his water for two or three hours or longer, while the proportion of pus formed is considerably lessened. I have seen patients put upon this plan steadily improve for six months, and I have given the iron regularly for a twelvemonth, in some cases with real benefit. In fact, it will often happen that a patient will resume the remedy himself, after having given it up, than which there can be no stronger evidence of its usefulness. It is true that many patients get tired of taking one remedy for so long a time, unless the improvement is decided and obvious. often happens that, by yielding too much to a patient's caprice in trying this thing and that, valuable time is lost. The patient might have been relieved, by steady perseverance in one judicious system, in considerably less time than he has spent in trying first one reputed remedy and then another, without success.

It is clearly right, in such a disease as this, to tell a patient at once that he cannot recover in a week; and it is not right to allow him to suppose that, by any special remedy, the disease can be cured, as by an antidote. If patients who are utterly ignorant of the nature of the malady from which they are suffering will obstinately persist in acting according to their own prejudices, and insist upon being misled, to their own detriment, it is out of our power to help them. All that can be said is, that if they had a little knowledge of physiology and medicine, they would have more confidence in us than in an ignoramus who, ignorant of the anatomy and healthy action of the organs he is treating, to say nothing of the complex changes these undergo in disease, and with little or no experience in the management of bad cases, confidently promises off-hand a certain and rapid cure.

In all bad cases, more especially if the pus is converted into the ropy, mucus-like mass in the bladder, it is of the first importance to use injections of warm water. This is a very simple operation, and affords, even in extreme cases which cannot be cured, the greatest relief. Sir H. Thompson recommends that not more than an ounce should be introduced at a time. This is allowed to escape, and then another ounce injected, and so on, till the water escapes clear. Some use injections of dilute nitric

acid (one drop of the strong acid to two or three ounces of water). The chief benefit, I believe, arises from removing the decomposing matter which irritates the mucous membrane and excites decomposition in the fresh urine as fast as it reaches the bladder, so that plain water (warm distilled or rain water) answers in almost all cases perfectly well. It may be injected through a double catheter, or through an ordinary flexible catheter, and drawn off by the same instrument. The bladder should, of course, never be fully injected, as distention of its coats always does harm. In bad cases, it is desirable to wash out the bladder in this way once every day, or oftener.

In all cases in which the formation of a considerable quantity of pus goes on in any part of the organism from day to day, it is of the first importance to pay attention to the state of the patient's general health, and experience has proved that the remedies which do most good are those included under the head of tonics. In many cases, too, stimulants may be required for a time. The quantity of pus varies, increasing if the blood becomes poor, while the formation of pus diminishes as the patient's health improves. A greater quantity of material becomes pus when the system is weak and low than when the nutrition of the body is properly carried on. This fact has been explained in different ways. It seems probable that, when the blood is poor, transudation of nutrient matter occurs more freely than in the opposite condition of health; and it is, I think, mainly by diminishing the tendency of the fluids to transude, that iron, many tonics, and alcohol act favorably. Pus, like other forms of bioplasm or living matter, grows the faster the more freely nutrient matter is supplied to it, and it may take up the pabulum which is really required for the nutrition of the healthy tissues. Pus lives faster than any healthy tissue.

I have often been gratified at the great change for the better which has resulted from a prolonged course of iodide of iron in cases where the mucous membrane of the bladder was seriously disturbed in its action, perhaps from chronic ulceration and destruction of the outer layer of epithelium over a considerable area of its surface, perhaps from a state of congestion only, with

changes in the epithelium approaching but not amounting to actual ulceration. Many of the most obstinate cases improve after some months, during which tonic treatment and careful management, as regards diet, have been steadily persisted in. Rest alone has no doubt much to do with the favorable result, but it stands to reason that in a prolonged state of exhausting disease depending upon an abundant discharge from a mucous surface accompanied with emaciation and much lowering of the general health, the patient's chances of recovery will be much more increased if the nutritive processes are assisted by good management of the digestive organs and the careful selection of foods and tonic remedies than if the case be left to the curative effects of time alone, when, for want of good management, the strength may fail and the powers become exhausted to a degree which renders recuperation improbable. Seeing the terrible forms of chronic disease from which patients do recover, one cannot resist the conclusion that the favorable or unfavorable result in some cases may depend upon whether the patient is placed under favorable or unfavorable conditions for a certain period of time, and it is, therefore, above all things, necessary, before we attempt to give advice to be acted upon perhaps during many months, that we should endeavor, as it were, to grasp and to consider the whole state of affairs and circumstances bearing indirectly or directly upon the patient's condition, as well as the tendency and probable course of the morbid actions, and not attempt to grapple only with the pus in his water or the disease upon which this depends.

