the soft-rubber catheter is the only one that I have used for years. The old female silver catheter is the most dangerous instrument I have ever seen. It should be discarded forever. In cases where the bladder has been perfectly healthy, and the catheter passed a number of times by way of experiment, the points of membrane with which the instrument had come in contact were abraded and congested, thus showing the danger attending the unskillful use of this instrument. If the frequent introduction of the instrument into a healthy bladder produces these results, how easily must the bladder of a pregnant woman be inflamed under such treatment, for the organ has been for a time more or less congested, and during labor perhaps severely bruised!

The question has been raised as to whether the irritation and inflammation following catheterization in some cases is not due to the introduction (during manipulation) of air, either pure or containing germs that will cause decomposition of the urine. The experiments of P. Dubelt, in which the air was injected into the bladder, show that it is perfectly harmless. Moreover, the same experimenter found that the injection of decomposing urine into the bladder did little or no harm, unless the mucous surface was abraded. Whatever may be the effect of such things on a healthy bladder, I do not doubt but that the introduction of germs by means of air or a dirty catheter, decomposing urine, or the rough or too frequent use of a catheter, would produce an acute exacerbation in an organ already diseased.

The influence of decomposed or decomposing urine in producing inflammation of the bladder will be more fully spoken of again.

Forcible and excessive copulation is a decided exciting, as well as predisposing, cause of acute or subacute cystitis, and, if persisted in, a chronic inflammation of the bladder is usually the result.

Foreign bodies in the bladder, such as pieces of wood, pins, needles, hair-pins, bodkins, and the like, that are sometimes slipped in by hysterical girls and those who masturbate, excite acute inflammation if not speedily removed.

2. Abnormal Urine.-No known abnormality of the urine will, I think, excite acute inflammation in a perfectly healthy bladder. In a bladder, however, that is suffering from chronic congestion; in one whose walls bear deposits of tubercle; in cases where some slight degree of inflammation already exists, then abnormal urine may and does give rise to marked inflammatory trouble. As a rule, however, inflammatory vesical disease precedes urine decomposition. In cystitis following overdistention, the retained urine, being mixed

with mucus thrown out by the irritated and tense mucous membrane to shield itself, rapidly decomposes, and still further aggravates the abnormal condition of the membrane.

Women sometimes from abnormal modesty, more often from the lack of opportunity, retain their urine until the bladder is distressingly overdistended, and the urine partially decomposed. Of course this is wrong, and can generally be avoided, but is neverthe less a frequent cause of disease of this organ.

Where there is considerable suppuration of the upper urinary passages (renal abscess, pyelitis, or pyonephrosis), the acid urine loaded with pus has, or seems to have, an irritating effect on the vesical mucous membrane, and in some instances probably lights up a cystitis, and certainly aggravates one when already existing.

Deposits of the amorphous phosphate of lime, or of the ammoniomagnesian phosphate, often greatly aggravate and render serious a previously mild cystitis, but seldom if ever produce acute inflamma-. tion in a healthy bladder. This may be said also of uric-acid gravel and other crystalline urinary sediments, they being at most only able to produce some hyperemia of the membrane with a little excess of the mucous secretion.

Urine which is already decomposed, or decomposing, as I have already said, can produce acute cystitis only in an already diseased bladder, or in one where abrasions of the epithelial surface exist.

To show how some of these causes may combine to produce cystitis, let me take, for example, the bladder of a pregnant woman, which has for some time shared congestion with the other pelvic organs. Retention and some distention of the bladder occur from some cause; a clumsy physician attempts to pass a metallic catheter, and does it roughly and rapidly, and relieves the viscus of its contents. A slight catarrh of the mucous membrane, the surface of which is somewhat abraded, ensues. By the catalytic action of the mucus present in it, the urine is rapidly decomposed. The decomposition is often aided by germs introduced with the catheter. Carbonate of ammonia, being set free from the broken-down urea, assists in alkalizing the fluid, precipitating the amorphous phosphates thereby, and forming, with the phosphate of magnesia already present, the ammonio-magnesian, or triple phosphate. The urine is further alkalized by the alkali of the mucus. The bladder-walls not having fully regained their tone, a little decomposed urine remains after each micturition, and aids in decomposing that which is next secreted, and would otherwise be normal. The mucus increases in amount, the ammonia is more rapidly set free, and the mucous

membrane more and more irritated, until a true acute cystitis is set up. Such cases are of almost daily occurrence.

The decomposed urine alone, however, produced without the overdistention or without the abrasion would not have occasioned a true acute cystitis, but might possibly by slow gradations have worked up a subacute cystitis. The rule, if it may be called such, is the one that I have already given-viz., that some abnormality of the urinary organs (as catarrh) almost invariably precedes urinary decomposition.

