral speculum . . . . . 151

33. Calculus with nucleus of cork ...... 172

34. Thorny calculus . . . . . . .177

35. 36. Different forms of calculi ...... 178

37. Pudding-stone calculus ....... 178

40, 41. Oxalate of lime calculi ...... 181

42. Hemp-seed calculus ....... 182

XIV LIST OF ILLUSTRATIONS.

43, 44. Cystic oxide calculi

45. Phosphatic calculus

46. Ammoniaco-magnesian calculus

47. 48. Fusible calculi

49. Sacculated calculi

50. Encysted calculi

52. Hollow sound .

53. Sounding for encysted stone .

54. Sounding for stone behind the prostate

55. Sounding for stone above the pubes

56. Cooper's forceps

57. Weiss's and Thompson's lithotrite

58. Fergusson's rack and pinion lithotrite

59. 60, 61. Different forms of lithotrite blades

62. English method of seizing the stone .

63. French method of seizing the stone

64. Position of stone for crushing .

65. Clover's evacuating apparatus .

66. Fillet . .

67. Grooved staff ....

68. Lithotomy knife

69. Beaked knife . . . •

70. The finger and knife in the groove of the staff

71. Lithotomy forceps .

72. Mode of seizing and extracting the stone

73. Lithotomy scoop

74. Prostate at birth

75. Prostate at 4 years

76. Prostate at 12 years

77. Crushing forceps

78. Physick's forceps

79. Cauula for plugging the wound in lithotomy

80. Arterial compressor

81. Double lithotome cache

82. Bilateral lithotomy

83. Fergusson's incision

84. Little's director .

85. Buchanan's rectangular staff .

86. Urethral dilator .

87. Female staff .»••••

88. Forceps for extracting foreign bodies from

89. Shot perforation of the bladder and rectum

90. Sims' s speculum

91. Emmett's speculum

92-96. Instruments for vcsico-vaginal fistule

97. Bryant's instrument for paring the edges of

98. Needle holder .

99. Hook for making counter-pressure the black!

the fistul

PAGE

LIST OF ILLUSTRATIONS.

XV

FIG.

100. Introduction of sutures .

101. Suture carrier . 103. Suture adjuster ....

103. Adjustment of sutures .

104. Bozemau's button suture

105. Sims's catheter ....

106. The cervix slit up to expose the fistule above, with the sutures in

position

107. Case of vesico-vaginal fistule requiring obliteration of the vagina .

108. Sims's operation of elytrorraphy ; sutures in place .

110. Wood's operation for exstrophy of the bladder

111. Maury's operation for exstrophy of the bladder

113. Abscess of the prostate . ......

114. 115. General hypertrophy of the prostate . . . 393, 116, 117. Hypertrophy of the middle lobe .....

118. Hypertrophy of all the lobes ......

119. Angular curvature of the urethra from hypertrophy of the prostate

120. Vertical elongation of the urethra from hypertrophy of the prostate

121. Sarcoma of the median portion of the prostate

122. Prostatic concretions ....

123. Two concentric concretions in the prostatic ducts

124. Prostatic calculus

125. Linear stricture ....

126. Bridle stricture ....

127. Annular stricture

128. Indurated annular stricture

129. Exploratory bulbous bougie

130. Dilatation of the urethra behind the stricture

131. Urinary cyst consequent upon stricture of the urethra

132. Narrow stricture, and dilated and reticulated membranous and pros

tatic portions of the urethra behind it

133. Effects of stricture on the urinary organs

134. Porte-caustique ....

135. Otis's urethrometcr

136. French catheter scale . 137-140. Gum-elastic bougies

141. Filiform bougies

142. Mercier's catheter for avoiding a false passag

143. Richardson's tunnelled-handled divulsor

144. Conical steel bougie

145. Bistouri-cachC .....

146. Gross's urethrotome

147. Civiale's urethrotome .

148. Otis's dilating urethrotome

149. Author's urethrotome .

150. Treat's urethrotome

151. Syme's staff ....

PACE

335 335 335 336 336 337

LIST OF ILLUSTRATIONS.

