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causing dysmenorrhea and sterility; to induce involution of the uterus. As to whether it is wise to curette an empty septic uterus following on labor or abortion, clinicians differ. Naturally, if the uterus contains retained placental tissue, this must be removed. If the curette is used, venous sinuses and lymphatic channels are opened and the protecting barrier of leucocytes is interfered with and possibly removed in places. Further, the Fallopian tube may thus also become infected. 4. To remove the remains of a mole pregnancy.

5. In the treatment of inoperable carcinoma of the cervix. In this condition septic absorption is one of the common causes of immediate distress. Curetting the fungating mass and subsequent treatment of the raw surface with strong formalin, frequently does away with sepsis, hemorrhage, and pain.

C. What are some of the contra-indications to utero-cervical dilation or to uterine curettage?

a. The absence of a positive indication. b. The presence of a suppurative process, either in the uterus, in the uterine adnexæ, in the paramentrium, or in any other pelvic organ or structure.

c. The presence of such conditions as phlegmasia alba dolens of uterine or periuterine thrombo-phlebitis. The curette is liable to disturb the thrombi in the uterine veins, at the placental site, or in the plexus pampiniformis. (Byron Robinson.)

D. By perfecting our surgical technique, the occurrence of this accident, perforation of the uterus, will become a rarity.

Before undertaking any intra-uterine maneuver, determine:

a. By vaginal examination.

b. By bi-manual, vagino-abdominal examination.

1. The presence or absence of adnexial or peri-adnexial disease. Curettement has determined the rupture of tubal, peritubal, ovarian, peri-ovarian, and peri-uterine pus colections. Even the pulling down of the cervix by tenacula has ruptured pus collections.

2. The size, the shape, the mobility, and the consistency of the uterus. If the uterus be bound down or immobile as a result of adhesions due to previous pelvic inflammatory processes, it is far more liable to be perforated. Under such conditions it

does not yield to the impact of the uterine instrument; it does not accommodate itself to the pressure exerted by the sound, curette, etc.

3. The presence or absence of tumors upon or within the uterus.

4. Some operations further recommend that the depth and direction of the uterine cavity be determined by the careful use of the graduated uterine sound or by the hysterometer, and that any deviation from the normal benoted. The use of the uterine sound as means of ascertaining the depth and direction of the uterine cavity is condemned by most operators. They rightly claim that the same information can be more safely determined by bi-manual vagino-abdominal examination. All malpositions, congenital or acquired, of the uterus, if recognized, predispose to perforation during the course of intra-uterine maneuvers. Malposed uteri are most frequently perforated opposite the point of angulation. The nutrition of the uterine tissues being impaired at the point of flexure, explains the not uncommon occurrence of perforation at this point. In a retroflexed uterus, it is the anterior wall which is more liable to be perforated; in an anteflexed uterus, the posterior wall.

5. Get a mental picture, as clear as possible, of the pelvic organs. Having a definite mind picture of the pelvic conditions existing in the individual case, if a uterine perforation occurs, it is more immediately. recognized, and one desists from further intra-uterine instrumentation. For instance, suppose that in a given case the uterus has, by examination, been determined to be normal in size, in volume, and in position, and that during the introduction of the uterine instrument the latter slips much to one side of the median line and to a depth greater than that of the uterine cavity, perforation will then immediately be diagnosed.

6. Observe the most rigid asepsis during the course of the operation and see that from the standpoint of asepsis and antisepsis, the patient has been prepared as carefully as though you were going to perform a laparotomy. A complication, necessitating a laparotomy may suddenly arise. In uterine wounds, be they inflicted by the sound, by the uterine dilator, or by the curette. you must minimize; you must avoid the liability of implantation of infec

tion. Not much can be done to cure existing infection. Much can be done to prevent the occurrence of infection. The endometrium sits directly on the myometrium without an intervening sub-mucosa to check endometrial infectious invasion. Chicago, Ill.

TO BE CONTINUED.

TWO CASES OF GONORRHEA.

BY GEO. B. Lake, M. D.

We take down our text-books and read "The approved treatment for gonorrhea"; we pick up a medical journal and read "My method of treating clap," and sometimes in this, even more, perhaps, than in other diseases, some of us are apt to forget that in reality it is individual patients (often impatient) that we are treating, and not a savage and baleful demon, as disease was regarded by our forebears.

I am not going to give my treatment for clap. The journals are full of it, and with profit, for we need all the help we can get in many of these cases; but I want to point a moral from two cases of this disease which were under my observation at the same time, and which called my attention with peculiar forcefulness to the wide divergence met with in acute cases, even in the same stage, and to the great variety of inclications for therapeutic intervention. which may arise.

