own direct influence or the trend of the times. It is such misrepresentation, willful or ignorant, of homeopathy that not only justifies the existence of this bureau but makes clear the particular work cut out for it. It is the disinterested laity that we must appeal to and teach the truths enunciated by Samuel Hahnemann, which the technico-physical 19th century has only served to confirm. The too great readiness to resort to surgery and the enormous trade in proprietary medicines are eloquent testimony of the therapeutic nihilism of the dominant school. The public is eager for a simplicity and faith in medicines on the part of the profession.

The homeopathic method with its simplicity but certainty, its safety but efficiency is what the laity is hungry for and we must see that they get it both for their good and ours.

CYSTITIS.

By Evelyn S. Pettit-Roberts, M. D., New Brighton, Pa.

This subject is particularly appropriate for the section of Gynecology because women have cystitis so much more frequently than do men. This fact is accounted for by the peculiar structure of the female bladder and its location, being so closely associated with the uterus and its appendages. Consequently inflammation of the bladder is often secondary to trouble in the uterus or vagina. It often follows parturition or displacements or inflammation of the uterus. In the vagina there may be either a specific or non-specific inflammation that will find its way into the bladder by way of the urethra. With all these causes operating we find cystitis a very common affection in women.

Its pathology is such as you would expect from the anatomy of the bladder walls. In the acute form will be noticed

first the swollen and reddened condition of the mucous membrane lining the organ, then there will appear abrasions of the prominent folds of the rugæ, while between these folds mucus or even pus will accumulate.

The inflammation may extend to the submucous tissue or even to the muscular layer. One author speaks of the weakening of the muscular fibers, allowing the contents of the bladder to push the mucous membrane through and push back the peritoneal covering, forming diverticulæ, which are not fully emptied when the bladder is evacuated. This retained urine becomes alkaline because of its retention and reacts on the bladder walls to increase the already existing irritation. This condition will be found only in the chronic cases. In severe cases resulting from diphtheria or overdistension the entire mucuos membrane may be exfoliated. This is very rare, how

ever.

As the disease goes on to a chronic condition, the redness of the bladder walls fades to a dull gray, there is a coating of mucus, pus and disorganized blood cells, and the blood vessels may be very prominent and filled with dark blood. There is thickening of the mucous membrane from the formation of the new tissue as will be found in any tissue the victim of a long-continued or chronic inflammation. This thickening will be found most at and near the neck of the bladder and will obstruct the urethral opening, and so interfere with the passage of the urine, adding another cause for the presence of the stale chocolate-colored, ammoniacal urine found in chronically inflamed bladders.

The use of the endoscope is necessary for the demonstration of the conditions so far spoken of. The general practitioner does not ordinarily use one, but

much of this pathological condition can be read through the symptoms by which we do the most of our work, and this brings us to the symptomatology. Examine a specimen of urine with litmus paper and find it alkaline-use chemical tests and find pus, albumin, mucus, traces of blood, etc.,-put it under the microscope and find epithelial cells that you know belong on the bladder walls, and you can know pretty well the condition of the vessel that contained it.

In acute cystitis the symptoms are severe pain, soreness over bladder, urging to urinate. and pain and burning accompanying the act. Smarting, pain and tenesmus following, until life is one of misery. The constitutional symptoms are often marked. A chill, followed by rise in temperature from one to three or four degrees; prostration, aching, sometimes singultus. The urine is scant, high-colored, acid, hot. This is the description of a severe case, such as would come from bacterial invasion following labor or such as is the "local expression of some constitutional disease-diphtheria, erysipelas and croup"-to quote Wood-and these are always of serious import and should be very carefully and thoroughly treated.

There are many milder cases where a little soreness and weight back of the pubes with slightly increased frequency of micturition with a little burning and distress accompanying the act is all the difference that will be noted in the condition of the individual. All of these symptoms are aggravated by the erect posture and by movement, and that is a valuable indication for treatment. The pain and soreness are aggravated by pressure on the neck of the bladder through the vagina, a good diagnostic point.

As the case goes on to a chronic condi

tion the first sharp symptoms will disappear but there will come deeper, more profound constitutional troubles. The septic material absorbed into the system from the decomposed urine and pus in the bladder will give rise to grave disturbances, cachexia and chronic septicæmia. The great frequency of micturition, especially at night, causes so many breaks in the patient's rest as to often seriously impair the health. Nutrition is impaired and the development of various nervous manifestations is to be looked for.