FIG.

152. 153. 154.

enlargement

Gouley's grooved and tunnelled catheter staff Grooved director

Stricture of the urethra, with false passage

prostate gland, and hypertrophy of the bladder Urinary abscess .

Fistule of the urethra .

157. Dieffenbach's method of urethroplasty

158. Nelaton's method of urethroplasty Urethroplasty by scrotal flap Polypoid fibroma of urethra Papilloma of urethra Articulated scoop of Bonnet Hunter's forceps Mathieu's forceps

•167. Introduction of lithotrite and seizure of the stone

168. Shot perforation of the urethra

169. Epispadias .

170. Nelaton's operation for epispadias

155. 156.

DISEASES OF THE URINARY ORGANS.

PAKT I.

DISEASES AND INJURIES OF THE BLADDER.

CHAPTER I.

INFLAMMATION OF THE BLADDER AND ITS RESULTS.

Inflammation of the bladder, technically termed cystitis,, generally begins in the mucous membrane, and presents itself under two varieties of form, the acute and chronic. Of these,, the first is exceedingly infrequent, while the chronic form of the malady, on the contrary, is sufficiently common, and often entails a vast amount of suffering, which, continuing for months, and perhaps yeai-s, finally brings the patient to a premature grave.

Some modern writers subdivide this disease as it affects one or more of the coats of the bladder. Thus, when the serous covering and its subjacent tissue are alone involved, it is termed serous cystitis, or epicystitis, of which extremely rare occurrence it need only be said that it is nothing more than a circumscribed peritonitis, resulting from extension of inflammation from the other tissues, or appearing as a metastatic phenomenon in the course of pyemia, typhus, and the exanthemata, and liable to be attended with the formation of abscesses, which open into the urethra, the bladder, the vagina, or the rectum. When all the coats are implicated, it is termed interstitial, or parenchymatous cystitis, which is discussed further on under the head of suppuration and abscess of the bladder. Finally, when the mucous membrane and submucous connective tissue alone participate in the morbid action, it is known as mucous cystitis, the ordinary form of the disease. 2

INFLAMMATION OF THE BLADDER.

Sect. I. — ACUTE INFLAMMATION.

Acute cystitis usually occurs in irregular, circumscribed patches, although the entire mucous membrane may be invaded Any portion of the organ is liable to suffer, but the parts most frequently affected are the neck and baa-fond. During its progress the morbid action often spreads from the mucous membrane to the submucous connective tissue, and from thence to the muscular tunic: The peritoneal investment is rarely implicated, m any considerable degree, however serious the attack.

The causes of acute cystitis are the imprudent use of can harides oil of turpentine, nitrate of potassa, and other stimulating articles; contusions of the perineum and hypogastric, from Uo! hicks, or falls; the extension of gonorrh^ anamination of the prostate; the injection of irritating fluids and rough use of catheters, bougies, lithotrites and sounds. Occasionally it is traceable to the effects of excessive venery and t inordinate distention of the bladder from negtect to void 2 u i^ Sudden transition from heat to cold and the rep 1- ion of cutaneous eruptions, also produce acute in persons of a gouty and rheumatic habit. But the most fie ouent causes, without doubt, are wounds of th bkd e , the Presence of calculous concretions, rough horseback or carnage Cle the intemperate use of stimulating drinks, and injury "e'd during parturition, whether

eHld's head, or the ^^^™^> —

cystitis. aA-nUa than in children and

Acute cystitis is more <=°»m0" " ™ 'weak and sickly,

old people, in the strong and robust tl ™ he . >

and in men than in women. „nd ^ ,!

antumn and w.nte, V^*™******, ««* - » ^itk ^^"eralrriating and drinking, and per

The minute features of acute mfla mrnot c J membrane of the bladder are hyperemia, epithelial m , 1

ACUTE INFLAMMATION.

