Dr. A. Edward Meisenbach asked Dr. Lewis whether he had noticed in using the Nitze and his own instrument any difference in the warming of the bladder? He himself had seen patients complain of the burning engendered by the lamp of the Nitze instrument. He said that it was interesting in this connection to note Dr. Lewis as being the third of a medical triumvirate in the application of air in the examination and treatment of the body cavities. Sims having introduced the method of distending the vagina by atmospheric pressure, Kelly revived and perfected it in the examination and treatment of the rectum, and now, Dr. Lewis demonstrates the advantages of distention by air in cystoscopic examination and treatment.

Dr. Bransford Lewis, closing the discussion, said that while he was not ungrateful for the words of commendation which he had heard, he nevertheless had hoped to hear more criticism. He was not afraid of criticism. It stimulates efforts to remove objections that were made. He said that he had received a great many valuable suggestions. He did not look upon his work as being perfected by any means. He thought the proper manner of looking at a scientific discussion was in a broad way. He looked upon the subject as one not alone of treatment, but of diagnosis; and of diagnosis and treatment combined. This catheterization is far ahead of segregation, not only from the standpoint of reliability of diagnosis, but because a great deal can be done with it in the way of treatment. He asked whether any treatment could be given with any segregating apparatus? He was very skeptical in his own mind as to the reliability of the diagnostic information given by the segregator. He knew of a number of instances in the experiences of his confreres in which the segregator gave misleading results. Dr. Bryson informed him that the segregator gave a false return in the case previously mentioned. Granting that there is a water-shed established with the segregator, and granting that urine comes from the left side and some from the right side, that there are tubercle bacilli in one specimen and none in the other, there is no way of telling whether the tubercle bacilli have come from the left side of the bladder, from the left ureter or from the left kidney. Its reliability was questionable also, because of variations in the location of ureter-openings. In his work in catheterizing them he had found marked deviations from normal locations in many cases, such as would absolutely prevent the reliable working of a segregator.

The speaker said he would like to compare the Nitze with his own instrument. He thought that the use of the Nitze instrument required quite a good knowledge of electricity and a good deal of skill not only for the sake of getting results, but also to prevent any injury to the patient. He himself did injury to the bladder with the Nitze instrument, and he had seen injury done to the bladder by the hot lamp of the Nitze instrument in the hands of others. At Lewin and Goldschmidt's clinic in Berlin, the speaker saw an ulcer of the bladder due to burning from the hot lamp. The brilliancy of the lamp in my instrument is unquestionable; but it is lacking in heat; it can be held against the cheek for half hour without burning the skin. This is what allows the use of this instrument with air as an inflating medium.

As to the remarks concerning the size of the catheters, the speaker stated that he had not yet had the advantage of working for twenty years on his instrument, as Nitze and others have had. Possibly with longer experience, some features would be further remedied. Increasing the size of the catheters was one of the points that he had in mind to carry out with his instrument.

As to the point raised by Dr. Jacobson concerning the funnel-end of the catheter, he had cut that off his catheters to enable him to withdraw the cystoscope while leaving the catheters in the ureters. The Nitze instrument does not enable one to withdraw the cystoscope after double catheterism; that instrument must remain in the bladder as long as the two catheters are draining-which must be very uncomfortable for an inflamed bladder or urethra. It is undesirable to catheterize the ureter on one side on one day and wait three days to catheterize the other side, because of the probable changes occurring in the urine in the meantime. There are marked changes in the character of the urine at different times of the same day even.

He acknowledged that air is slightly more irritating than water when the bladder is distended. Yet, the members of the society had seen how little irritation there was in the case before them, which was a case with a badly inflamed bladder! The use of air is disagreeable, but not enough to prevent catheterization or to be a very weighty objection. On the other hand, there was the ability to drain comfortably without the presence of the cystoscope in the bladder. If it is necessary to drain for half an hour with a straight tube like a Nitze cystoscope in the bladder, he thought that the irritation would be greater than it was from the temporary use of air.

