any means imply that it will retain this power after it has been swallowed and has reached the uric acid deposit in an immensely diluted form or altogether converted into some other chemical compound. Leaving aside the fact altogether that renal concretions are generally protected against the solvent action of any body that theoretically might reach them in the urine by a coating of mucus and debris, it is exceedingly questionable whether any of the so-called solvents could reach these concretions in a concentration sufficiently great to really exercise a solvent effect. This criticism applies with particular emphasis to lithium salts that are so popularly employed for the purpose of dissolving deposited urates. The so-called lithia waters in the first place at best contain only a few decigrammes of lithium carbonate to the liter, and some of them, as I have had occasion to determine personally by analysis contain none at all. As these waters always also contain relatively large quantities of other alkalies, only a very minute quantity of uric acid (according to Berthollet's law) would be able to combine with the lithium, the bulk would form sodium and potassium urates (even in the test tube), while most of the lithium would be converted into chloride, phosphate of sulphate and excreted as such. Now, while lithium carbonate actually possesses active uric acid dissolving properties (in the test tube) the same cannot be said of the chloride of lithium; so that when one remembers that most of the lithium carbonate would be promptly converted into lithium chloride by the hydrochloric acid of the gastric juice, and absorbed as such and not as carbonate at all, it becomes clear how irrational it is to claim that the ingestion of a few centigrammes of lithium carbonate could dissolve uric acid or urate concretions anywhere in the body.

Very similar criticisms can be advanced against all the other so-called urio acid solvents.

The use of urinary antiseptics, at their head urotropin, is always indicated in nephrolithiasis. In fact urotropin owing to its property of splitting off formaldehyde locally comes nearer to being a rational uric acid solvent than any other remedy that I know of; for formaldehyde combines with uric acid (at least in the test tube) to form a very soluble compound.

To promote the passage of renal calculi glycerin deserves a trial; true, the remedy is apt to produce hematuria so that it should not be given persistently if the evacuation of the stone is not promptly brought about by its use. This will occasionally happen, but not often. The symptomatic treatment of the pain and colic, the treatment of pus infection, should it occur, the treatment of the hemorrhage differ in no way from the treatment of nephralgia, pyelitis or pyelonephritis or renal hematuria due to other causes.

AN EXPERIENCE WITH THE OCCURRENCE AND REPAIR OF TWO
CASES OF VESICO-CERVICO-VAGINAL FISTULA.

T

F. A. Long, M. D., Madison, Nebraska.

HIS is not intended to be a scientific dissertation on the subject of vesico-vaginal fistula-a subject beyond my caliber. When I received aninvitation to be present and contribute to the program it occurred to me that my observations and experiences with the occurrence of this trouble and the histories of the cases, might be of interest to the general practitioner.

This paper is based on an experience with two cases occurring in my own practice, the first a rent of the cervix extending into the bladder, the second a case of pressure necrosis.

Patient No. 1 was a lady of a highly nervous, not to say hysterical temperament, the mother of four children before the occurrence of the accident which brings her to our notice. In the first labor, owing to an unusually large fetus, a craniotomy was required. In the second labor, for luck I presume, another physician was called to attend the case, and he thinking another craniotomy needed, later called me, but we delivered ber of a living child. The third was a premature labor brought on by grief over her husband's sudden death, and was a breech presentation, although an easy labor, the child being small. In due time another marriage was contracted, and the pregnancy which followd was complicated during the early months by a vaginitis and hyperemesis, and the child when born was small and the labor fairly easy. The fifth pregnancy was accompanied in the early months by an indefinable pain referable to the lower part of the uterus and a hyperesthetic vagina, defying all attempts to pass the examining finger. Under anesthesia, a caruncle was discovered in the line of a cervical cicatrix on the anterior lip, which was thoroughly cauterized and the symptoms subsided.

