ing either acute or subacute. One or two visits to the Doctor or Dispensary gives the necessary relief. The The economic loss in these cases is slight, for the patient returns to his occupation and at the most has lost but a few hours or days from his work. On the contrary, in OMCC cases we are dealing with a progressive disease which is difficult to relieve under the best of conditions. The patient is made to undergo treatment once or twice a week over a period of months or years. Each treatment means at least an hour away from work and when we realize the thousands of patients who are being treated daily for this condition, we begin to appreciate how much this means in a loss in wages. Moreover, these patients, instead of improving and being fitted for their vocations, are gradually getting worse and worse as they grow older, until the time comes when they are stricken from the payroll and are forced into destitution. When such a time arrives, relief is sought at any price but alas! it is too late.

It is not within the scope of this paper to suggest remedies, economic or otherwise for the relief of this condition. But I cannot help feeling that an educational propaganda which will teach people the importance of taking care of their noses, throat and ears, would in the future be of inestimable value. Put such a problem before them in dollars and cents, cite them case after case of hardship and destitution which has been caused by deafness and I have no doubt that in the course of years something will be accomplished. The time to cure a person of his deafness is before he gets it. This may sound paradoxical but it is true. There are many timely warnings such as frequent colds, buzzing in the ears, the constant hawking of mucus, a dryness in the throat, sticking pains in the ears, etc., and these all mean that Nature is trying to assert herself. Stupid fools of humanity who will not heed her!

II WEST 81ST STREET.

and four of micrococci. There seems to be little doubt that most of the bacilli which the various French investigators have found in the urine of cystitis patients are identical with the colon bacillus. Albarran was the first to make a systematic bacteriological investigation of the urine in cystitis and out of fifty cases of suppurative cystitis, pyelo-nephritis, and abscess of the kidney, forty-seven were found to show numerous bacilli. In fifteen of the In fifteen of the cases the various bacilli could be cultivated separately in pure culture. the rest of the specimens cocci were also present and Albarran came to the conclusion that the organism which he called "Bacterie pyogene" produced the greatest number of cases of cystitis.

In

Melchior found the colon bacillus in 25 out of 30 cases, 17 times as an isolated microbe. The bacterium next in The bacterium next in frequency was the Streptococcus pyogenes, which was found 5 times, 3 times in pure culture. In one case he cultivated the typhoid bacillus from the urine, in a patient suffering from patient suffering from cystitis, two weeks after convalescence from typhoid. I believe it is now generally granted that cystitis is a microbic disease, and that the proper prophylactic precautions consist in preventing the entrance of bacteria into the bladder, more especially in cases of urine retention and when the bladder is the seat of a lesion which offers a predisposition to infection. It is obvious that it is of great importance to ascertain the different avenues thru which the various pathogenic organisms reach the bladder. We know that infective bacteria are found constantly in the normal urethra of healthy males. Lustgarten made a bacteriological study of the urethras of eight

healthy men and found ten different types of bacteria, among them being many which are known to cause cystitis. These observations have been corroborated by such men as Rovsing, Galewsky, Legrain, Petit and Wasser

mann.

The meatus is a favorite lodging place for bacteria, and, consequently, great care should be observed in thoro cleansing of the part before the passage of an instrument. Schweiger has shown conclusively that the urine from scarlatinal patients is contagious as well as that from varicella, typhus recurrens and malaria. The elimination of the tubercle bacillus in the urine of phthisical subjects was demon-strated by Lentz. He demonstrated this by numerous experiments on rabbits. These animals were confined in a box, into which the steam of an atomizer mixed with the urine of tuberculous patients was introduced and the rabbits necessarily inhaled the fumes. In one particular series of experiments this procedure was done daily, on rabbits, for 71 consecutive days. The animals were then killed and numerous tubercles were found in the lungs, the peribronchial glands and the liver. It is also known that the transition of bacteria from the colon

and rectum is quite common. It certainly seems to me that a proper and complete diagnosis of cystitis cannot be made without a most careful study, bacteriologically and microscopically, of the urine, and of the numerous pathologic lesions that co-exist. The cystoscope is, at present the one instrument that is invaluable in diagnosticating these different cystitic conditions. By various classifications of cystitis we are oftentimes enabled to simplify our diagnosis.

Guyon classifies cystitis as follows:
1-Blennorrhagic cystitis.

2-Tuberculous cystitis.
3-Calcareous cystitis.
4-Cystitis due to retention.
5-Cystitis due to prostatitis.
6-Cystitis due to vesical tumors.
7-Cystitis of the female.
8-Membraneous cystitis.
9-Cystitis doulorence.

Rovsing's classification is as follows:
I-Catarrhal.
2-Suppurative.
3-Tuberculous.

He again divides the suppurative variety into ammoniacal suppurative cystitis and acid suppurative cystitis. His classification has special reference to the action of the essential microbic cause on the urine and tissues of the bladder. But it is well known that in many cases of non-tuberculous cystitis the urine is acid, especially in cases in which the colon bacillus is found as the sole microbic factor. He also ignores, almost completely, the pathological varieties with which the surgeon must be familiar in order to comprehend the nature and extent of the disease. No classification is complete which does not indicate the anatomical location, the clinical features, the pathological characteristics and the bacteriological origin of the disease. The anatomical varieties are:

I-Pericystitis.
2-Paracystitis.
3-Interstitial cystitis.
4-Endocystitis.