The two young men were not far from the same age, and they both came to me with their first "dose" as soon as the initial symptoms of the disease presented themselves; but here the similarity between the

two cases ends.

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Mr. A. B. C. is a small, slight man, gle and of unimpeachable habits. A man to whom all forms of debauchery are entirely foreign; whose life has always been clean and above reproach, and whose lapses from strict continence could, in all probability, be counted upon the fingers of one

hand.

To him his clap was one of the epochal experiences of his life. He knew something of its seriousness and the difficulties attending a radical cure, and he placed himself unreservedly in my hands, following all my instructions to the very letter and reporting to me almost daily. His case

was never severe. Ardor urinae persisted for but three days. He had no chordee, and but little discharge, though the gonococus was repeatedly demonstrated microscopically.

This was one of the rare cases where, by diligent treatment and intelligent co-operation on the part of the patient, the infection was prevented from extending back into the posterior urethra.

The discharge disappeared at the end of three weeks, but the patient still reported faithfully for treatment. The moisture at the meatus and the squeezings from the prostate were frequently submitted to microscopical examination. All the tests recommended by Ferd. C. Valentine to determine the possibility of a recrudescence were finally tried, and the entire urethra was examined with the urethroscope and specimens taken from various parts. The patient never once asked for a discontinuance of the treatment until I discharged him after seven negative findings, extending over a period of four weeks, during which time the tests alluded to above had been conscientiously employed. The whole course of the case, from acceptance to discharge, extended over eleven weeks.

Mr. X. Y. Z. is a large, corpulent man, florid and flabby. Married. A loose liver in every sense of the word. The number of his amours is legion, and his wine-cellar is notorious. In some way he had escaped venereal infection up to this time, but even after his suspicious relations he did not refrain from cohabiting with his wife, and so, of course, he infected her, but that is another story.

He presented himself with a red and swollen member, a copious, creamy discharge, and agonizing pain on urination. Chordee was of nightly occurrence. My strict injunctions as to rest, diet, and the disuse of stimulants were more or less disregarded, and as a result, at the end of a week, he developed a left epididymitis. I put him to bed. and instituted appropriate treatment, under which he improved promptly and was soon anxious to get up. The first day that I permitted him to leave his bed he disobeyed my instructions as to rest and quiet by going for a walk, and the next day he rode a number of miles behind a mettlesome horse and over rough roads.

But in spite of all this he continued to

improve for several days, until his (comparative) abstemiousness became too much for him (he had abstained from sexual relations for nearly three weeks), and he went out and took a few drinks and indulged in cohabitation. The result was that when he sent for me the next day I found him suffering from a ferocious right epididymitis and orchitis, with high fever and considerable prostration.

I explained to him the gravity of what he had done, and he seemed very contrite; but his realization of his condition was of the slightest, for when he did not find himself well within a week after this, he discharged me and drifted into the hands of some charlatan. As to his condition now I know nothing. He has passed entirely out of my observation.

These two cases show how the same disease may present such a varying picture in different cases that its treatment must be as widely varied as if it were different diseases, and what is true of this disease is true of many others.

Let us treat our patients and the conditions which present themselves in them rather than a shadowy host of diseases which were formerly supposed always to be standing ready to devour the unwary.

Wolcottville, Ind.

PRACTICAL THOUGHTS ON

CYSTITIS.

BY T. G. STEPHENS, PH.D., M.D.

"To the sick and suffering medical science has proved, in the nineteenth century, an angel with healing in its wings." The The healing art in all its branches has made more progress during the last hundred years than it had made in all the history of the world. Greece was the first place of rational medicine. Achillis, who studied medicine under the Centaur Chiron, was a physician of high repute, and a leader of the Grecian army without a superior until the siege of Troy, when Paris, with his unerring arrow, severed his heel strings, the only vulnerable part; hence the origin tendo Achillis. Hippocrates (about 460 B.C.) was called the father of medicine, and Ambrose Pare, who died in 1590, was called the father of surgery. Nearly 300 years ago Harvey explained the circulation.

of the blood, and the idea he conceived has yielded fruits to the present time. Perhaps I have gone beyond the scope of my subject in the above remarks, although I don't intend to mislead the reader astray.

