fifteen grains of quinine. At 4 p.m. he had another chill, and a temperature of 101° F. At 2 o'clock next morning he had another chill less severe, and his temperature rose to 103° F.; he had still another slight chill in the afternoon. His urine, unfortunately, was not measured during the first twenty-four hours after the operation. He passed some urine, however—I don't know how much; but it was dense, high-colored, and contained no albumen. He was very restless, complained of severe head-ache, and slept none at all for three days during this attack. His tongue was coated and he had no appetite. He had no pain, except the head-ache. All this time he was confined to bed and on milk diet; there was no vomiting nor diarrhoea. He was now thoroughly examined, and all his organs found to be healthy except his heart. He had both mitral and aortic disease, with great hypertrophy of the left ventricle. He was ordered spts. ether, nit. 3ss., tr. digitalis, mv. liq. ammon. acet. ii t. i. d. He had no more chills after the 7th, and by the 10th his temperature was normal and he felt quite well. On the 14th, a No. 5 gum-elastic catheter was passed, and left in the urethra for two hours; no bad results followed. This was done daily for the next three days without any chill or rise of temperature. On the 20th, at his urgent solicitation, he was put under the influence of chloroform and an attempt was made to pass Thompson's divulsor, but without success. No. 5 gum-elastic catheter was however passed and immediately withdrawn; this was about 2 o'clock in the afternoon. Next morning at 11 o'clock, twenty-one hours after the operation, he had a chill and his temperature rose to 103 3-5. He was given quinine, grs. xx, and by evening his temperature was 1013; next morning it was normal, but he felt impatient and discouraged. He was ordered to remain in bed and have a hot hip-bath night and morning. Two days later, business difficulties compelled him to leave hospital and return to the country, * and I have not heard from him since.

A

Now, it is an established fact in pathology that operations of any magnitude on any part of the body, are followed by febrile reaction, and as a rule this reaction is in direct propor

tion to the magnitude of the operation-or, in other words, to the amount of injury done, due allowance being made of course for the patient's surroundings, &c. This rule does not hold good in operations about the urethra and bladder, where the most trifling operation may produce alarming or even fatal results; while severe operations, such as lithotomy and lithotrity, external urethrotomy and rupture of structure by divulsion, are seldom followed by bad symptoms and hardly ever by the group of symptoms constituting the disease called "Urethral fever." This disease seems to follow as a rule the simpler operations on the urethra, as the passage of a catheter or the gradual dilatation of a stricture, and though it may occur in any patient, those who have diseased kidneys are thought to be specially liable to it; while the use of anaesthetics seems to afford protection against it. It generally sets in a few hours after the operation, and it varies greatly in degree, the simplest consisting of a chill, or perhaps two, followed by slight fever and head-ache, which continues for twenty-four or thirty-six hours, and then leaves the patient as well as before. This slight form is no doubt constantly overlooked, as the patient is frequently quite well by the time of the surgeon's next visit.

Secondly. There may be a severe rigor, followed by high fever, great restlessness or delirium, and in a few hours by profuse perspiration. These chills with fever and sweating may be repeated at intervals of a few hours for several days, and the patient recover in a week or two without the supervention of other more alarming symptoms; or, there may follow a number of days of general febrile excitement, delirium and prostration, with scanty high-colored urine, perhaps containing albumen, diarrhoea, and frequently copious perspirations. There may be remissions from time to time. To this class both the cases which I have reported belong,-the second case having a series of chills with high fever, lasting over three or four days; the patient in the first case suffering from continued fever for weeks, with many of the symptoms enumerated above, and also some pus in his urine, which I believe to have originated in the bladder.

There are still other cases in which the operation is followed by a violent rigor, high fever, prostration, alarm, anxiety and excitement, violent vomiting, profuse diarrhoea, suppression of urine, and death from uræmia.