Kolischer describes, in connection with the pericystitic variety, a peculiar form of edema of the mucous membrane of the bladder observed by means of the cystoscope known as "edema bullosa." It appears in the form of circumscribed blisters about

the size of a pea, the rest of the mem-
brane being normal. This pathologi-
cal condition is always associated with
pelvic exudates near the bladder and is
seen most frequently in women wo are
the subjects of salpingitis. Under the
pathological classification we have:
1-Blennorrhagic cystitis.

2 Suppurative Cystitis.
3-Ulcerative Cystitis.
4-Exudative Cystitis.
5-Exfoliative Cystitis.

Clinically we have, of course, the acute and chronic types.

We might classify the bacteriological varieties as follows:

I-Bacillus coli communis infection. 2-Saprophytic (mixed) infection. 3-Staphylococcus infection. 4-Streptococcus infection. 5-Streptococcus erysipelatos infec

tion.

6-Typhoid bacillus infection.
7-Diplo bacillus infection.
8-Gonococcus infection.
9-Tubercle bacilli infection.

I feel that the bacteriological classification is most important, in that it clears up, to a great extent, the various pathological changes that take place and suggests to us a rational course of treatment. It is well, I think, to classify our treatment first into

1-Prophylactic and curative.
2-General systemic and local treat-

ment.

3-Palliative and operative.

In regard to prophylaxis, close attention should be paid to hygiene and the general health of the patient. Regulation both as to the urinary secretions and the alimentary tract is most important, also ingestion of large quantities of spring water, frequent baths, and massage. As far as curative treatment is concerned we must

The Treatment of

This often little-berated malady is, in reality, one of mankind's scourges. No disease, so universal, and characterized by repeated and violent disturbances of respiration, leading to permanent injury to the thoracic viscera, with consequent serious disturbance of the circulation, can be considered a minor malady.

In the treatment of bronchial asthma the three most important factors to be considered are (1) the pathological conditions of the upper respiratory tract; (2) the neurotic element which enters, as a causative agent into the production of the attacks; and (3) the chronic bronchitis and emphysema, which are so often associated with the disease.

After excluding the presence of a complicating tuberculosis, a careful intranasal examination should be made. Polypi, if present, should be removed; turgescent areas of mucous-membrane should be cauterized, and hypersensi

Bronchial Asthma.

tive areas, leading to frequent attacks of sneezing, should be, likewise, carefully treated. Moderate nasopharyngeal catarrh should be treated by douching the nose daily with a mild solution (.8 per cent.) of sodiumchloride.

The oft-repeated attacks, with many sleepless nights, soon lead to a further deterioration of the patient's general condition and increase the neurotic symptoms, which, in turn make the attacks more frequent and severe. A vicious circle is thus produced. Patients with a distinct neurotic element as a determining factor in the attacks, should, if possible, be disciplined psychically. Daily cold sponges, followed by friction, and regular breathing exercises, as recommended by Saenger, should be ordered. In carrying out the latter measure, the patient breathes easily and deeply, counting five and its multiples between each inspiration, increasing the intervals daily.

It is of the greatest importance, that such patients should secure a good night's rest. To secure sleep nothing can compare with the nightly administration, over a considerable period of time, of chloral hydrate and morphine, 10 to 15 grains of the former, and to grain of the latter. Contrary to the popular belief, the formation of a drug habit under such conditions is rare, and the results obtained far out

weigh the possibility of causing a drug habit. If morphine is objected to, the compound mixture of chloral and potassium bromide, of the National Formulary, in drachm does, may be substituted.

For the treament of the associated bronchitis, nothing is as valuable as the administration of potassium iodide, which need not be given in larger doses than 10 grains, three times daily. If the salts of the iodides are badly borne, Sajodin, in 10 grain doses, combined in a capsule with the trioxide of arsenic grain 1/30, and atropine sulphate grain 1/250, may be given three times daily.

Occasionally, in the intervals between the Asthmatic attacks and when the bronchitic cough is most severe and the muco-purulent, expectoration is profuse, a pill containing Camphor, grains 1, Codeine and powdered ipecac grain of each, is of great use. [Extract of Hyoscyamus, grain may be added to each pill, which is given every 2-3 hours, when there is evidence of much spasm in the bronchioles.]

Change of climate is so uncertain and of so little avail is ameliorating the symptoms in most cases of bronchial asthma, that no definite advice can be given concerning the principles regulating this therapeutic measure. The patient, however, should live in the open air as much as possible and in a

locality free from dust and irritating fumes.

Of the treatment of the acute attacks, very little can be said that is new, save to mention the excellent and rapid relief often obtained by the sub-cutaneous injection of adrenalin chloride (1-1,000) in doses of 10-15 minims, well diluted. This drug may be tried in all cases of bronchial asthma, in which the vaso-dilator control seems to be weak. The injections should be given only occasionally when other

measures fail and under no conditions should they be given to patients with diseased blood-vessels or to those suffering from increased arterial tension. Inhalations of fumes, of which those of nitre paper are the least harmful, should be discouraged, or employed only occasionally when great urgency demands it; as they are thought to favor the aggravation of the malady, if used often and over long periods of

time.