chloroform, and thus have obtained at once, not stimulation, but paralysis. Rosenberg concludes, therefore, that by a preliminary use of cocaine on the mucous membrane of the nose, this irritation is done away with, and one of the greatest dangers of chloroform anæsthesia is avoided.

Again, he argues that since the inhalation of chloroform produces a diminution in the blood pressure, cocaine is indicated because it tends to bring about a slight elevation of the blood pressure. He regards cocaine not only as a stimulant, but thinks that it may have an anti-toxic effect also. In any case, he thinks he has shown that an animal, after the administration of cocaine, bears chloroform better and longer without the appearance of threatening symptoms. According to his experiments, a dog receiving one cm. of chloroform a minute through the mask without cocaine dies in seven or eight minutes, whereas with a preliminary use of cocaine he lives fourteen or fifteen minutes.

The other advantages claimed by him from the use of cocaine to the nasal mucous membrane before the administration of an anaesthetic, are as follows:

to be less disagreeable to (2) The period of excitecase of alcoholics is much

(1) Induction of anesthesia seems the patient and struggling never occurs. ment is absent in many cases, and in the diminished. (3) Vomiting occurs but rarely during narcosis, and when it does occur it is accompanied by very little straining. (4) The narcosis is followed by no distress or headache, and the patient does not complain of the smell of chloroform or ether for several days afterwards, as often happens in other cases.

Rosenberg adds the following suggestions for the administration of the anaesthetic:

(1) The idea that in long operations chloroform should be taken away from time to time and the patient kept just upon the border of waking up, is absolutely wrong, for each time the chloroform is given we again encounter the original danger of reflex heart syncope. Chloroform must be given drop by drop, and given continuously until the end of the operation. (2) Nervous patients should always be encouraged before the administration of an anæsthetic, and should be spared as far as possible the sight of a blood

stained room or of many instruments. (3) Quiet is necessary, and the anaesthetic should be given, not in the operating-room itself, but in a neighboring apartment. (4) A careful physical examination should be made of all organs, and the urine should be examined before an anesthetic is administered. (5) Above all, the clothing must be loose; the first condition for a safe narcosis, among other things, is a free and untrammeled breathing. It is not so important to observe the pulse as the breathing. (6) The giver of an anaesthetic must give his entire attention to this duty. (7) A few minutes before the beginning of the administration of the anaesthetic, the patient having blown his nose thoroughly, is given a spray of about two cc. of a 10 per cent. solution of cocaine in each nostril. The spray should be given with the patient in the sitting or standing posture, and never while lying down. The spray is arranged so that about one cc. of the fluid is discharged at each pressure of the bulb. The stream is directed first towards the posterior nares and then upwards; in this way we obtain complete anæsthesia of the mucous membrane of the nose with a very small quantity of cocaine. Of course, the tube must be placed inside. and not in front of the anterior nares. Painting with the solution is not nearly as effective. After three minutes, one cc. of the solution is again sprayed into either nostril, so that the patient receives altogether about six cc. of the solution, which means about six milligrams of cocaine, a dose which works perfectly well and from which not the slightest danger can be anticipated. The anesthesia lasts about half an hour, and must be renewed again if the operation is prolonged. The sense of smell is not interfered with, although the susceptibility to the effects of irritative substances is taken away. Even after the shortest narcosis, the spray is to be administered again when the operation is over, and this appears to hasten the awakening and to do away with unpleasant after-effects of the anæsthetic. Rosenberg's conclusions may be summed up as follows:

(1) Syncope of the heart during chloroform narcosis, when not resulting from carelessness or from an overdose of the drug, as far as the effects of the chloroform itself are concerned, is reflex. (2) The asphyxia which accompanies it is caused by stimulation of the peripheral endings of the trigeminus in the mucous mem

brane of the nose. (3) Every substance used for anesthesia produces the same reflex symptoms of irritation as chloroform. (4) The exhibition of cocaine to the nasal mucous membrane does away with this reflex irritation and thus lessens the danger of sudden death. (5) Cocaine possesses a certain antidotal or anti-toxic effect against chloroform. (6) Chloroform may be regarded, when used in this way, as safer for the purpose of general anæsthesia than ether. (7) The giving of an anesthetic should not be entrusted to any but a physician.

ENDOMETRITIS FOLLOWING GONORRHOEA.*

BY H. B. HERRICK, M. D., CLEVELAND, OHIO.