The causes of Cystitis are many. Some authors say it never occurs idiopathically, but I cannot see why it should not. should not. However, it usually comes secondary to some other affection. It may result from traumatism, a strain, bruise, over- exertion, long - continued pressure during childbirth, over distension of bladder, following labor, when the parts are numbed by the pressure of the head. It frequently occurs that the parturient woman will express no desire to urinate for many hours, even twentyfour or more, after the birth of the child, and if the nurse or physician does not see that the attempt to urinate is made. and be positive that it is successful, grave consequences may follow the prolonged distension of the bladder. The mucous membrane may be loosened and may come away en masse or the sudden relief from the pressure when the bladder is finally catheterized may produce a congestion which will go on to the chronic form of cystitis.

If there is inability to urinate and the catheter must be used, another cause of cystitis may exist. If the instrument is unclean or be not carefully introduced, bacteria may be carried through the urethra to the bladder, producing one of the most serious phases of the disease.

There is a tendency in some people to a catarrhal condition of any or all of the mucous surfaces, and in these an acute attack is very apt to run into the chronic form. Cystitis is also called vesical catarrh and in those people inclined to catarrh every little cold or strain on the system of any kind will aggravate an existing chronic cystitis, giving acute symptoms.

Other causes are displacement of the uterus or inflammation of that organ or of the vagina, either specific or non-specific. The exanthematous diseases are often the cause of quite extensive involvment of the vesical mucous membrane.

The diagnosis is ordinarily quite easy, yet one finds it hard to know for sure sometimes, especially if one is only a general practitioner and not familiar. with the use of the endoscope and Kelly's speculum. Most of the points have been given the pain, frequency of urination and distress accompanying and following the act, the acid urine in acute, and alkaline in chronic cystitis; the mucus, pus and blood that may be found in the urine and in the old cases the darkcolored, foul-smelling, ropy urine often found.

But this pain may be from other causes. A displaced or prolapsed uterus will cause frequent and painful urination and the differentiation must be made by the character of the urine, by the aggravation from being on the feet and the amelioration from replacing the uterus. I have had cases of painful and frequent urination from gaseous indigestion. There would be severe pains in the lower abdomen and over back of the pubes with frequent and painful micturition and the urine normal. Treatment directed to the relief of the digestive distrubaces relieved the seeming cystitis.

When the pus in the urine is accompanied by much albumin and there is no pain on urination you will be safe in concluding that the trouble is in the kidneys, especially if there are tube casts in the sediment.

The treatment of this trouble is harder than the diagnosis. The prophylactic measures are important, the various causes spoken of are to be avoided or removed. Catheterization should be avoided whenever practicable after operations or childbirth, and if it must be done let the catheter be absolutely clean and aseptic, the meatus and surroundings thoroughly cleansed, the hands clean, and then pass the instrument by sight and not touch and you will not carry bacteria into the bladder.

In the acute form rest in bed is necessary, as the quiet and the recumbent position both tend to relieve the pressure and the irritation. Hot fomentations over the pubes or perineum, hot sitz baths or a big hot vaginal douche will often afford much relief. Dr. Wood recommends the use of a stream of warm water directed against the meatus for ten or fifteen minutes every four hours or so in cases where the pain is mostly in the urethra.

When the urine is too concentrated and acid it can be diluted by the ingestion of large quantities of water or milk or mucilaginous drinks, such as slipperyelm or flax-seed. I have a patient who keeps lemons in the house always and when any dysuria develops she drinks a glass of lemonade. It always relieves, and many medicines were tried and did not relieve.

It is very necessary that the function of urination should be always regularly attended to, as carelessness in this respect may induce troublesome weakness and irritation.

I have not often resorted to the practice of washing out the bladder. It is at times necessary in chronic cases with much mucus, pus or retained urine. It needs to be surrounded with all the precautions necessary for a surgical operation. Asepsis is to be considered rather than antisepsis. Not many instruments are necessary - a glass funnel, a piece of rubber tubing and a glass catheter, with vessels for containing the solutions. Boric acid solution is the only kind I have ever used, though. The mode of using this (modified Skene's) apparatus I can describe by quoting from Carleton. "It is used as a catheter to empty the bladder of the urine; after this is done the washing out is accomplished by pouring the solution to be used into the funnel, which is raised high enough to allow it to flow by gravity into the bladder; the funnel is then lowered to permit the fluid to escape. This process is repeated as often as necessary, using any desired quantity and pressure." To exclude air from the bladder either fill the catheter before introducing it or introduce when the bladder is not entirely empty, and let the urine flow sufficiently to fill catheter and tube.

When the fluid returns clear the washing can be discontinued. Leave some fluid in the bladder at close of the operation. Do not wash too frequently, and remember that after a few washings in these chronic cases the bladder walls grow more tolerant of the presence of the solutions hence stronger ones can be used, indeed ought to be used.

