such as this (Slide XXI) is preferable. Here you see shadowgraph catheters curled up into the diverticuli shown in the previous picture. The next picture (Slide XXII) shows the same method of illustration in another case of bladder diverticulum in which catheters also are up the ureters. It illustrates the predilection of a diverticulum for the urethral area. This case is interesting because it presented the complication of a malignant papilloma growing out of the mouth of a diverticulum. This I removed by resecting the bladder wall with the diverticulum and the papilloma en masse. The specimen I pass around. With a catheter in the ureter I was able to get it off without resection of the ureter. The next case is that of bilateral uretero-vesicular valvular incompetency as illustrated by this picture (Slide XXIII). It is a picture of a young woman who, following labor two years previously, had an acute cystitis as a result of catheterization. It rapidly grew so severe that she was unable to hold her water at all. For two years her bladder has been entirely incontinent; therefore, she had given up all hope of enjoying life and had been bedridden for eighteen months. I attempted to cystoscope her but could find practically no bladder cavity and the procedure was so exquisitely painful that I had to give it up. I attempted various methods of chemical antisepsis which only made the girl's life more miserable. The cystitis was apparently of colon bacillus variety. She seemed to be a good case for inoculation with bacillus bulgaris which I did and her pain was relieved in almost twenty-four hours. Inside of two weeks she could hold her water for ten minutes, and inside of two months she held her water for one-half hour. At that time I took the picture you see here (Slide XXIV) which shows the uretero-vesicular valves to be entirely incompetent, and that her urinary vesicle includes ureters and renal pelvis and calices. The bulgaris bacillus treatment was continued. I was now able to cystoscope her and to pass catheters up to each kidney and do a differential renal function, in which I found the kidneys to be functioning normally, and I injected the bulgaris bacillus up into each kidney pelvis. Three months after the beginning of the treatment the patient was able to hold her water for two hours and had taken on fifty pounds in weight. She has been working in New Haven now for four months and last week came to me for examination at which time the bladder wall was practically normal and the urethral openings had almost closed down to normal. Radiographic fluid was injected into the bladder under double the pressure previously used and showed that the fluid leakage was greatly diminished (Slide XXV). This case is especially interesting inasmuch as it presents the problem of ascending infection to the kidney as the result of uretero-vesicular valvular incompetency not due to obstruction to the outflow of the bladder at the urethra but resulting entirely from interstitial cystitis. The method of treatment is of course not original, but is new enough to make me anxious to hear from others here as to their success with it. DISCUSSION. DR. A. C. HEUBLEIN (Hartford): Dr. Hepburn's slides are very interesting to me for Dr. Hepburn and I did the work together on many of his earlier cases. These cases represent the result of constant painstaking effort on Dr. Hepburn's part and a very slight effort on my own part. Pyelography is a most complicated procedure and yet it may become comparatively simple if the cystoscopist and radiographer combine their efforts. There are so many delicate steps in the entire procedure that if one part of the technique fails, the whole falls to the ground. Good team work is essential. I am sure that Dr. Hepburn agrees with me that this work should be carried on in the hospital and not in an office. It is perfectly obvious that stereoscopic negatives have a great advantage over the single plate, for the latter method may give the impression of a stone lying tangent to the skiagraph catheter when in reality it is a lymph node lying in front of or behind the catheter. If the apparatus for making stereoscopic radiographs is not available, we can frequently differentiate a urinary stone from a calcified lymph node by making two plates, one with a patient lying back to the plate, the other abdomen down. The greater distance the object radiographed is away from the plate, the larger the shadow, and vice versa. One thing I want to emphasize and that is to ground the tube stand if one is doing the cystoscopic work on the radiographic table. In one of our earlier cases the patient and Dr. Hepburn both experienced a shock which was disagreeable, spoiled our plate and paralyzed the patient's bladder sphincter for a few days. I am convinced that ureteral kinks are very much more common than is generally conceded. The only way that we can recognize this condition is by the method shown here to-day. I feel that it should be resorted to more frequently than it is at present, in most communities. DR. MCKNIGHT (Hartford): I