Dr. Lewis stated further that he had noticed some points about this work that were new to him, and he could not state positively how they would all turn out; one thing particularly, was the marked benefit that followed in tuberculous conditions after this catheterization. He could not understand this. He knew that tuberculosis of the peritoneum is often cured by simply opening up the abdomen and closing again, without anything else being done. The question arises whether the introduction of air into the bladder does not cause the same improvement in tuberculosis of the bladder as it does in the case of tuberculosis of the peritoneum. In reading on tuberculosis of the bladder, it is common to see the advice given that the less instrumentation carried out, the better for the condition. Tuberculosis of the bladder was only diag nosticated by this procedure and the operation was not repeated, yet improvement was noticed in some cases. In one case in which a double catheterization was performed one year ago, tubercle bacilli were found in the urine from both kidneys. This observation was confirmed by Dr. Gradwohl, who made the guinea-pig test. Last week, the essayist got clear urine from both sides, and no tubercle bacilli could be found. The evidence of improvement in other cases consisted in marked lessening in the amount of pus.

In other words, as Dr. Meisenbach stated, catheterization is going to do a great deal of good. Infection is avoided by careful sterilization of

No. 3. The Bransford Lewis Operating and Office Table: In position for cystoscopy or ureter catheterism. Patient's pelvis elevated. legs flexed and comfortably supported by crutches, placed at any angle or hight desired; hands grasping handles. Foot-stool present if desired. No strain in the posture. Willbrandt Surg. Mfg. Co.

No 2. The Bransford Lewis Operating and Office Table: In position for cystoscopy or ureter-cathe terism, further illustrated in photo No. 3. The Emil Willbrandt Surg. Mfg, Co., St. Louis.

all parts of the instrument, as well as by sterile applications. Dr. Lewis quite agreed with one of the speakers who advised against the indiscriminate employment of this procedure just as he would decry the indiscriminate use of morphine or other medicinal agents. He only carries out this procedure in cases where it is necessary to make a diagnosis, or apply treatment. It requires some practice in order to perform the catheterization. The more inflammation in the bladder there is, the more difficulty there is in doing this work.

Dr. Lewis stated that he had been lately working on some additions to the instrument, one a prism-telescope which was inserted directly through the cystoscope, and enabled the observer to "look around the corner" and see the conformation of a prostatic outgrowth, etc.

The Nitze and the Casper instruments help somewhat in this diagnostic work, but it is not possible with these European instruments to get as good a view of the prostate as is desired.

The speaker was also having made a cystoscope for purely operative work within the bladder. By working through air distension, he expected to be able to accomplish much more than is possible through a fluid medium. Any active bleeding into the latter medium would immediatey stop any operative procedure, which would not necessarily be the case with the air medium.

Dr. Henry Jacobson demonstrated a new instrument which is a modification of the Bottini-Freudenberg electro-incisor for prostatic overgrowths. It has a dial which can also be placed on a cystoscope and enables one to tell just where the cutting is taking place. Every time the instrument is turned, an indicator on the dial turns with it, pointing to the place where the knife is situated. So if the cauterizing blade is not burning the channel where the cystoscopic picture determined, it can be changed to the proper angle.

TUBERCULOSIS IN GERMANY.-Germany has special hospitals for the accommodation of 30,000 tuberculous patients. The statistics of these institutions for the years 1896 to 1901 showed that of 100 cases treated 87.7 were dismissed as cured or improved, 8.8 as unimproved, 3.1 as worse, and that 0.4 died. The imperial health office of Berlin has reported concerning the destructiveness of tuberculosis in Germany as follows: Of 1,000 deaths of persons between the ages of fifteen and sixty, 316 die of tuberculosis. Persons under sixteen and over sixty are seldom affected with the disease.

FRESH AIR HOSPITAL FOR INFANTS.-Some philanthropic citizen whose name is withheld is cooperating with Chief Dispensary Physician Scherck, through Dr. E. W. Saunders to provide a fresh air hospital for the treatment of intestinal and other summer diseases in infants. Dr. Scherck tells us that sufficient funds are in sight and that the hospital will probably be an accomplished fact by another summer. It is purposed to locate it on the Bluff overlooking the river north of the city.