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with white blood cells in various stages of degenera- tion. The vessel walls were swollen and the lumen of the arteries was crowded with corpuscles. Around some of the larger arterioles the lymphatic engorge- ment was very great; the cells were densely crowded together and evidences cialis generico tadacip of granular degeneration were very apparent. The tadacip 5mg online perigangl ionic spaces were occu- pied by a serous infiltration, which in some places gave way to an enormous crowding together of lym- phocytes. The cortical cells in close proximity to the ialood-vessels were swollen; the nucleus was distinct and the protoplasm was vacuolated in some instances. The condition of the nerve cells varied greatly in dif- ferent fields examined. Chemical Examination. — Briefly, the chemical analysis of the cerebro-spinal fluid resulted as follows: First puncture : amount, seventy-three cubic centi- metres, clear; reaction, neutral; specific gravity, 1. 010; albumin, 2.25 per cent.; chlorides, 4 per cent.; urea, o.i per cent.; sugar, negative: traces of phos- phates, sulphates, and globulin. Frotagon was also tested for and found. Second puncture: amount, sixty-six cubic centimetres, cloudy and opaque; reac- tion, neutral; specific gravity, i.oog: albumin, 3.5 per cent. ; chlorides, 4.5 per cent. ; urea, o. i per cent. ; phosphates, 0.75 per cent.; sulphates, 0.25 per cent.; sugar, negative. White and red blood corpuscles, pus corpuscles, and hamatin crystals were also present. The large amount of albumin present suggests an intense inflammatory condition of the membranes, which evidently steadily progressed, as the albumin increased from 2.25 per cent, in the first specimen to 3.5 per cent, in the specimen of fluid obtained imme- diately after death. The chlorides and other salts, traces only of which are present in normal fluid, were found to be greatly in excess, particularly in the speci- men from the last puncture. Bacteriological Examination. — Many precautions were taken in collecting the fluid during tadacip erectalis 20 mg both lumbar punctures so as to exclude all possibility of cialis generika tadacip contami- nating it with e.xtraneous germs. The needle, tube, and glass receptacle were previously sterilized by steam; the fluid was kept at the body temperature by means of hot moist tadalafil tadacip 20 mg packing about the tube and gradu- ate, and the latter was kept covered with .sterilized gauze. As soon as tw-elve cubic centimetres were collected, that amount was transferred to a sterilized precipitating tube and the latter was plugged with sterilized cotton. The liquid, after standing twelve hours, was placed in a centrifugal machine and its suspended solids were precipitated. Aiier tadacip online kaufen precipita- tion the supernatant fluid was drained off and the floc- culent precipitate was stained by Gram's method and mounted in balsam. This method of precipitation and staining, with the tadacip pille 20mg cialis generika exception of keeping the tem- perature of the fluid at 100° F., was carried out after the second puncture. On examination of the slides prepared from the fluid of the first puncture, large numbers of the micrococcus pneumonia; crouposa; were found, together with an occasional streptococcus pyogenes. Slides from the fluid of the second punc- ture revealed an increased number of both germs, particularly the streptococcus. Pus cells were numer- ous in each field examined from the fluid of the sec- ond puncture. As the writer had no facilities for making cultures of the germ, an attempt was made to demonstrate its specific nature by the inoculation of rabbits. Two tadacip price in india were inoculated from fluid of the first puncture, tadacip 20 price india as follows: buy tadacip canada The aseptic precautions described above were supplemented by the use of a sterilized hypodermic needle, and the fluid was kept at a temperature of 100° F. until injected subcutaneously into buttocks of rabbit. Two cubic centimetres were injected into each rabbit. .\t the end of twenty-four hours both had an elevation of temperature of little more than a degree, and manifested symptoms of a mild .septica;- mic infection. At the end of forty-eight hours their temperature was still elevated and they were eating poorly. Twenty-four hours later they seemed to have regained their usual condition. Three rabbits w-ere inoculated with fluid from the second puncture in the manner described above. At the end of twenty-four hours two of them gave evidence of an intense infection, while the third gave birth to eight young, evidently premature. Of the young two died, while the mother manifested no further evidence of infection. The two remaining rabbits were greatly prostrated; their tadacip 5 mg temperature ranged from 103.8° to 105.2" F. (normal rabbit temperature, 103.1° F.); they refused to eat and lost weight rapidly. At the end of forty-eight hours one appeared to be dying, but both recovered after a few days. An examination of the blood of these rabbits revealed the same germ that was found in the spinal exudate, which here occurred both singly and in pairs. The microscopical appearance of the germ found in the spinal fluid and the blood of the inoculated rab- bits exactly corresponds to that of the micrococcus pneumonia; crouposa; or micrococcus Pasteuri (Stern- berg). Its virulence upon the rabbits, however, ap- peared much less than that of germs from pneumonic sputum, as the animals tadacip 20 mg uk usually die when inoculated with the latter. It is assumed, therefore, that the germs injected had from some cause or other become attenuated. Tlie subject needs further investigation by reinoculation and culture experiments with the fluid obtained by puncture before the identity of the germ can be established. The above notes are only August I, 1896] MEDICAL RECORD. 