and thickening of the subepithelial connective tissue, as indicated by increased vascularity, the discolored patches being pervaded by line or coarse capillary vessels, and exhibiting, in some cases, points of ecchymosis, loss of transparency, softening, and tumefaction, with alteration of the natural secretion. At the commencement of the disease, the secretion of mucus is somewhat augmented in quantity, but thinner and less viscid than in the natural state. When at its height it is almost entirely suppressed, and the membrane is consequently somewhat dry ; but as this period is always of short duration, the secretion is soon reestablished, and often exists in great abundance, being of a thick, ropy consistence, and of a pale straw, grayish, drab, or greenish color. In the higher grades of the disease, the secretion, instead of being mucous, is puriform or muco-purulent, and tinged with blood, which seems to be poured out, under these circumstances, in the form of an exhalation, though occasionally it is no doubt caused by a laceration of some of the capillary vessels.

In violent attacks, the inflammation is no longer limited to the mucous and other tunics of the bladder, but it extends to and involves the surrounding and associated organs. The parts which are more particularly liable to suffer are the ureters and the prostate gland. Along the former the morbid action is propagated to the kidneys, giving rise either to derangement of their functions, or pyelitis, which is not an uncommon cause of death. The mucous lining of the ureters, from one extremity to the other, is abnormally red and turgid, and their inferior outlet is sometimes almost obliterated, or choked up with lymph, mucus, or pus, or by all these fluids variously combined with each other. The prostate gland may be considerably swollen, especially when the disease affects the neck of the bladder, and thus seriously complicate the primary disorder, by increasing the local distress, and serving as a mechanical obstacle to the evacuation of the urine.

Acute cystitis is generally ushered in by bold and well-marked symptoms. The first which usually attracts attention is a dull, obscure, cleep-seated pain, or rather a sort of gnawing uneasiness, in the region of the bladder, which, rapidly increasing in intensity, soon extends to the neighboring organs. At this early stage, there is little or no constitutional disturbance ; or,

20 INFLAMMATION OF THE BLADDEB.

if there be any disorder of this kind, it is manifested by slight chills alternating with flushes of heat, some thirst, and a little excitement of the pnlse, which is, perhaps, somewhat more hard and frequent than usual. The patient now begms to experience frequent calls to void his urine, which is expel ed in small quantities, or it may be drop by drop, accompanied with violent straining, distressing spasm, and a peculiar burning or scalding at the neck of the bladder and along the course of the Tethra! The hypogastrium is distended, painful, and so exquisite y tender as to render even the weight of the bedclothes ntolerable. The limbs are drawn up, and the body bent fo w cl to relax the abdominal muscles, and relieve the tension TZ ZlL As the disease progresses, the desire to pass It becomes uncontrollable, the pain in the ^ ~ a lancinating, tearing, or throbbing character, and the small aWUv of urine which dribbles off is thick, ropy, and turbid, r d sh or need with blood. The pain shoots along the es^t' g oinsfupper part of the thighs, and spermatic cords T^Llu^^elon^it is often almos * ™^ able It is augmented by the slightest movement ot the body, ^ess^I and percussion, by the passage of the contents ^the

to what occurs in canuumu. , ■i.ll.nt inj-ermis-

to hypogastrie -Sion-/°XnSdiltt^ouch C»e eases e^isitely ^Z^y^^' » — ' dl'ib;

\X L the. is eo^ete retention o, this fluid. nnvmj coior, soon becomes

The urine, at first acid ^_f™™£jZn its admixture alkaline and of a dirty drab, or deep red £ue * ^ ^

with blood. It contains mucus anc epitheliui d disease, flakes of lymph anc pus wh ^ forming to remain at rest, subside to the bottom

ACUTE INFLAMMATION.

a ropy, glutinous mass, equal to one-fifth, one-fourth, or even one-third of the entire excretion.