would like to say, Mr. President, that I find myself in a very peculiar and unusual position. Heretofore after Dr. Hepburn and Dr. Heublein have made their examinations and located the trouble I have had to do the work, but in the present instance they have left nothing for me to do. I wish, however, to express my great appreciation of the value of the work they have done in their special lines. While I was sitting here in that frame of mind which a man usually is in when he knows he is going to be called upon to say something and has nothing to say, I was trying to recall an instance where they have located a stone in the urinary tract and I had failed to find it just where they said it was. I can't recall an instance, and I have operated on a number of cases that they have prepared for me. I will never forget one case where Dr. Heublein said there was a rather smooth oblong stone in the right kidney. It was a healthy looking kidney, looked perfectly normal. I couldn't feel that stone, and used all the means I knew of except opening the kidney, and I was about to give it up when I thought "If Heublein says it is there it is there,” and finally succeeded in pressing it out into the pelvis, from which it was easily removed. The case in which the doctor spoke about the calcified glands was very interesting. After I got them out I felt I wouldn't want to tackle many of those cases. These glands were surrounded by large veins which didn't show up when they were under pressure, and it was rather a piece of good luck than skill that we got them out without any accident. I am not in the habit of advertising much but some of my friends do it for me, and perhaps I will close by reading this extract from the Hazardville correspondent of one of our Hartford papers. It speaks of a certain person who had been operated upon and says: "The stone the surgeon removed from the kidney was a peach stone which Miss swallowed years ago. It was perfect in shape." DR. W. S. BARNES (New Haven): I think this proves to the members that urology is certainly a valuable aid to the surgeon. I do not know that Dr. Hepburn mentioned what he used as the material for injection. We have had reported cases in which there has been trouble from injecting the pelvis of the kidney with various silver salts. We have in a solution of thorium nitrate a very efficient preparation for demonstrating lesions along the urinary tract. I think that diverticuli of the bladder occur quite frequently. I recently had a case of this kind under my care in which the lesion was situated similar to that reported by Dr. Hepburn. It was situated very close to the right ureter and had existed for many years. In fact this case had been operated upon by a prominent surgeon in New York City for an obstruction at the neck of the bladder, probably due to prostate, but the condition proved to be a diverticulum of the bladder. DR. HEPBURN (Hartford): In regard to what radiographic fluid to use in pyelography, I started in with argyrol, 45%, and then collargol, but 15% thorium is, I think, the most valuable although personally I have never had trouble with any of them. I have been careful never to do pyelography where there was any sign of blood in the urine suggesting that the fluid might be forced into the circulation. The Treatment of Ectopic Gestation Based on CALVIN H. ELLIOTT, M.D., HARTFORD. In presenting this paper, I wish to state at the outset that I do not claim anything new in theory or results from previous writers. All I wish to do is to add our little list of cases and conclusions in hopes that it may be of some value to the medical profession. It is not in the scope of this paper to discuss the theories as to the causes of ectopic gestation, nor to discuss in detail the symptoms which are well known to all. I was able to get partial records of some and complete records of others, of thirty-four cases with two deaths during the last five years on our service at the Hartford Hospital. This does not include the cases on the surgical and private divisions of the hospital. From these thirty-four cases, only twenty-seven records were found in such shape as draw any conclusions. The following is a summary of the analysis of my examination of the records : 1. Age of patient.-Approximately 60% were between 20 and 30 years, 35% were between 30 and 40 years, 5% were 40 and over. 2. Previous history.—Approximately 60% were multiparous, 40% were primiparous. 3. Miscarriages had occurred in 9 out of 27 cases or 33%. Previous inflammatory diseases of pelvis were recorded in 4 cases or 15%. Ectopic gestation in the opposite tube was recorded in 2 cases out of 34 or 5.9%. Menstruation.-There was no menstrual disturbance in 4 cases or 15%. Present Illness.-Dated from a few hours to 42 months with an average of 3 weeks. Abdominal pain is the most frequent and impressive symptom. It occurred in 100% of the cases. The character was sudden and knife-like in 12 cases (44%), and “dull aching,” or general abdominal pain, in the remaining cases. Bloody vaginal discharge or irregular menstrua |