159 offered as an incentive to more thorougli work in sus- pected cases of bacterial peri-encephalitis. The features of particular interest presented in this case are: First, the temporary relief of the cerebral symp- toms and improvement in the patient's condition fol- lowing lumbar puncture. Second, the finding of a germ, probably the micro- coccus pneumonia' crouposa; in the cerebro-spinal fluid obtained during life. Third, the protraction of the delirium and the un- usual length of the disease (forty-six days). RUPTURE OF THE UTERUS.' Hv JOil.V C. MacEVITT, M.D., BROOKLV.N, N. Y. One of the most formidable, dangerous, and unex- pected accidents to the parturient woman with which the obstetrician has to contend is rupture of the ute- rus. Without the slightest premonition the attendant is carried from a peaceful contemplation of a natural process to a most direful result. buy cheap tadacip In the literature of the subject it is the exceptional author who outlines any premonitory symptoms, and they are so vague and difficult to appreciate that until time and experience designate more tangible evidence we will still rest in fancied security by the patient's bedside until in the presence of the disaster. The frequency of rupture of the uterus generika-apotheke tadacip is hard to determine, tadacip 20mg generic cialis owing not only to the failure of physicians to report their fatal cases, but to the fact that the greater majority of the cases are not recognized. Baudeloque in his thesis states that in his post-mortem examinations, after craniotomies, he ■ usually found a ruptured or contused condition of the organ. Sudden deaths during labor reported as due to concealed hemorrhage, shock, embolism, heart fail- ure, etc., are probably due to this cause. Statistics by foreign and American obstetricians of note, based upon personal and collected cases, range from one in four hundred to one in five thousand. This appar- ently great difference is undoubtedly tadacip by cipla due to the classi- fication of the injur)', some recognizing a tear of lim- ited extent in the cervix or body, whereas others recognize only those whose grave symptoms indicate laceration into the peritoneal cavit)'. Tears in which the whole extent of the cervix is involved, according to the theory of Kaltenbach, are of a non-traumatic origin. To cure a diseased condition remove the cause, is an axiom tadacip erectalis 20 mg tabletten in practice. In these cases, in most instances, the cause is unrecognizable until the harm is accomplished. Cases presenting a history of Casarean section, previous ruptures, or operation in- volving the uterus for carcinoma or fibroid neoplasm should put the attendant upon his guard to be in readiness to operate upon a moment's notice, or, bet- ter still, he should advise such a patient to seek treat- ment in some hospital where adequate skill and con- venience for operating under proper precautions exist. A successful operation, one of the very few, in which both mother and child were saved after a rupture with protrusion of the child into the abdominal cavity, was performed by Dr. Tucker, of Bay City, Mich., he for- tunately recognizing the rupture at the moment of its occurrence and performing without delay cceliotomy, buy tadacip uk his only instrument being a small penknife. Many factors enter into the etiology of this acci- dent. Eighty per cent, of these cases occurs in multi- pariE, due to a thinning and weakening of the uterine muscular fibres in previous labors. It is asserted and disputed that a healthy uterus can rupture itself ' Kead at the fourth annual meeting of the .•Association of Alumni of St. Mary's Hospital. through the force of its own muscular contractions. External violence, such as falls, blows, traumatisms in which the uterine tissue is injured, oftentimes pro- duces rupture. Freund relates a case in which labor appeared two days after the patient had fallen, strik- ing the enlarged abdomen against a curbstone, and in which the uterus ruptured shortly after the onset of labor. Disproportion between the size of the child and the maternal soft parts, as exemplified by statis- tics, shows a great preponderance of male children in these cases. Hydrocephalus was an early recognized cause ; also previous operation upon the womb, already referred to, laceration of the cervix, narrow pelves and pelves presenting abnormal bony prominences, the symphysis pubis and enlarged ileo - pectineal eminence being often at fault in this respect, and mal- presentations presenting irregular surface to the con- tracting uterine muscles: but above all I believe the greater number of ruptures is produced by bad man- agement and a failure to recognize imperative inter- ference early enough. Vou can easily understand how the administration of tadacip (generic cialis) ergot during the second stage of labor, so often indulged in by midwives and criminally incompetent practitioners, notwithstanding the well-known action of the drug, the untimely and unskilful use of the forceps, the condition of malpres- entation after the liquor amnii has escaped, when the woman has been in labor for hours, without pre- paring her for the ordeal by the administration of an ancesthetic, will lead to this accident. The following two cases will serve to illustrate gross incompetency in management. Case 1. — A poor, ill nourished Polish woman, the mother of two children, without any history of pre- vious difficult labor, was taken with labor pains on the morning of January 6th. In the afternoon a mid- wife was sent for, and, according to her evidence be- fore a coroner's jur}-. she found the woman suffering from pains every four or five minutes, with the os slightly dilated. Without waiting for complete dila- tation she ruptured the membrane. This was about two o'clock in the afternoon. At eleven she left the woman with advice to the husband to send for a doc- tor. The doctor arrived at 3 a.m. The woman was

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