When the disease is fully developed, there is always more or less constitutional derangement, as indicated hy the quick, hard, small, and frequent, or frequent and wiry pulse ; the hot and dry skin ; the coated tongue ; the impaired appetite ; the urgent thirst ; the constipation of the "bowels ; the anxious and dejected countenance, and a state of constant restlessness and agitation. The limbs are drawn up as in acute enteritis, and there is generally great distress in the anus and rectum, from an extension of the inflammation. Nausea and vomiting, with severe precordial oppression, are rarely absent in this stage of the complaint, and there is occasionally complete suppression of the urine. Towards the close of the disease, the surface is bathed with a cold, clammy perspiration, and exhales a peculiar urinous odor; the mind wanders ; hiccup supervenes ; the strength rapidly declines ; the countenance assumes a Hippocratic expression ; the extremities become cold ; and the patient finally sinks into a state of coma, from which he cannot be aroused.

Some diversity occurs in the symptoms of cystitis, dependent upon the particular seat of .the morbid action. When the neck of the bladder is mainly affected, excessive pain and a sense of weight or fulness are experienced in the anus and perineum ; there is obstinate retention of urine, with an incessant desire to micturate; and severe scalding or burning is felt along the urethra, from one extremity of it to the other. When the anterior wall of the bladder is inflamed, there is great tenderness on pressure and percussion, with a sense of constriction, in the hypogastric region ; the patient lies on his side, and the knees are partially flexed, to prevent tension of the abdominal muscles. There is likewise, under these circumstances, less pain about the neck of the bladder, the desire to micturate is not so frequent, and the water can be retained longer and better. When the inflammation occupies the bas-fond of the bladder, the rectum is more apt to suffer, and the patient is harassed with constant straining and tenesmus.

Acute cystitis usually runs its course with considerable rapidity. It seldom continues beyond the sixth or eighth day without terminating in resolution, tending to suppuration, passing into gangrene, or assuming a chronic type. When the malady is about to decline, there is a gradual abatement of the local and constitutional symptoms ; but a sensation of numbness, weight, or uneasiness usually remains in the affected part after the violence of the disease has subsided.

The prognosis in cystitis depends upon the various circumstances enumerated among the exciting causes, and the possibility of removing them. When the inflammation is limited, the constitution sound, and the fever moderate, the disease generally yields very readily to treatment, and may even disappear of its own accord. When the system is enfeebled by previous suffering, debauch, or intemperance, death is apt to ensue from uremia, gangrene, or pyemia.

The treatment of acute cystitis is directed, first, to subduing constitutional excitement ; and, secondly, to allaying local irritation. For accomplishing the first of these ends, the remedies mainly relied upon, in the earlier stages of the complaint, are general and topical bleeding, cathartics, and diaphoretics aided by an antiphlogistic regimen. Promptly and vigorously employed, there are few cases of acute cystitis which resist these means beyond the second or third day, and such as do are always more easily managed afterwards by mild treatment. I have repeatedly cut short, by the lancet alone, attacks of this disease so severe as to leave the patient no rest, and so threatening as to induce the worst apprehensions for his ultimate recovery.

There is a variety of cystitis, properly denominated acute, as it respects the local distress, in which there is an entire absence of constitutional disturbance, and yet the suffering is exceedingly severe. In these cases there is no remedy, according to my experience, which is followed by such prompt and permanent relief as copious bleeding at the arm. The operation rarely renuir s to be repeated, and is generally sufficient, with the aul o General laxative and a close of Dover's powder, to efiect a cure tfZtj-^ or forty-eight hours; sometimes, indeed, much

"The' bowels demand early attention, especially if they are over loaded with fecal matter, the pressure of *A^P^ injurious to the inflamed and suffering organ. Whew tHen

lid derangement of the biliary ^£££25 tive is castor oil, or sulphate of magnesia, aided by an t m ma 01 cool -tet thin gruel, or soapsuds. If an opposite condition

ACUTE INFLAMMATION.

exist a dose of calomel should be given, either alone, or, in urgent cases, in union with rhubarb and jalap. Under no circumstances is it proper to administer medicines calculated to irritate the lower bowel, and, through it, the urinary bladder. _ Vs soon as proper depletion has been practised, and the alimentary canal well cleared out, diaphoretics are indicated, the one which I have found most useful being the tratrate of antimony and potassa, in the form of the antimonial and saline mixture, of which the dose is a tablespoonful every two, three, or four hours.1 This seldom fails to produce copious diaphoresis, to allay vascular excitement, to calm the affected organ, and to keep the bowels in a soluble condition. Where the skin is already soft, or where a diaphoretic and opiate are required, nothing is so beneficial as Dover's powder, in doses of five grains, with the sixth of a grain of morphia, three or four times in the twenty-four hours. If the stomach is irritable, the effervescing draught is preferable to anything else.