Dr. Wood strongly recommends the use of calendula and hydrastis in the strength of 1:20-and to be used once or twice a day. The calendula to be used when there is much pus or evidences of ulceration and hydrastis if much tough, stringy mucus. He would first cleanse

the bladder by the use of boric or carbolic solutions, using the hydrastis and calendula as healing medicines after the others have done the cleansing.

Chronic cystitis is an exceedingly difficult thing to cure. Many cases can be cured by persistent, careful effort extending over a length of time, but some will resist all treatment, as most of us have found to our sorrow.

I speak of the remedies last, though I always use them first, and only resort to the local measures when medicines are proving too discouraging. And what what shall I say of remedies? Every author I consulted has his own list, and it is not like every other's. The remedies I have found most useful have been Berberis Vulgaris, Equisetum, Triticum repens, Cantharis, and Belladonna: Mercurius corr., if the kidney is implicated also and much pus in the urine. Petroselinum where there is sudden urging or where I know from the history that trouble has ben brought on by neglecting or putting off calls to urinate. It helps every time in these cases. I use it in the 12x. Berberis vulgaris when the back aches as though it would break.

Equisetum hyemale in the newly mar

ried.

Arnica when there is soreness of the lower abdomen associated with difficulty of urination. Arnica helped me out on one of the most discouraging cases I ever handled. I had given everything I could think of or that was suggested in our County Medical Society, and all to very little purpose. I did not resort to irrigation as the urine was so free from abnormalities I did not judge it necessary. Much of the cystitis was due to gaseous indigestion and a slight prolapse of the uterus. The constant complaint of soreness in lower abdomen finally led me to read up Arnica and it helped very de

cidedly. I cannot say the case was cured because the patient is a chronic growler and will be on some doctor's hands as long as she lives.

Under the different remedies we find "violent urging" to urinate, as under Mercurius corr. or "constant urging," as under Cantharis and Aconite, but in "sudden onset" of the desire I find only under Petroselinum and Cannabis Sat.

Under Apis we find this peculiar symptom vouched for by Farrington. "It seems as if the sight of water brings about a constriction of the spincter muscle."

Under Ferrum phos. Wood gives this -"Cystitis with dysuria, which is brought on by standing."

I have not mentioned all the remedies, but if I have given anybody any new or useful ideas I shall feel that my little раper is not entirely a lost effort.

THE CURETTE AS A SURGICAL
MEASURE.

By J. H. Thompson, M. D., Pittsburg, Pa.

I do not purpose to enter upon the consideration of the pathology of the many diseases requiring the use of the curette, nor to any extent, upon the discussion of their symptoms, but a very superficial observation of their manifestations, and serious results, even when the patient survives, renders it evident that the most important feature in its treatment is prevention. One would suppose the knowledge that the disease is preventable would invariably lead to the employment of the measures which ensure against its development, but to accomplish such practice requires much additional education of the profession, as well as of the masses.

Curettes are used to remove the superficial portions of the uterine mucosa in endometritis; to secure bits of tissue for

diagnostic purposes in suspecting cancer of the body; to remove portions of an ovum incompletely cast off; and to clean out the broken down tissue of a cancerous cervix where the disease has progressed beyond hope of a radical cure. Sharp curettes, handled with extreme delicacy, are most serviceable; the blunt curettes often advocated are but insufficient substitutes.

A careful microscopical study of the tissue should follow the removal by the curette in every case, and the following conditions should be looked for: Normal uterine mucosa. Acute endometritis. Endometritis decidualis. Mucous polypi. Remnants of abortion. Tuberculosis of the endometrium. Carcinoma of the body of the uterus. Sarcoma of the uterus. Cancer of the cervix.

In one of my cases adeno-carcinoma of the body of the uterus was diagnosed from scrapings. On curetting, a large amount of tissue was brought away, and to control the free hemorrhage which followed it was necessary to close the cervix with silk-worm gut ligature.

In adeno-carcinoma of the body of the uterus and in inoperable cases of carcinoma of the cervix, vaginal hysterectomy is advised. It has frequently been urged that hysterectomy should be performed even though the growth cannot be entirely removed, in order that the patient may be saved the distressing and excruciating pain so frequently experienced in the late stages of the disease, particularly in those cases in which the uterus has not been removed. Experience, however, teaches us that the surgeon is not justified in promising such relief, since in many instances after removal of the uterus, the patient has suffered agonizing pain.

The best results are obtained by curetting as much of the necrotic and slough