M. Guyon's second patient was in an earlier stage of treatment when his lecture was delivered, but the vesical pain, fever, and dry tongue had disappeared. In a neighboring ward lay a man who had entered with retention and infiltration of urine from giving way of the urethra; at the same time a largo pyonephrosis of the right kid ney was detected. The infiltration and retention were treated in the usual manner. Within two months all the physical signs of pyone phrosis had completely disappeared. " To run to the assistance of the kidneys by methodical treatment of the lower part of the urinary tract should be a fundamental law of surgery." But drainage does not always succeed. Thus, in oue case of severe unilateral pyelitis the result of backward pressure from an enlarged median prostatic lobe, I first removed the lobe suprapu bically and the bladder was then drained for more than two months, but the formation of pus did not subside. After a year, although the stream was full and free and the residual urine only amounted to an ounce, the amount of pyelitic pus was still one-third. I there fore incised the kidney and evacuated an abscess from the deep part of the cortex and drained the pelvis. The urine at once be came crystal clear and remained so for some days, until the renal drain was left out, after which it relapsed, but never reached again the same severe grade. Prolonged renal drainage in these cases does not mean for a few weeks, it is a question of mouths, and the struggle lies in preVenting the wound in the integuments from clos ing. One mistake will occasionally be made, namely, that of pre serving hopelessly damaged kidneys. The drain-wound heals and the abscess recurs. This may be indefinitely repeated until the patient suddenly develops acute septic infection.
Vesical Pyuria.—The treatment of suppuration from the bladder consists in first removing the cause of any permanent irritant, such as stone, stricture, or enlargement of the prostate, which may be dis covered, and for the management of which the reader is referred to the article on such diseases. Should any such irritant be absent, the various methods of treating cystitis must be employed.
The treatment of the acute form must be carried out regardless of the cause, for in all operative work about the bladder, inflammation must be first subdued before any instrumental interference is com menced. In the acute stage there are three powerful agents in reduc ing the severity of the attack, viz., I. Rest in bed with elevated hips; 2. Free imbibition of diluents; 3. Anodynes administered by the bowel. The elevation of the hips withdraws from the bladder the pressure of the intestines. The diluents render the urine copious and as non-irritating as possible. Those which are the most reliable are "teas," made of linseed, buchu, or triticum repens. Those who can obtain it fresh and good can rely upon the liquid extract of Col linsonia Canadensis, or the extractum stigmatum They are often invaluable. Taken separately or in combination with these should be a sufficient amount of alkali to render the urine less irritating. Citrate of potash or liquor potassm are the most useful.
Anodynes act best by the bowel. A suppository of watery ex tract of opium, gr. ss., or of morphine, gr. I-1-, combined with extract of belladonna, gr. ss–i., is the most serviceable. In addition to these remedies a hot hip-bath from 100° to 105° should be given for a quarter of an hour two or three times daily, and hot applications made to the perineum and pubes either by Leiter's coils, hot flannels, spongio-piline, or poultices frequently changed. Hot rectal enemata twice or thrice a clay are most soothing, besides being of value in keeping the lower bowel clear. Laxatives and a fluid diet complete this plan of treatment. In subacute cystitis the balsams are of use—sandalwood, copaiba, turpentine. In chronic cases, if the source of the trouble has been removed, vesical irrigation must be employed, but with this reservation, that if signs of tubercular deposit in any part of the body are discovered the use of the catheter must be sedulously avoided. The injections which will be found the most serviceable are boro-glyceride solution; iodoform emulsion (five grains suspended in an ounce of mucilage and water), left in the bladder after it has been thoroughly cleansed by weak solution of permanganate of potash ; salicylic acid (one-half per cent. cautiously increased), and finally a solution of mercury perchloride of the strength of 1 in 10,000.
The cure of cystic pyuria in the female depends greatly on the cure of the metritis, perimetritis, ovaritis, or uterine displacement which frequently accompanies and often has been the cause of the com plaint. Much stress, and deservedly, has been placed upon resting the female bladder in the aggravated forms of cystitis when drugs and injections have failed. This is accomplished by dilating the urethra or by making a buttonhole fistula in the base through the vaginal roof. Dr. More Madden has found that marked relief is obtained by forcible dilatation of the urethra and the induction by this means of temporary incontinence of urine, accompanied by the free application of glycerin of carbolic acid to the mucous membrane. Two or three applications at intervals of ten days may be required.
Urethral Pyuria. —The treatment mainly consists in quieting the cystitis of the neck of the bladder which coexists to a greater or les ser extent in every case; in removing any permanent cause of ob struction, such as stricture, or any direct irritation such as a prostatic calculus. Subsequent injections in the deep urethra may be made by means of either Guyon's or Ultzmann's syringe. With the for mer, five or ten drops of a solution of nitrate of silver in strength varying from five to twenty grains to the ounce are thrown directly into the membrano-prostatic urethra. Ullmann recommends most strongly the irrigation of the neck of the bladder as well, and this is carried out by throwing into the deep urethra eight ounces of the nitrate of silver solution of a strength of one grain to eight ounces. This enters the bladder slowly, and after being held for a few minutes is expelled by the patient voluntarily.