3. Inflammation of Adjacent Organs.-Acute cystitis may arise from the extension of inflammation from neighboring organs, as in vaginitis, metritis, uterine and vaginal cancer, extra-uterine pregnancy, abscesses of the colon or other organs opening into the bladder, pelvic peritonitis, cellulitis, etc. Gonorrhoeal inflammation of the urethra may extend to the bladder. As gonorrhoea of the female urethra is comparatively rare, such an extension is seldom seen. When it does invade the urethra, it is very apt also to extend to the bladder, and is very severe. Inflammation of the renal pelves and ureters may extend to this organ, and cause cystitis, the usual course, however, being from the bladder to the ureters and the kidneys.

4. Certain diseases of the general system affect the bladder, such as the eruptive fevers. In scarlet fever, and measles especially, I have noticed that the mucous membrane of the bladder suffers, to some extent, like the mucous and tegumentary tissues elsewhere. Diseases of the heart and liver act more as predisposing causes, by producing chronic vesical congestion, than as exciting causes, and when they do produce cystitis it is usually of a low chronic type. Old age, when the bas fond is greatly deepened, acts more as a predisposing cause, by allowing the collection and decomposition of urine. Paraplegia and other affections of like nature, by allowing overdistention and decomposition, as a rule, produce cystitis, but of a low form.

5. Drugs, Improper Foods, and the Virus of Gonorrhea.-Of all drugs, cantharides is undoubtedly the most active in producing true acute cystitis. In many cases it produces simple irritation and hy peræmia, stopping short of actual inflammation. Arsenic and turpentine also produce irritation and active hyperæmia, but seldom if ever go further.

Alcoholic beverages persisted in for a length of time act more as predisposing than as exciting causes. They may, however, produce a low grade of cystitis, or, like the medicines given above, light up an acute process in an already diseased vesical membrane. Dr. A.

Jacobi has seen aggravated cases of cystitis caused by the free and long-continued use of large doses of the chlorate of potassa.

The various foods can not produce acute cystitis in a healthy bladder, but may aggravate an already diseased condition. The prohibition, therefore, of stimulating condiments, alcohol, asparagus, and onions, in these diseases will at once suggest itself. I have already spoken of gonorrhoea as a cause of cystitis, and need not dwell on it here.

M. Eugene Monod ("Annales de Gynécol.," May, 1880), in discussing the question of cystitis, presents the following conclusions: 1. The urinary symptoms incident to pregnancy proceed from two different causes, to each of which there corresponds a distinct clinical group of symptoms. The first group receives its explanation from the pressure produced by the gravid uterus, which leads to retention of urine. The second is caused by vesical congestion which results from the predisposition of the bladder to inflammation, owing to its close vascular connection with the uterus.

2. During the first weeks of utero-gestation, there may occur a variety of acute cystitis which is unquestionably caused by the development of pregnancy.

3. Immediately after, or during the first weeks following normal delivery, there may arise a variety of cystitis which, owing to the time of its appearance, deserves to be called post-puerperal cystitis.

4. The anatomical relations between uterus and bladder, as well as their vascular interconnections, account for the frequency of vesical disorders accompanying many uterine maladies. Certain physiological changes of the bladder during menstruation, and at the time of the menopause, also influence the establishment of bladder troubles. Thus there is seen to exist a whole class of vesical inflammations belonging only to women, and, contrary to the generally accepted opinion, cystitis is by no means rare in women.

CHAPTER XLI.

ORGANIC DISEASES OF THE BLADDER (CONTINUED).

TREATMENT OF CYSTITIS — CROUPOUS AND DIPHTHERITIC CYSTITIS-CYSTITIS WITH EPIDERMOID CONCRETIONS.

CYSTITIS requires both local and constitutional treatment, and withal it is a troublesome disease to manage, especially in its chronic form. The constitutional treatment consists, first of all, in so regulating the character of the urine that it shall be unirritating to the diseased organ. Pain and vesical tenesmus should be relieved if possible. The skin should be kept in a healthy and active condition and the bowels regular and free, in order to prevent all straining at stool and secure free action of the portal circulation. Free elimination by the skin and bowels will give the kidneys and bladder less to do. To overcome existing constipation, saline laxatives should be used. A glass of purgative mineral water, given an hour before breakfast, answers very well in most cases. Cold-water enemata are advised by good authorities.

Winckel recommends the use of saline laxatives, pushed to a point where intestinal hyperæmia is produced and maintained for a time. He believes that the blood may, in this manner, be to a certain extent diverted from the bladder; and I am of the belief that the practice is a sound one. A case of my own is of interest as showing the benefit effected (supposably) in this way. A lady had catarrh of the bladder of some months' standing, which I had been treating in the usual way, with only slight benefit. She was one day attacked with cholera morbus with serous purging and vomiting, the former almost as severe as that of Asiatic cholera. The effect, for a time was to almost suspend the action of the kidneys. When she recovered, she was delighted to find that her cystitis had left her.

Among the conditions which produce irritating urine, and hence tend to produce cystitis or to aggravate it if it already exists, are malnutrition from any cause and the strumous, gouty, and rheumatic diatheses. When either of these is present it should be