Cystitis is an inflammation, classically speaking, composed of four stages (color, rubor, tumor, dolor): clinical symptoms, frequent discharges of urine, painful obstructed and tenesmus. It may affect one or all the coats of the bladder, but commonly it is confined to the mucous membrane. Co-existent with cystitis pyelitis, or inflammation of the pelvis of the kidneys, may be produced by bacteria ascending the ureters. In the chronic condition it appears often in the form of cysterrhea, and often difficult to differentiate from a mild degree of interstitial nephritis. The successful diagnosis of chronic cystitis is much more successful than the surgical cases, which are much more difficult to manage.

As to the curative measures in cystitis, we confine our present researches entirely to a few cases of the chronic form. Keep the body warm; flannel next to the skin at all times with the avoidance of chil's and other available means which are inclined to keep the skin in a normal condition. The bed-chamber at an equable temperature if the patient is advanced in years; not less than 85 degrees F. or higher.

A variable temperature has a tendency to excite the renal secretions. The relation of the secretion of the skin to that of the kidneys is a very close one. A man of average weight passes about 50 ounces of urine daily, which is some shade of yellow with a specific gravity of 1015 to 1025, and the total amount of sweat in the twenty-four hours is 32 ounces. "The successful treatment of cystitis is a much more difficult task, for the reasons: I. The constant presence in the bladder of the urine with its irritating qualities, especially so to an inflamed mucous membrane. 2. The difficulty in getting medicine to reach the inflamed surface. 3. The pent up inflammatory products which, in their decomposition, often make urine still more irritating by exciting ammoniacal changes." There is no doubt if the urine could be kept from entering the bladder during an existence of inflammation, the latter would rapidly heal. I now present, from a clin

some

ical standpoint, a few cases from my notes: Rev. H., 74 years old, called at my office late P.M.; said there was and had been something wrong with his bladder for time, and could not, at the present time, urinate, and his suffering was great. I tried to introduce a No. 12, US., soft, flexible catheter, but was unsuccessful; then tried a No. 14 without succeeding. Prescribed a brisk cathartic and a hot hip-bath. Sent him home. The night following I was summoned to his bedside. I tried again to introduce the catheter, and was unsuccessful. On making a careful examination I found hypertrophy of the middle lobe of the prostate gland. I then used a French instrument called Caudee, or elbow catheter, successfully drawing off between two and three pints of fetid urine. This catheter has a soft and flexible stem, but toward the point where it is turned so as to form a short beak. The material from which it is composed is made more firm and stiff. As it passes down the urethra the beak keeps close to the roof and slides over any obstruction which may exist in the floor of the canal. Recovered.

I was called to see J. T. who had been under treatment in a distant city; had had Parkinson's disease for years; was compelled to use a catheter at times. His instruments were rough, dirty, and he never sterilized them. On examination per rectum I found the prostate gland much enlarged.

I and

tried to introduce different catheters failed, the prostatic portion of the urethra was exquisitely sensitive and tender. On the removal of the instruments

a small quantity of pus and blood followed. There was a well pronounced case of cystitis and prostatitis. There is no doubt but the complication was caused by pathogenic bacteria being carried on unsterilized catheAfter making several unsuccessful attempts to use the catheter, commencing a small flexible one, then a silver

ters.

with

catheter with a large curve, I asked for counsel, and three physicians responded who were equally as unsuccessful as myself, the patient's condition being extremely urgent. The ovoid shape of the bladder occupying a position much above the plane of the symphysis pubis, almost reaching the umbilicus, I punctured it (supra pubic cystotomy), removing five pints of fluid, mostly urine, associated with mucus and

pus, which imparted a glairy, stringy character to the mixture, and increased the difficulty of its being discharged. Made a good recovery from the cystitis and much improved prostatitis. On the ninth day following the paracentesis vesica, I succeeded in introducing, without any trouble, a French instrument, a boule, which was extremely flexible and had a long tapering extremity terminating in a round bulbous point. I then closed the artificial opening.

J., age 26 years, presented himself for treatment. Had suffered from cystitis for several years. Unfortunately, a few months before was thrown from a sleigh, and receiving an injury of the lumbar region, bloody urine following. I treated him four months; the improvement was gradual and permanent.