The action of the above medicines may be favored by tepid drinks, the warm bath, and hot fomentations. The best drinks are such as are somewhat demulcent, as gum Arabic water, slippery elm water, rice water, or flaxseed tea, rendered palatable by the addition of a little lemon juice, citrate of potassa, or the neutral mixture. In the use of these and similar articles, care must be taken not to allow the patient to indulge so freely as to run the risk of producing too great a flow of urine ; the object should be merely to allay the acrimony of this fluid, and to render it more acceptable, so to speak, to the suffering organ.

Diuretics, strictly so called, are improper in this affection, and should, therefore, be avoided. When the urine is acrid, high-colored, or very scanty, a small quantity of nitrate of potassa, or spirit of nitrous ether, mixed with some demulcent fluid, may, under such circumstances, be given to modify the renal secretion, and allay vesical irritation. In the gouty and rheumatic forms of the malady, colchicum, combined with morphia, is sometimes beneficial. In the later stages of the disease, an infu-

1 The combination, which I am in the habit of* using in this and otber forms of inflammation, consists of two grains and a half of tartrate of antimony, two ounces of sulphate of magnesia, two grains of sulphate of morphia, a drachm and a half of tincture of veratrum viride, half a drachm of aromatic sulphuric acid, two ounces of syrup of ginger, and ten ounces of water.

H H

INFLAMMATION OF THE BLADDEB.

sion of uva ursi and hops, in the proportion of one ounce and a half of the former, and half an ounce of the latter to the quart of water, often acts like a charm in the lighter grades of cystitis, in allaying pain and spasm at the neck of the bladder. An ordinary sized wineglassful of this should be given five or six times a day, either alone, or in combination with morphia and citrate of potassa or bromide of potassium, or the latter articles and balsam of copaiba.

Among the more important local remedies for arresting cystitis, and tranquillizing the affected organ, are, leeching and cupping, anodyne enemata, fomentations, and the hip-bath.

For an adult, in ordinary cases, fifteen or twenty foreign leeches applied to the perineum and verge of the anus; to the upper and inner part of the thigh, or when the summit of the bladder is affected, to the hypogastrium, will rarely disappoint expectation. The pain and distress in the back, which often constitute a source of so much suffering, are usually promptly relieved by the application of cups, either dry or wet, to the sacrolumbalregion.

Of all the local remedies none hold a higher rank m the treatment of this affection than anodynes, administered by the rectum, either in the form of injections, or in that of suppositories. They not only allay pain and spasm, but they quiet the bladder, and render it more able to bear the presence of the urine, a desire to pass which is a principal cause of the patient's suffering. The best form of injection, for an adult, is from half a drachm to a drachm and a half of laudanum to two ounces of tepid water, thrown up with a vulcanized syringe, with a long nozzle which is far preferable to all the patent contrivances of the kind of which I have any knowledge. The bowel should be previously cleared out with a purgative, or an enema, and care should be taken not to force the fluid against the anterior wall of the rectum. The best suppository is powdered opium, from two to four grains, thoroughly mixed with cocoa butter, and introduced upon the end of the forefinger, well oiled.

As auxiliary remedies, in the treatment of this disease, mention may be here made of fomentations with flannel wrung out of hot water, either simple, or medicated with laudanum, laudanum and camphor, poppies, or hops. To and confine the heat, the surface of the flannel should be e.n eied

ACUTE INFLAMMATION.

with a piece of oiled silk. Instead of fomentations, dry heat, applied to the hypogastrium and perineum by means of an India-rubber bag of special construction, filled with hot water, is exeeedingly grateful to the affected part, as well as to the general system.