Finally, true pyæmia and septicemia may follow operations on the urethra and bladder, as they follow operations elsewhere, and then they are frequently mistaken for urethral fever, which is not to be wondered at when we consider the similarity of the symptoms in these diseases. Pyæmic abscesses are found postmortem in the prostate, the liver, kidneys, joints, &c., and then these cases seem to support the view that urethral fever is essentially a form of pyæmia. Without going into the discussion of this subject, I believe that urethral fever is due to nervous shock, and that clinically it is not always discriminated from septicemia and pyæmia. In support of this view I would simply ask, in what other way can we explain its rapid onset and different degrees of severity from such different degrees of causaative irritation, or how can we call those symptoms pyæmic which set in two or three hours after the passage of a gum-elastic catheter which can scarcely have abraded the urethra, and before the passage of urine over the possibly abraded surface can have left anything for absorption by it? And, again, how seldom do these. symptoms occur in the course of the different suppurative diseases of the genito-urinary tract? With reference to treatment, the great object of course is prevention, for when once. established medication seems to have little, if any, effect. Knowing as we do that patients with kidney disease are specially liable to it, and that in them it is particularly dangerous, every case ought to be carefully examined before operation. and the patient placed in the most favorable conditions. Some surgeons recommend the use of five-grain doses of quinine, two or three times a day, for several days before the operation, Any operation about the urethra, or even the dilatation of a stricture, generally causes so much pain that anæsthetics are called for, and it is a satisfaction to feel that in using them you are not only sparing the patient the pain of the operation but lessening its risks. Tr. ferri. perchlor, in ten minim doses, three

times daily, has been used as a prophylactic, and Fleming's tr. of aconite in two minim doses immediately after the operation, has been very highly spoken of, and especially by Mr. Harrison, of Liverpool, who, in a recent clinical lecture (which was published in the Lancet last winter) said that he invariably used it and that he had found it almost unfailing.

Quinine in large doses may be said to be the standard remedy when the disease has been established. Diarrhoea, vomiting and suppression of urine, &c., and other special symptoms, must of course receive appropriate treatment.

CASE OF PARTIAL PLACENTA PRÆVIA.

By J. A. HUTCHINSON, M. D., C. M.

On the 20th of August last, I was called in haste to attend H. S. æt 33, a woman living on Bonaventure street, who was said to be bleeding from the womb. On my arrival at the house, I found a rugged French woman, seated on a chair in a weak condition. On enquiry she told me that she had had eight children and one abortion at the third month of pregnancy; that she was now in the seventh month of gestation; that her general health had always been good; that she had never any previous hæmorrhages, or felt anything unusual during her present pregnancy; that she had been engaged running a sewingmachine during the day, and had felt slight pains in the abdominal region; and that about two hours previous to my arrival, she experienced a severe pain, and felt that blood was escaping from the vagina. She then sent for her husband to come and bring a doctor, and, as previously stated, it was two hours before I was in attendance. She had remained in the chair all the time, being afraid to move, as she felt that the hæmorrhage was still continuing, and imagined that if she attempted to lie down, the child would be immediately expelled. This she wished to avert until a doctor was present. I at once caused her to lie down, and found that her clothes were saturated and the blood had coagulated in large clots. Fortunately, the hæmorrhage was easily controlled, and on a vaginal examination

being made, the os was found to be dilated to the size of a pennypiece. I could also feel the boggy and unresisting mass of the placenta, which was at first mistaken for a coagulum of blood. At this time I did not push the examination further, and finding the hemorrhage had subsided, allowed the patient to rest for a time. She had still a strong, regular pulse, and did not exhibit much evidence of exhaustion. The labor pains occurred at intervals, but were not at all severe. The child was still alive, as the foetal heart could be heard, and with greatest distinctness on the right side. Made another examination, and diagnosed placenta prævia, as what I had previously mistaken for blood clots could not be detached, and on auscultation the uterine souffle was heard with greatest distinctness over the site of the os. Under the circumstances, I deemed it advisable not to temporize, but to aid nature in the expulsion of the child, as it was then of a viable age, and, at any rate, this occurrence seemed inevitable. With this end in view, a moderate dose of ergot was administered, which was hoped to serve a double purpose, viz: to increase the contraction of the uterus, and by pressing the head of the child against the placenta, would check the escape of blood; and, also, to assist in the expulsion of the child. The necessity of puncturing the membranes was happily avoided, as at this time the liquor amnii began to escape. It did not seem to flow away readily, being, I think, impeded by the pressure of the placenta. At every pain an additional amount would be evacuated, and would be accompanied with clots of blood. When the os became largely dilated, I could pass my fingers up at one margin of the placenta, and feel the head of the foetus. The hemorrhage continued, though not to an alarming extent, in the intervals between the pains. At the next examination, found a hand down below the head and at the margin of the os not covered by the placenta. This I pushed up, and, at the same time, separated the attachment of the placenta from around the margin of the os. A strong pain following, the head came down, engaging in the os, and the child was soon after born in the second position. Unfortunately, the child showed no signs of life and could not be resuscitated.