I was called to see J. R., age 75, who had had retention of urine for forty-eight hours. An osteopath had been treating him without relief. I found him in a state of coma, vigil eyes, half closed, inattention to anything around. They had a dull and half glazed look, but he was not absolutely unconscious. If his eyes were touched they were closed, and perhaps the head was slowly turned away. The characteristic phases in these anomalous cases enumerated are closely hinged, as well as the treatment. The bladder was large, oval, and extended to the umbilicus; pulse, fifty-five. I could not do anything with a catheter, as the prostate gland was very large. I punctured the cyst in the median line (supra pubic cystotomy), withdrawing six pints of urine having a strong ammoniacal odor; eight hours later he expired. In the treatment of chronic cystitis all the medicines. used in the acute form may be considered, but they are not sufficient; they are far less affective than the local methodical treatment, which consists in washing out the bladder every day regularly by the aid

of of an elastic catheter, to which a T-tube is fastened by means of a rubber tubing, one arm being connected with an irrigator, and the other with the escape tube. Money's double channel catheter is also a

very convenient arrangement. In addition to the use of hot water, various medicaments may be used in it as the occasion requires: hydrogen peroxide, carbolic acid stands high in cases of this kind. Natter and Jalan de la Croix state that they have

used as much as 10 to 30 per cent. of the acid; was necessary to prevent the movements of bacteria in putrid infusion of beef. Oral remedies, benzoic acid, if the cystitis is ammoniacal, its septic effects is remarkable. Urotropin, potasse chlorate, in full doses, always after meals; it reaches the pent up products which, in their decomposition, often makes the urine more irritating, by exalting ammoniacal changes, also nuclein No. 2, 5 per cent., P. D. & Co.'s., as a reconstructor.

Sydney, Iowa.

ARNICA,

BY W. C. ABBOTT, M. D.

Arnica is one of the American plants whose use came to us from the Indians. It is found also in northern Europe, and is a popular remedy in Germany. Both the roots and the flowers are used in the tincture, largely employed for external applications. The flowers are objectionable from the constant presence of insect parasites, whose products are believed to strongly influence the action of the remedy, especially when it is administered internally. The roots should, therefore, invariably be preferred.

The chemistry of arnica has not yet been satisfactorily determined. It contains a glucoside, arnicin, whose chemical composition is C20H3004. An alkaloid has also been found, arnicin, the formula being C12H22O2. Shoemaker says the plant contains trimethylamine. There is also a volatile oil and a resin, the former of which was considered by Bartholow the most important active principle. Until these principles have been produced commerically and tested therapeutically, it is better to rely upon a purified extract or concentration, containing all the above active principles and any others which the plant may contain.

Our recommendations are based upon the use of such a preparation. This concentration, known as arnicin, is an amorphous, brownish mass, soluble in alcohol, ether and alkalies, almost insoluble in water. It is precipitated by tannin. The flowers contain 4 per cent. arnicin.

Arnica is a typic example of those remeIdies in which the antagonism between the

effects of small and those of large doses is marked. Small doses slow the pulse, increase arterial tension, stimulate the vagus, induce a sense of warmth in the skin, act as a tonic to the digestive functions, and stimulate respiration; and, like digitalin, increase the urine when vascular tension and cardiac power are low.

Large doses accelerate and weaken the pulse, relax vascular tension, depress and finally paralyze the vagus, and increase the excretions generally, especially the urine and perspiration.

In toxic doses arnica irritates the throat, induces burning pain in the stomach, nausea, vomiting, frontal headache, falling temperature, vertigo, insomnia, rapid pulse, and hurried respiration, followed by exhaustion, profuse sweating, dilation of the pupils, sometimes muscular spasms, coldness of the extremities, slowness and irregularity of the pulse, coma, collapse, and death from asphyxia. Death has ensued from 3 ounces of the plant, and from 2 ounces of the tincture. The severe gastrointestinal symptoms are believed to be due to the larvæ of insects and their excreta, which are always present in the flowers, but never in the root.

Atropine is the best antidote, with strychnine, ammonia, camphor, or other stimulants, all in small and frequently repeated doses; with warmth to the skin, frictions, and artificial respiration. Arnica is eliminated by the kidneys mainly; to some extent by the skin.

Therapeutics of small doses: Lloyd looks upon arnica as a specific stimulant to the spinal system of nerves; hence he advises its application in adynamic fevers of the typhoid type, in chronic paralysis, amenorrhea, chronic rheumatism, asthenic dropsy, low forms of ague, and depressed conditions occurring early in low fevers. He pronounces it the best remedy for nyctalopia and amaurosis. It is useful in the neurotic manifestations occurring after traumatism or mental shock; in conditions of low sensibility, vascular languor; in fact, in all debilities. It is useful in sexual debility from abuse, in paralysis, asthenic forms of rheumatism, anemia, and weak conditions of the circulation; also in myalgia, muscular soreness occurring from overexertion, strain. or injury, nervous headache due to debility, heart strain, and the precordial aching which occurs after

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