installation, or flushing, may prove sufficient to finally relieve the patient of his distressing symptoms. If, however, they recur-as they may after a day or two in cases of severe infection-the installation may be repeated. At the same time the possibility of a complicating acute prostatitis should be considered, and a prostatic abscess, as the cause of a frequent recurrence of the symptoms in spite of careful treatment, should not be overlooked. 20 EAST FORTY-SIXTH STREET.

CLINICAL REPORTS.

Clinic-Buffalo Hospital Sisters of Charity

L. G. HANLEY, M. D,

REPORTED BY

JOHN STOWE, M. D., Interne.

EXTRAUTERINE PREGNANCY-OBSTRUCTION OF BOWEL-A RUPTURE

OF SAC.

CASE I.-February 2, 1909, Mrs. B., age 34; number of children, 4; no miscarriages; youngest child one year old, has had no sickness. Has always been regular with her menstrual periods till November 1, 1908, when she had menorrhagia, which lasted about three weeks. Menstruated December 20, 1908. Says she has been failing since October. Was admitted to hospital February 2, 1909, suffering from obstruction of the bowel. There had been no movement for six days, abdomen distented, tender, tympanitic, vomiting, and looks very anemic. Enemata were given highNobles and syrupus fuscus and water, no effect. Examination per vaginam: a soft boggy mass, circumscribed and filling the pelvic cavity. Hemoglobin, 30; white corpuscles, 10.600; patient prepared for operation. An opening was made in the posterior culdesac, when a dark sanguineous fluid escaped: on further examination the bowels and omentum were found adhered together by clots. A suprapubic incision was made and pelvis cleaned of all clots and membrane. The right tube was ruptured about the middle third, and from appearances must have contained a fetus of two months gestation, which, however, was not found, but might have been lost among the clots. There was over two quarts of blood in the abdominal cavity. It was necessary to separate and wipe several feet of bowel, so matted were they from adhesions. The uterus was twice its normal size; the right tube was removed, but the ovary left in place as it appeared healthy. Abdominal cavity flushed with normal salt solution. A vaginal drain was inserted, "patient placed in Fowler's position and stimulants administered. Patient improved and left the hospital March 18, 1909, cured.

INTERSTITIAL ECTOPIC GESTATION.

CASE II.-Miss W., admitted to hospital March 1, 1909, discharged March 20, 1909, age 22; family history, good; personal

history: began to menstruate at twelve years of age, regular every twenty-eight days. Present attack began January 28, 1909, with sharp pain in the right side; this was accompanied with nausea and vomiting, and she was compelled to remain home in bed for four weeks. Pain that was at first confined to the right side has become general over the abdomen.

Examination shows a tumor on the right side connected with the tube and uterus; patient prepared for operation, and on opening the abdominal cavity a tumor 4 inches long and 2 inches thick, with 4 inches of ileum attached was brought into view. Bowel relieved and tumor removed, which showed that the sac with the product of conception was partially in the uterus. Cavity in the uterus was closed, ovary not removed. Patient made a quick recovery.

ECTOPIC GESTATION.

CASE III.-Mrs. M., age 20, family history good. Personal history: no diseases except the ordinary diseases of childbirth. Menstrual period began at fifteen years of age, regular every month till December 5, 1908; was seen February 7, 1909, at 6 P.M., by Dr. P. H. Hourigan, who found her suffering from shock, pain in right side and all symptoms of internal hemorrhage. When admitted to hospital one hour later was pulseless, with rapid and shallow breathing; hemoglobin, 40, and in extremis. Patient given an anesthetic, abdomen opened quickly, when right tube was found ruptured. This was immediately clamped and hypodermoclysis, normal salt solution given. The abdomen was filled with blood, tube removed, but ovary left in place. Patient left the hospital in three weeks.

Double Vagina

BY IRVIN HARDY, A. B., M. S., F. S. Sc., Lond.

Surgeon in charge, Allegheny Heights Hospital, Davis, W. Va.

ABOUT September 25, 1903, I was called to see Mrs. B., age

The

23, white, primipara. I found her in labor; pains severe, which were coming on at intervals of fifteen or twenty minutes. After the usual preparation of hands and rubber gloves, I proceeded to make a vaginal examination and found what I at first thought to be a misused urethra, but by passing index finger into canal I found it opened into the uterus. I could feel the presenting part of child, which was vertex. This canal or abnormal vagina opened into uterus just at upper limit of cervix. normal vagina, which was below, was rather small. From below up their relation was, normal vagina, abnormal vagina, and urethra, as I shall show by diagram. The abnormal os was doing its best to dilate, so at first there was a question as to which vagina would afford passage for the child. Later on-about two hours the normal os dilated and while pains were severe she was unable to complete the labor unassisted. I called my asso

ciate, Dr. R. Hardwick, and we proceeded to deliver with forceps, lacerating the perineum somewhat. The child was normal. Since that time she has had two normal births with no trouble.

Urethra

Abnormal vag

Uterus

Normal vag

My reason for reporting this case is that so far as I can learn there is no similar case of double vagina on record, i.e., double vagina, single uterus; one vaginal canal directly over the other. If not, this should be made a matter of record.

THE

Retention of Urine and its Treatment

[The Hospital, February 27, 1909.]