On the eighteenth of March last was called to see Mrs. F., who was suffering the constitutional effects of an old endometritis. Patient had been in severe pain for several hours, had had two chills and had vomited several times; temperature 102, pulse 100. Her previous history was as follows: Age twenty-eight; born in New York state; parents both living; menstruated at eleven and was married at seventeen. Four years and a half after marriage was infected with gonorrhoea by her husband; was sick six months; three months after recovery became pregnant; had an abortion at third month; was sick two weeks. There was no discharge following convalescence. Three years ago husband infected her with gonorrhoea a second time. Sick in bed two weeks. In one month, discharge was entirely relieved. Immediately following recovery, she separated from her husband; but in November, 1893, she contracted the disease for the third time, since when, up to my first visit, she had not been free from a discharge. At the menstrual period the discharge was very profuse and pain severe. Just before coming under my charge, patient had been treated in Oberlin by a reputable physician for three weeks, and in this city by a quack for ten days.

At her marriage, patient weighed 140 pounds. Her weight when I first saw her was 110 pounds. On examination, the following local condition was found: There was no vaginitis. Cervix

* Read before the Cuyahoga County Medical Society, November, 1894.

pointed toward symphysis pubes, large, sensitive, with pus slowly oozing from cervical canal. Cervical canal quite well open, but mucous membrane at internal os and body of uterus was very tender. Body of uterus was fully double its normal size and retroverted. Left ovary was enlarged and very tender. The diagnosis, as in most of these cases, was not difficult. In 1880, Schultze first described what he called a diagnostic tampon, and he is surprised his method has not attracted a greater amount of attention. It seems to us that in most cases the diagnosis of endometritis can be made without recourse to Schultze's method. In all cases where the presence of a glaring discolored mucous mixed with pus can be seen coming from the cervical canal, our diagnosis is quite easy. There is also a history of profuse menstruation and of inter-menstrual spotting. In those cases where the inflammation is confined mainly to the fundus, the discharge is thin and watery in character, discolored, and often possesses a peculiarly pungent, offensive odor. At present, the prevailing treatment for this difficulty is a surgical procedure to dilate cervix, to curette uterus, using a sharp or dull curette, or both, followed by an intra-uterine douche, applying caustics and packing uterine cavity with some sterilized gauze. Part or all of these steps to be repeated from time to time. This is a radical procedure, and in my experience has relieved some cases. But it is attended by no small amount of danger, and during my stay in New York heard several surgeons express want of confidence in its success.

In this case, as in a few similar cases, the following treatment was used: First, rest in bed in a bright and well ventilated room. Second, hot fomentations were applied over lower abdomen, and especially over the left ovary, as long as there was any pain or tenderness on pressure. Third, two vaginal tampons were inserted every other day. One saturated with pure glycerine was passed into posterior fornix to support the uterus after that organ had been replaced as nearly as possible in its normal position. The other tampon was saturated with a solution of glycerine, (acidi carbolici, acidi boracici or ichthyol can be used with advantage if there is much pain) and was placed between symphysis pubes and cervix. Then if the canal is open (and if not it should have been carefully

dilated), there will be free and complete drainage from uterine cavity. Fourth, every morning the patient was directed to take a vaginal douche from a fountain syringe while in the lying posture ; the water to be as hot as can be borne, the period to be from a quarter to half an hour. Fifth, the diet was simple, easily digested and nutritious, that the blood might become as healthy as possible. To secure healthy, rich blood for the repair of diseased tissue, we must have proper food and a good digestion. Care was exercised to have the bowels evacuated daily.

In the case reported it was not necessary to dilate cervical canal, for it appeared to have been dilated not long before being seen by us. In the majority of these cases it will be necessary to

dilate cervical canal. This line of treatment was followed for twenty-five days, when discharge had stopped. Uterus was greatly reduced in size, and to the present time has retained a good position. The ovarian tenderness was fully relieved and patient has menstruated with ease. At present writing, Mrs. F. is well, weighing one hundred and thirty-five pounds.

We have reported this case, not because it is in any way peculiar, for it is just such a case as every practitioner is liable to meet every day. It has been proven by Dr. Jacobs and others. that 85 per cent. of women requiring removal of uterine appendages has been infected with gonorrhoea. Thus how essential that every physician should be fully prepared to care for gonorrhoea and its sequela! We have reported our treatment because it is somewhat different from that now popular, and because of its simplicity and effectiveness seems to be of value to the general practitioner. This class of cases is quite numerous, and it is very essential that the disease be early recognized and corrected, that the uterine appendages may not become involved and a severe surgical operation become necessary, or the patient become a helpless invalid.

We are deeply interested in this class of cases, and believe our line of treatment will relieve a large per cent. of persons suffering such diseases. We should be pleased to hear from others who may hold similar or different views as regards the treatment of these cases.