Irritable Bladder and Frequent Micturition.—Catarrh of the bladder and all forms of inflammation of the mucous membrane, as well as various other morbid affections, are associated with frequent desire to evacuate the organ. The mucous membrane is, as we say, irritable, and a very moderate accumulation of fluid in the organ will produce the same effect upon the nerves as the distention effected by many times the quantity of urine in the healthy state of the bladder. But this irritability or undue excitability is met with in many conditions where no pus is produced and when no inflammation exists, and it may be well to

refer in this place to a few of the most common circumstances which seem to be connected with this most troublesome symptom. Irritability is often caused by severe congestion of the vessels of the mucous membrane, and passes off without any actual inflammation or the formation of pus. Any swelling or inflammation of parts or organs near the bladder may cause irritability and excitation of nerves at a distance, irritation of the lumbar region of the cord, or of afferent nerves which pass through the centres of origin of the nerves distributed to the muscular coat of the bladder. Enlarged prostate often causes irritable bladder. In a man of fifty-seven, besides enlarged prostate, there was frequent pains at the tip of the penis, of the character of that which often accompanies renal calculus, but evidently caused by the state of the prostate. This patient lost flesh rather rapidly for a time, but he subsequently improved. In another case the patient had experienced pain at the tip of the penis immediately after passing water, for a period of fifteen years. The urine contained much mucus and was highly ammoniacal. The patient had to pass water nine or ten times at night. He was much relieved by a long course of tincture of perchloride of iron. In neither of these cases was there or had there been any evidence of stone or grit in the kidneys or bladder.

Irritability of bladder of a very troublesome kind is often due to mere concentration of the urine, irrespective of any undue acidity. Indeed, when the specific gravity is 1.030 or upward, some degree of irritation is often experienced, and it will be found that the bladder is excited to contract as soon as a few ounces of this highly concentrated urine have accumulated. The condition in question is often met with in hot weather, and in tropical climates, especially when people live too well, it is frequently a source of the greatest annoyance and discomfort. It occurs at all ages, and in children it is not an uncommon cause of the practice of "wetting the bed." Nurses and injudicious mothers not unfrequently increase the severity of the trouble they think to cure by reducing the allowance of liquid to the poor child, and thus add thirst to the scolding and other hardships needlessly inflicted upon the unhappy victim of bad management.

The general plan of relieving irritability of the bladder caused by highly concentrated urine is at once suggested by a consideration of the facts. Dilution of the secretion is required, but in addition we must take care the patient is not supplied with too much nitrogenous food. Milk pudding and a moderate allowance of well cooked fruit, lemonade, oranges, grapes, often help the cure of chronic cases; but in some instances, when the state of the secretion in question has been kept up for a considerable time by injudicious management, it may be necessary, in addition, to give an occasional dose of gray powder or blue pill with citrate of potash, bicarbonate of potash, or soda or lime water, for a week or two. Whenever alkalies

are recommended care should be taken that the patient or his friends are instructed as to the importance of not continuing alkaline remedies without interruption for too long a time, for fear of producing another form of “irritable bladder," which is more severe and more difficult to cure than the one for which the remedies have been prescribed. In cases of irritable bladder from concentrated urine, and in cases in which the irritability is increased by this circumstance, linseed tea or barley water, flavored with lemon juice, will be found of great service, and will be extremely grateful to the patient, ice being added to the infusion if the weather is very hot. Considerable draughts of iced liquids must not, however, under any circumstances, be allowed. The mere dilution of the urine frequently brings relief, but the exhibition of considerable quantities of diluents for a couple of days now and then should be persisted in for some weeks after the attack has passed off. There is no hope of relieving chronic cases of this trouble as long as the ordinary diet and mode of life, with little exercise and too high living, are persisted in. The formation and elimination of the urinary constituents, like other physiological actions, may be increased or decreased to a certain extent, which may become habitual without occasioning organic disease, although not within the range of what we call healthy limits. People who suffer from faulty physiological action, both as regards excess and deficiency, can hardly be considered to be in health, although they do not