The rupture of the membranes at 4 a. m. on Christmas morning heralded the onset of labor. There were scarcely any pains all day, and the dilatation by evening had progressed as far as it seemed the cicatrices of the cervix would admit, and appeared enough to admit of the application of the forceps, which, in view of the history of former labors, and the almost hysterical condition of the patient, I felt constrained to do. Delivery was accomplished at 9 p.m. after completing the dilatation by the fingers. The delivery was not hard-on the other hand rather easy. The uterus was irrigated and the woman otherwise cared for, and although she complained some of pain, I attributed this to her hyperesthetic nervous system. Instructions were given to have her make an effort to urinate in about three hours. In about twenty hours, I called and was informed that she had not urinated, did not feel as if there was anything in the bladder, but that she had flowed considerably. On passing a glass catheter I could get nothing except a little blood in the eye of the instrument. Again introducing it and making a vaginal examination I came on the end of the catheter in the vagina and immediately told the patient she had sprung a leak. She was put on a treatment of 73 grains of urotropin three times daily and a tonic of hypophosphites, and the va

gina was irrigated twice daily with a solution of lysol and borate of sodium. The patient was told plainly what the condition was, and what to expect, and with this assurance the following six weeks passed uneventfully.

With no desire for the glory of repairing a vesico-vaginal fistula, for I had never witnessed the operation, the necessity for doing so in this case, for reasons I need not here state, was forced upon me.

With the assistance of two agreeable confreres the operation was done February 5th. In addition to the customary preliminary toilet for all operations about the genitals, the bladder was thoroughly irrigated with borate of sodium and lysol solution, and the uterus was lightly curetted and irrigated with sublimate solution. The posterior vaginal wall was retracted with a weighted speculum and lateral retractors used on both sides. The index finger of the left hand was passed through the urethra into the bladder the better to steady the field of operation, and the edges of the fistula, which was three-fourth of an inch in length in the bladder, and included a laceration of the cervix in the median line, running forward toward the urethra, were pared down to the mucous membrane of the bladder and deep enough to remove all granulation tissue. Silkworm gut sutures were introduced, the middle one first, about three-sixteenths of an inch apart, care being taken to avoid the mucous membrane of the bladder. The cervical laceration was also repaired. Fine superficial catgut sutures were placed between the silkworm gut sutures, the better to approximate the vaginal mucous membrane. The vagina was lightly packed with sterile gauze and a soft rubber catheter was placed in the bladder, anchored with adhesive strips to the thigh, and by tubing, connected with large bottle, containing an antiseptic, under the bed. The packing in the vagina was removed and renewed daily, and the vagina irrigated with lysol solution. It had been intended to irrigate the bladder daily with boric acid solution, but the hypersensitiveness of the patient, seemed to forbid and after two daily washings, this was abandoned, much to my regret, and later to my chagrin, for while we got perfect union of the repaired fistula, and had every other reason to feel good over the result, a cystitis developed, which gave us considerable trouble before it finally subsided under later irrigations of the bladder, several weeks after all the ligatures had all been removed.

Patient No. 2 was a woman of phlegmatic temperament, 35 years of age, the mother of six children. She had never had the assistance of an obstetrician in any of her previous labors. She had not felt well for ten days preceding the onset of labor, had had considerable thirst, and frequent and rather free urination, and a partial inability to get about. She had had some labor pains for thirty hours before I saw her and the last eight hours, pains had been severe. She lived twelve miles in the country, and when I arrived the head of the child had been at the outlet for some hours, but would come no further; in fact this state of affairs was the immediate cause of my being called. Maceration of the child's head showed at a glance that it was not living, and the bloated condition of the face showed beginning decomposition. Bringing the patient to the edge of the bed, with great effort I succeeded in delivering the shoulders, and even then the rest of the body had to be delivered by traction. The child, by nature very large, was so bloated as to have in a great

measure lost semblance of a human being, and the cord was fully one and one-half inches in diameter throughout its entire length. The uterus and vagina were thoroughly irrigated with lysol solution, in view of the septic condition of the fetus, and the history of probable septic absorption by the mother. A specimen of urine drawn from the bladder some hours after labor had a sp. gr. of 1036 and a decided reaction to Haines' test for sugar. The urine responded to the sugar test for four days, lessening each day, and then disappeared not to recur again. A pain in the vagina and a strong odor of decomposition twenty-seven days after labor led to an investigation which revealed a sloughing patch in the anterior vaginal wall just forward of the anterior cervical margin, which also had a fissure in line with the necrotic mass forward.

Borax and lysol douches were ordered twice daily, and ten days later, or thirty-six days after confinement, leakage from the bladder into the vagina was reported. Urotropin was ordered, as in the preceding case, and the borax and lysol douches continued. In ten more days all the slough had separated, leaving a fistula, the opening of which into the bladder, admitted the tip of the index finger and was located just forward and was continuous with the laceration of the cervix.

