be promptly evacuated with castor oil, or if the oil cannot be retained, with small and repeated doses of calomel. As the bacteria grows best on a milk diet, the milk should be stopped at once and withheld from two to six days, according to each individual case. Babies should not be kept longer than three days from the breast, as the breasts begin to "dry up" after three or four days non-use. While it is best to pasteurize all milk that is fed to infants, no amount of pasteurizing or sterilizing will render the milk a suitable diet during the diarrhoea. It simply feeds the germs and perpetuates the disease.

Egg-albumen has also been found to be an excellent food for these bacteria, and for this reason should be eliminated from the diet. Instead of milk and egg-albumen, give the baby rice and toast water; or better still, predigested gruels. These gruels are readily taken by most children, are very nutritious, and are said to be split up in the intestine into acids, rendering the intestinal contents acid. If this latter statement is true, they act as a germicide, as the Shiga bacillus lives only in an alkaline medium.

Serum treatment: The reports from the use of serum are at variance. Rosenthal from the Moscow Hospital gives most encouraging results; a mortality of four and one-half to five per cent. Like diphtheria antitoxin, the anti-dysenteric serum must be given early. Any one who has had experience with diphtheria antitoxin knows he obtains best results when it is administered within the first twenty-four hours. The reason for it is that the antitoxin neutralizes the poison before the toxin begins to paralyze the heart muscles and nerve centers. Again, after two or three days, the system has to battle not only with the Klebs-Loeffer bacilli, but the streptococci also, and the antitoxin has no power over the latter. In summer diarrhoea, as a rule, for the first two or three days, we are dealing only with a Shiga bacillus infection, and the antidysenteric serum neutralizes only the toxins of this bacillus.

Dr. Casey: I would like to speak a few words with reference to the prophylactic treatment of the disease. The doctor had a great deal to say about the various micro-organisms which might, no doubt, be the cause of these intestinal troubles. Of course that is very valuable information from any standpoint; still we should not overlook the fact that during the summer months children that are badly fed are the ones that will die of these diseases. We know during the winter months

children have diphtheria if they have it at all, and men who make a study of these things tell us they find diphtheritic germs, if they develop the catarrhal stage that child will develop diphtheria. You take a child in the summer months, badly fed and badly nourished, and the slightest symptom, as the doctor has pointed out, should be looked upon with suspicion. Take cholera infantum, for instance; it is certainly toxæmia developed from pathogenic germs. He says he does not know how the germs obtain access to the system, but they get there; and in all probability, if the child was in a healthy condition the disease would not manifest itself. We know that the alimentary canal has a great many germs, and the point I wish to make is that we should not overlook the prophylactic standpoint of feeding the child. The old idea of over feeding, and the child must have loose bowels during teething months, from seven months to two years, I do not embrace. But there are two points of very great importance: One is the heat of the summer months, and the other is bad food. Now this is a subject, a disease, that concerns us all very much, and what we want to do is when we find a child with diarrhoea to look upon it with a great deal of apprehension.

Dr. Morris: I regret that I did not hear the paper. I will report some cases, however. They were cases of acute autoinfection, which occurred about one year ago, ranging in age from six months to two years. One child was a year and a half old, perfectly healthy, and fully developed; he was taken ill quite suddenly. The symptoms at first were those of vomiting and a generally depressed condition; there was no temperature, and the child would eat-no loss of appetite. This went on for twenty-four hours. The pulse was not accelerated, the vomiting became quite marked, the stools did not contain much undigested food, or any evidence of entero-colitis. This child went straight on and died, without acceleration of pulse, and the termination was in a comatose condition. We held autopsies on three children, and no evidence in the alimentary canal of inflammation; no colitis, no extension in any case, and the only thing on autopsy was the condition of the liver. Dr. Park has been working these cases up. He saw one case summer before last, and one case last summer. He is withholding his report on these cases in order to add to it. the experiences of this coming summer,