HE danger of completely emptying the bladder in certain cases of retention of urine is probably not sufficiently appreciated by the majority of practitioners in this country, nor is it enough emphasised in the clinical teaching in our medical schools. Yet the fact is referred to by Sir Henry Thompson in his book published in 1888, and modern textbooks on the subject, both English and Continental, warn against such a danger. In cases of acute retention the bladder may be safely emptied without any fear of evil consequences, but it must be clearly understood what is meant by acute cases. Acute retention of urine not only means inability for the first time to pass water, but also connotes no history of increased frequency, of dribbling, pain above the pubes before passing water, or of ammoniacal urine; any of these symptoms will give rise to the suspicion that a chronic retention of urine has already existed unknown to the patient. Nor need there be any fear of emptying the bladder in those cases of long-standing retention where the bladder has never been allowed to remain partially distended for any length of time; that is to say, where the patient has been relieved daily

of his residual urine by the catheter from the very beginning. It is with cases of long-standing retention which have never been relieved by the catheter that the danger lies of death within any time from twenty-four hours to three weeks after the removal of the urine. The immediate cause of death is suppression of urine.

The whole urinary system in such patients, from the calyces of the kidney down to the bladder, is one large cavity; the opening of the ureters into the bladder is no longer oblique, and the normal valvular mechanism of this arrangement is gone; the ureters, the pelvis, and the calyces of the kidney are all dilated. As a result of these changes the kidney is turning out urine against pressure, and not under normal conditions. When the urine is suddenly drawn off this pressure is at once lowered, and the lining membrane of the whole tract lacks the support that it has accommodated itself to. As a result the parts become engorged with blood, leading to the injected kidneys and bladder hemorrhages mentioned above.

How then should a case such as this be treated? In the first place the patient should never be attended to in the practitioner's surgery; he should be put to bed either in his own home or in the ward of a hospital. By means of a catheter a small amount of urine should be drawn off, not more than one-third of the whole bladder contents. This amount, of course, cannot be accurately judged. If in an adult the bladder is well above the umbilicus, it probably holds three pints; if but just palpable above the pubes, only some fifteen ounces. An equal amount of warm boric solution may then be run in through the catheter, allowed to mix with the urine, which is probably foul, and then drawn off again. This may be done some three or four times, so that the fluid in the bladder then consists of urine mixed with boric solution. The patient should be kept quietly in bed, and in twelve or even twenty-four hours' time a further quantity may be drawn off, leaving behind less residual urine than had been left before. In this way in the course of some three or four days the bladder may be cautiously emptied with perfect safety. During this time the patient may be on a full diet for a person at rest, the bowels should be well emptied, and some urinary antiseptic may be given. If a catheter cannot be passed and a suprapubic puncture be found necessary the same precautions must be taken, and a small amount only of urine drawn off on the first occasion.

In acute retention there is no danger in rapidly emptying the bladder, and it is, indeed, necessary to relieve the patient of his pain. The treatment of this condition comes under two heads— to assist the patient to pass his water, or to draw it off by means of some instrument. The decision will depend on the cause of the retention and the amount of pain.

The common causes of retention of urine are three: gonorrhea, stricture, and enlarged prostate. In the first of these conditions it is sometimes said that a catheter should not be passed for fear of infecting the posterior urethra; but this objection is not of much weight, for acute retention does not occur in the acute stage of the disorder, and is due usually to a prostatitis supervening on a chronic or subsiding posterior urethritis, and is brought on by some neglect of treatment when the patient thinks he is getting much better. But the catheter in this condition should be used with extreme care. If a soft india-rubber one fail to pass, a No. 12 French coudé catheter can be tried. No doubt a hot bath and morphia will often relieve the patient in this condition; but it is not a treatment over which much time can be spent, as the patient is in extreme pain from a bladder that has never been distended before, and permanent damage may result.

In retention due to stricture the pain is usually not so great and the retention less absolute. It is useful in such cases to have from the start some definite line along which to work. First, an attempt may be made to pass a catheter, but not too much time should be spent over this. If this fails, the patient should have a hot bath and a dose of morphia, and while he is in the bath another attempt at catheterisation may succeed. Even if this does not, the patient will very likely be successful in passing a small amount of urine. He can then be left for, say, an hour, when a general anesthetic should be given and a third attempt made to reach the bladder with a catheter. If this again fails, the bladder must be punctured above the pubes. The best catheters for cases of stricture are the olive-headed French ones, and if morphia is given a dose of half a grain should be used; small doses are useless.

In the third class of cases, the old man with enlarged prostate, there are two methods that can be used, and two only-the catheter and supra-pubic puncture. Baths and morphia are not likely to be successful, and the use of the drug may be dangerous. A soft rubber catheter will often find its way in along the tortous urethra, and, failing that, the best kind to be used is the coudé or bi-coudé catheter. Whatever the cause of the retention, the immediate after-treatment is the same; keep the patient in bed, put him on a light diet, and get the bowels well open.

A

The Ophthalmo-tuberculin Reaction

[Abstracted by HERMAN D. ANDREWS, M. D.]

REPORT of 1,087 instillations of tuberculin in the conjunctival sac by a uniform method was made by Dr. E. R. Baldwin in the issue of the Journal of the American Medical