Agreeable confreres were again called into requisition, and an operation in all essential details similar to the one described in the preceding case, done. The after treatment was the same with the addition of daily bladder irrigations of sterile borate of sodium solution. The catheter retained in the bladder was attached to a nursing bottle lying in the bed. The sutures were removed on the fourteenth day and union found to be perfect.

Several things impressed me as of the utmost importance in the care and treatment of these cases: The necessity of keeping the bladder and vagina sterile from the time of the accident to the time of operation; the tying of the sutures, just tight enough, and not too tight; and the irrigation of the bladder.

ECHINACEA.

C. S. Chamberlin, M. D., Cincinnati, O.

HERE is a vast amount of harm done in the world by men who seek a little notoriety, which they mistake for reputation, through opposing any and every improvement or discovery which would lead to the benefiting of mankind. The chief offenders in this line are those who deride and deny the virtue of any discovery in medical science which, if found to be based on good grounds, will take some dangerous and almost certainly fatal disease out of that class and place it in the category of illnesses which are no longer looked upon as fatal."-Editorial, Medico-Chirurgical Journal, February, 1906.

The reception accorded echinacea by many of the leaders among the regular profession has not been generous. Dr. A. G. Clyne, of Bethel, Ark., commenting upon a former paper by the writer upon this subject,

says: "I received the copy of the Louisville Medical Monthly with your article upon echinacea contained therein. Your reports of cases are fully in line with results obtained in my own practice. When I tell some of my colleagues of the drug and its therapy they will not believe. It is, indeed, a marvelous remedy.

Echinacea angustifolia is an herbaceous plant, the thick, black, pungent root of which is the part used in medicine.

According to Lloyd (1): "Echinacea contains minute amounts of a colorless alkaloid, which, however, does not constitute the therapeutical qualities of the drug. The sensible constituent is a colorless, organic substance of acrid reaction, which imparts the sensible properties to the drug, being intensely acrid and persistent-distressingly so in a pure condition. It exists in prime echinacea in minute amounts, less than one-half of one per cent, and is probably in itself a mixture.

In a letter to the writer, Dr. H. M. Gordin, professor of organic chemistry, school of pharmacy, Northwestern University, says: "A preliminary examination has shown the abscence of any alkaloid in appreciable quantities. The acrid principle can be extracted by means of ether, benzol, chloroform or hot alcohol. These solvents extract a thick, oily liquid which contains the acrid principle and is present in the drug to the extent of about 1.2% in the crude condition. On treating the crude.

oil with ether and potassium hydrate the ether extracts about 0.6% (of the drug) of a very thick oily liquid of very great acridity. Upon acetylizing the oily liquid by means of acetic anhydride, it loses the tingling taste, but acquires a bitter taste."

With regard to the physiological action of echinacea, Dr. A. G. Clyne, in a paper read before the Arkansas Medical Society, May 16, 1905, says: "The first apparent effect of a dose of the tincture, or fluid extract, when swallowed, is a pungent, rather mild acrid taste, soon followed by a tingling, not unlike that from aconite. Hence, acting in this manner as a local mild irritant, the flow of saliva is increased, and in like manner it seems to gently act on the stomach in the same way, thereby promoting digestion and general nutrition. The action of all glandular organs seems to be increased, both in secretion and excretion."

J. M. French (2) says: "The tincture produces a feeling of pungent warmth when taken into the mouth, which increases to a tingling sensation after time, and remains for half an hour or more. This feeling resembles, to some exent, the tingling produced by aconite, and still more that of xanthoxylum. If swallowed undiluted, it causes a constriction of the throat, with great irritation. It promotes the flow of saliva, causes diaphoresis, and increases the activity of the kidneys. The glandular organs, almost without exception, are stimulated by its use. It tones up the appetite and increases the power of digestion, encourages absorption and assimilation, and stimulates nutrition. It encourages secretion and excretion, and stimulates tissue waste more powerfully than any other known remedy. It does not appear to have any toxic effect.'

H. W. Felter (3) is of the opinion that the medicinal properties of echinacea are due to a resinous substance which the drug contains and this view coincides with my own. I am also convinced that this resinous substance loses much of its therapeutic value when the drug is allowed to dry. This loss is probably due either to oxidation or to the insolubility