Dr. McAdory: This is an important paper, and I wish to rise and discuss the treatment of the condition and the causes which Dr. Welch has so ably gone into. I will say also that any ideas I may use are those of my friend Dr. Parke. The first thing I wish to impress on every doctor here is the importance of relieving the cases in an acute stage, and not to allow them to become chronic; for when they do become chronic you have a very tedious condition to deal with. In my experience, when I have one of these cases of dysentery in children, if I can control the mother-and if I do not control the mother I think I am to blame-and can clean the bowel thoroughly and withhold all forms of milk until the action from the bowel has become more nearly normal-until practically all musus and blood have been removed from the stools, and if I can nourish him on broth and water for five or six days, why, the child gets along all right. But as you all know, it is a matter of great difficulty to keep a mother from feeding the child, and it is a matter of the utmost importance to keep all forms of food away from the child until the diseased condition is practically well. Because, as the doctor truly states, the symptoms, and the cause of death, is really the absorption of toxins, and any form of nourishment that we give while the child is suffering from this acute condition will not be digested, but gives rise to decomposed matters and thus causes trouble. If any of you will recall cases of death that have occurred in this condition, if you will be really honest with yourselves, you will. see that the chief cause of death is auto-intoxication; and the main thing I wish to insist upon is necessity of vigorous treatment to begin with in order to relieve the condition in the acute stage and the necessity of withholding food until the bowel reaches a healthy stage.

Dr. McLester: I think I may add something to what Dr. Morris said. But recently Dr. Parke brought me specimens from the liver of each of these three cases, and for the past three weeks I have been working on these specimens. There is a good deal of degeneration present, fatty degeneration, and I think that is practically the only change in the liver. There are very few liver cells, all the cells having undergone fatty degeneration.

CYSTOSCOPY AND URETERAL CATHETERIZATION IN GYNAECOLOGY.

BY HENRY DAWSON FURNISS, M. D., OF NEW YORK.

In the practice of gynæcology one is impressed with the number of patients encountered suffering with symptoms referable to the uropoietic system. While bladder diseases are not so frequent in the female as in the male, they are plentiful enough. It seems that one reason for the more frequent occurrence in the male is due to the fact that the urinory stream is liable to be impeded by enlarged prostate, stricture, etc., while in the female an obstruction to the urinary outflow is infrequent. It is a well known fact, demonstrated experimentally and clinically, that the simple introduction of organisms into the bladder is not sufficient to produce a cystitis; to this must be added a predisposing cause, as congestion, obstruction to the outflow of urine, or traumatism as from an instrument of a stone. In the female, the shortness of the urethra and its position, render it liable to infection; besides this, the bladder is liable to infection from the extension of disease processes of the neighboring structures more often in women than in men. The liability of the extension of inflammation from the bladder up the ureter is greater in men than in women, owing to the fact that retention, with back pressure is more frequent in the male sex. The kidney affections may be primary (infection taking place through the blood), secondary to disease in other tissues, far or near, by deposit or continuity, or due to an ascending infection.

When a woman comes to you suffering with any urinary disturbance, it is important that a most careful history be taken, for some point that may seem trivial to her may give the clue to the whole situation. In the case of stone in the kidney, for example, hæmaturia with a slight pyuria may be the only symptoms present, because the stone so closely fits the surrounding structures that it is unable to move and cause pain; yet careful questioning may elicit the fact that years ago this

patient did suffer from pain in the kidney region. In others, the family history, or the history of the patient's previous health, may serve to direct your attention in the proper way. Recently I had a case in which a suggestive point was misleading. The woman was thin, and of the type often spoken of as tuberculous. When a child, she had arthritis of the right knee, with subsequent ankylosis. This immediately brought into my mind, taken in conjunction with the other symptoms, which agreed, tubercular cystitis; this was an error, as proved by the cystoscopic examination and the subsequent history.

A careful pelvic examination will bring out, or negative, diseases of the neighboring organs. In many instances a bimanual examination will enable us to mark out an area of disease in the bladder, the urethra or the ureters, which may be thickened and tender. The kidneys can often be palpated, thus learning something of their location, size, consistency and form. The urine should be examined chemically, microscopically and bacteriologically, especially where tuberculosis is suspected. The urine shows the signs or effects of disease. Sometimes from an examination of the urine we are enabled to determine the source of the blood or the pus present, but in most instances not. The finding of atypical cells, or the examination of pieces of growth passed in the urine will determine the presence and nature of a neoplasm. By a careful history, a thorough physical examination, and a painstaking urinalysis, we may be able to make a diagnosis of the nature of the disease and its location, but very often not; and it is just here where cyctoscopy, meatoscopy of the ureteral orifices, and ureteral catheterization furnish their most valuable aid.

A few words in reference to the method of examination and the instruments to be used. No one instrument and no one method is going to be found entirely satisfactory. Personally, I prefer an instrument of the water dilating variety, direct view with catheterizing attachment as embodied in the Tilden Brown instrument, for with this we can examine all of the bladder except the anterior wall and fundus, which are seldom affected, and catheterization of the ureters with a direct view instrument is far easier than with an instrument of the prism type. Nearly all examinations with the water dilating instruments can be carried on without anaesthesia, and