Care should be taken to avoid forcing air into the bladder when the urine contains blood or pus, as it sometimes leads to putrefac tion and the evolution of gas, which may cause spasm. As the blad der is expelling the last portion of the injection, if the surgeon is holding the catheter, he sometimes feels a slight click or concussion, which the patient with a sensitive bladder is conscious of and would rather avoid. I believe it is caused by the mucous membrane being drawn into the eye of the catheter as the bladder is emptied of the last few drops. It is prevented by watching the flow, and withdraw ing the catheter until the end is well within the prostate as the last portion of fluid escapes. Catheters for this purpose should have the opening of moderate size, with the edge bevelled, so as not to scratch the urethra; to avoid more of the catheter being introduced into the bladder than necessary, the opening should be close to the end of the instrument. When using rubber bottles for washing out the bladder care should be taken that they are thoroughly aseptic and not struc turally disqualified by age.
We have, I think, been disposed to make this excellent practice of irrigation a fashion in bladder cases, where, though there may be a call for the catheter, the ablution following may prove unnecessary. In some cases of partial retention where the catheter is required, it must not be forgotten that so long as the vesical mucus is normal in quantity and quality, it serves a purpose in protecting a surface, which, by reason of the inequalities of the bladder arising out of the enlargement of the prostate, has no means of completely contracting or covering itself, until time has elapsed for the excretion of the re quisite amount of residual urine. I am reminded of this when I hear patients complaining of irritability of the bladder, which takes a little time to subside, directly after they have been washed out.
Washing out is required for various purposes, most commonly for the removal of mucus or muco-pus, which often collects in the depen dent parts of the bladder, especially where the prostate is large. If left to accumulate, this viscid secretion excites spasm and causes am moniacal decomposition of the urine, thus adding considerably to other sources of irritation. I know no better solvent for this than common salt, in the proportion of a teaspoonful or so to a pint of tepid water, for use with an irrigator. In connection with this remark Dr. Gouley " has pointed out that bladders which have long contained purulent, slimy urine do not bear the contact of limpid fluids of low specific gravity well at first, and it is therefore necessary in some instances to increase artificially the density of the water.
Such a lotion is less irritating to the mucous membrane than plain water, as we recognize in the treatment of ozinna. In other instances, a solution of boracic acid answers better. Very hard waters should not be used for such purposes. It is just as easy " to chap" the bladder in this as the hands. Distilled or rain water may be substituted.
The next class of cases includes those where the contents of the bladder are rendered offensive by decomposition. We know how disagreeable the urine can become both to the patient and to the practitioner. Carbolic acid will be found an appropriate antiseptic, but it must not be used stronger than one in eighty, otherwise, if it becomes absorbed, it may occasion that peculiar condition known as .carboluria. Solutions of sanitas, boro-glyceride, and sulpho-carbol ate of soda may also be employed for the same purpose.' Resorcin, creolin, and nitrite of amyl are also recommended as useful disinfec tants. When the urine remains purulent after cystitis nothing often succeeds better than a quinine wash, as first recommended by Mr.
Nunn," who speaks of its action as a bactericide. The neutral sul phate should be used in the proportion of one grain to an ounce of distilled water to commence with, and if the solution is not quite clear, a drop of dilute muriatic acid may be added. Some of the in jection may be left in the bladder. The internal administration of quinine, in doses of five grains, not only acts as a sedative to the bladder after cystitis, but is useful in sterilizing the urine. Its effi cacy for this purpose has been urged by Dr. Simmons," who, in ex plaining the nature of this action, refers to an observation by Dr. Kerner, that seventy per cent. of the drug is eliminated by the kid neys in from three to twenty-four hours after it has been taken. Quinine is employed in this way after operations on the urethra, with the best results. It sometimes happens that after attacks of cystitis the urine remains alkaline, and there is a tendency to throw down phosphates, which often concrete in the form of a mortar-like sub stance. From five to ten grains of citric acid in a pint of warm water, used as an injection, will often correct this disposition, which is prob ably primarily due to excess of vesical mucus. The mineral acids are not well borne locally.