" The warm hip-bath, or immersion of the entire body in warm water, is sometimes eminently serviceable in relieving the local suffering, and exciting the cutaneous emunctories. Generally speaking, the latter is to be preferred to the former, on account of the greater convenience and less fatigue which attend its administration, as well as the more thorough relaxation of the system. The temperature of the water should range from 85° to 92°, and the immersion should be continued from twenty minutes to an hour, according to the effects of the remedy, which should always be carefully noted.

The excitina; causes of this disease lead to certain modifications of the treatment, which should be well understood by the practitioner. The principal circumstances which require to be considered in this relation are urinary concretions and other foreign bodies, the nse of cantharides, the extension of gonorrhceal inflammation, the repulsion of gout, rheumatism, and cutaneous eruptions, stricture of the urethra, and enlargement of the prostate gland.

The treatment of cystitis, dependent upon the presence of a calculus, is to be conducted upon general principles ; no eftbrt should be made to extract the foreign body, much less to crush it, until the inflammation is suhdued. The case is different when the cystitis has been induced by the presence of a foreign substance which has penetrated the bladder from without, as a splinter, or piece of bone. Here the first object should be to remove the extraneous body as early as possible, on the well-known principle that the disease induced by it cannot be cured so long as it remains in contact with the affected viscus.

Cystitis, caused by the absorption, or internal use of cantharides, requires a treatment somewhat peculiar. This variety of inflammation, technically called strangury, is induced by the specific action of cantharidin upon the neck of the bladder, terminating in a constant desire to pass water, accompanied with excessive pain and spasm at the neck of the organ, horrible scalding along the urethra, and sometimes the discharge of frag-

26 INFLAMMATION OF THE BLADDEE.

merits of fibrinous exudation, along with priapism. The symptoms are generally urgent, coming on within the first twenty-four hours, and, therefore, require prompt and vigorous interference. A large emollient poultice is applied to the vesicated surface, hot cloths are laid upon the abdomen, the perineum, and the genitals, and a drachm of laudanum, mixed with two ounces of tepid water, is injected into the lower bowel. Demulcent drinks, with spirit of nitrous ether, or liquor potassae, are freely taken ; and, in severe cases, a full anodyne is exhibited by the mouth. A popular remedy, of great value in this affection, especially in its milder forms, is a decoction of parsley root and watermelon seeds. It should be used as freely as the stomach will bear, either alone, or in combination with spirit of nitre and paregoric. There are few cases of strangury which resist these means, or which require more active treatment, as bleedmo- purging, diaphoretics, and the warm bath.

Cystitis, occasioned bv an extension of gonorrhoea, usually after the third week of its existence, is characterized by severe tenesmus, a frequent desire to micturate, and great pain m passino- the last drops of urine, which is sometimes tinged with blood. The inflammation, which may occur at any period ot the specific disease, is, in great measure, confined to the neck ot the bladder, and rarely assumes a violent character. The treatment is antiphlogistic, aided by the internal exhibition of copaiba, and the use of anodyne enemata.

When cystitis depends upon a gouty or rheumatic state of the constitution, or upon a retrocession of these diseases col chicum 8 indicated and ought to be conjoined with other antip U*»bo means. One full dose, given at bedtime, is preferable to small oTs frequently repeated. Another valuable remedy m th s va ret of cystitis Is calomel, administered with a view to its I^utionil effects. In obstinate cases of tMs ^ ^ fact, almost indispensable. ' It may be given, three o totea day, in doses of two grains, combined with hall a .grain ot opium to prevent it from acting too freely upon the bowels Id aid in procuring sleep. As soon as the gums become on toj the mercury is discontinued, or administered m smallei quantitj

° Wh^S has been induced by the sudden repulsion of some cutaneous disease, as herpes, urticaria, or erysipelas, the