ACUTE CYSTITIS OF OBSTRUCTION. The acute cystitis of obstruction is a Serious form of the disorder which is also seen in connection with stricture of the urethra: and prostatic enlargement. These cases generally present themselves to our notice in the following way : We are called to see a patient who has been suffering from stricture for some years; the difficulty has gone on increasing, the urine has become ammoniacal, and his rest is hourly disturbed to pass water, which he does in small drops after much straining. Broken down with all these symptoms he becomes feverish, his tongue is brown, and he exhales a sickly sort of ammo niacal odor. In addition, his temperature is high, pulse rapid and feeble, and he may have had a rigor followed by perspiration. Prob ably with difficulty, a small catheter is passed, and some highly fetid urine escapes. Both the general and local state indicate a condition of acute cystitis with inflamed or surgical kidney. I have seen a good many cases of this kind, and about their treatment no doubt whatever can be entertained. The position is this : The patient can not wait to derive the benefit of dilatation. No operation for the stricture, such as internal urethrotomy or a divulsion, is to be recom mended, as the sufferer would be almost sure in his condition to die acutely pynmic. The only way of dealing with him under these cir cumstances is to regard his bladder in the light of an acute fetid ab scess requiring an opening at its most dependent point. It would be just about as rational to propose to treat a fetid ischio-rectal ab scess that was poisoning a man acutely, by putting a trocar into it, as to think of relieving a septic suppurating bladder from obstruction with a catheter only. A grooved staff, or, failing this, anything to indicate to the finger the line of the'urethra, should be passed, and a perinea' opening made into the membranous urethra of a size to admit a large drainage-tube. The urine should not all be removed, if the catheter is first introduced, as it is as well to leave sufficient behind to fully realize the effect of the incision that is made. The bladder should then be washed out and allowed to drain through the opening.
In cases of the kind to which I am now referring, where this course is promptly taken, I have seen patients pass as it were in a few hours from approaching death to rapid convalescence. By this treatment I have here and there lost a dying patient, but, on the other hand, I know that I have saved many more who would otherwise have died. The opening gives immediate relief, and if it is made to correspond in size with the drainage-tube to follow, there is really no bleeding or further trouble.
In the treatment of less urgent forms of cystitis, reference is often made to the reaction of the urine as indicating the necessity for ad ministering either acids or alkalies. Our object should be to obtain that condition of the excretion which most nearly corresponds with its normal state, as we sometimes find that alkalies are poured in with a vigorous hand and regardless of the fact that healthy urine has an acid reaction. Still we must not forget that a highly acid condition of the urine is often intensely irritating to the inflamed mucous mem brane with which it comes in contact. Sir George Johnson has shown the value of milk in some chronic cases of cystitis, and of skimmed milk in others. The pharmacopoeia contains a number of drugs which seem to exercise a soothing or anodyne action upon the mucous mem brane of the bladder and urinary organs generally; of these I would mention pareira brava, uva ursi, and buchu. Amongst the best de mulcents are well-made barley-water, the ulmus fulva or slippery elm, and the triticum repels. Belladonna and hyoscyamus are often ex tremely useful in allaying the irritability of the bladder associated with cystitis. There is a combination of the infusions of uva ursi and hops, with a little carbonate of soda added, the use of which will be often of value in these cases. Of other drugs I have found ser viceable in varying degrees and kinds of chronic cystitis, I may here mention hyposulphite of soda in half-drachm doses; its virtue in purulent urine is sometimes remarkable. Salol, the syrup of tar, saw palmetto, salicylate of soda, pichi, and the fluid extract of the Collin sonia canadensis have also proved themselves of service.