ejected is large, even as much as one or three gallons in the twenty-four hours. The character is like paralytic gastrorrhea-thin, yellowish or greenish aromatic material, containing hematin and bile; the latter and pancreatic fluid may be present in large quantities. The odor is offensive, but not feculent. Epigastric or umbilical pain or distress usually comes later; the bowels are constipated, but movements may occur early. The quantity of urine is much diminished. Hiccough is a prominent symptom in some cases. The distension of the abdomen begins in the epigastrium and extends downward, and when extreme is more to the lower abdomen and to the left, while the right hypochondriac region is flat. The percussion note is not as tympanitic as in obstruction, and is flatter in the lower abdomen. There is a distinct splash, and by it the location of the greater curvature may be made out. There is great thirst, and the aspect of the patient indicates grave disease. The pulse becomes rapid and weak, while the temperature may be subnormal. It is usually from 100° to 101°. If the stomach-tube is used, a large quantity can be siphoned off. The diagnosis is from obstruction and peritonitis with gaseous distension. Obstruction high in the small intestine cannot always be differentiated. "Bloodgood states that in high intestinal occlusion, initial pain with peritoneal shock, which may somewhat later disappear, and vomiting without marked distension, are the symptoms which differentiate it from acute dilatation." In the latter the pain follows the vomiting, collapse is gradual and progressive, and the abdominal distension begins in the epigastrium. In high intestinal obstruction he (Bloodgood) found epigastric distension a very late symptom, and had not found great distension present at the operation. Peritonitis, pain and fever are the early symptoms; vomiting comes on later, and the tympany begins in the lower abdomen. The temperature is generally higher than in gastrectasis. Prognosis is not so bad as at first supposed. The mortality is given 72 per cent. (Conner), 85 percent. (Thompson and Appel). More recently it is much less, and with early recognition, prompt lavage and proper posture, this mortality will be greatly reduced. In fatal cases death occurs usually in about seventy-two hours; it may occur in eleven hours, and has occurred as late as the tenth day. The treatment consists of prompt evacuation of the stomach by the stomach-tube, followed by copious lavage. It would be an excellent practice in all post-operative cases, whenever vomiting is prominent, to resort to this measure. In order to release the pressure on the duodenum, the patient should lie on the abdomen, with the foot of the bed elevated, or, in extreme cases, a knee-chest position. It is astonishing in grave cases to see the prompt relief given by these measures. The lavage should be re peated when the fluid reaccumulates, or if the condition of the patient does not improve. Strychnia and physostigmin have been given. Rectal feeding should be given. BIBLIOGRAPHY. 1. Alleman. F., 1900-01: Dilatation of the Stomach and Bowels follownig Laparotomy, with Report of a Case. Penn. Medical Journal, Pittsburg, vol. 44, pp. 403-411. 2. Appel, T. B., 1904-5: Acute Gastric Dilatation Following Operations and in Disease. Penn. Medical Journal, vol. 8, pp. 550-555. 3. Bonachi, 1905-6: Dilatation Aigue Postoperatoire de l'Estomac. Bull. et Mem. Soc. de Chr. de Bucarest, vol. 8, pp. 113-115. 4. Braun, W., 1904: Zur akuten postoperativen Magenauftreibung. Deutsche Med. Woch., Leipz., vol. 30, p. 1553. 5. Braun, W., and Seidl, H, 1907: Klinisch-experimentelle Untersuchungen zur Frage der akuten Magenerweiterung. Mitteil. a. d. Grenzgebiet d. Med. u. Chir., Jena, vol. 17, pp. 553-578. 6. Callender, G. R., 1908: The Condition of Acute Dilatation of the Stomach as a Post-Operative Complication After Laparotomy. Annals Gynecology and Pediatrics, Boston, vol. 21, pp. 416-422. 7. Chavannaz, G., 1905: Dilatation aigue postoperatoire de l'estomac. Bull. et Mem. Coc. de Chir. de Paris, N.S., vol. 31, pp.866-70. 8. Idem, 1909: Dilatation aigue de l'estomac apres gastroenterostomit. Journal de Med. de Bordeaux, vol. 39, pp. 5-7. 9. Cohnheim, P., 1899: Ueber Gastrektasie nach Traumen, die Aetologie der Magenerweiterung (etc.). Archiv f. Verdauungskr., Berlin, vol. 5, pp. 405-44. 10. Discussion on the Causes, Diagnosis and Treatment of Dilatation of the Stomach. British Medical Journal, London, vol. 2, 1902, pp. 1389-1397. 1. Ferguson, A. H., 1902: Three Cases of Acute Gastrectasia, Two Following Operations. Am. Jour. Obst., New York, vol. 46, pp. 247-58. 12. Halstead, A. E., 1906: Acute Post-Operative Dilatation of the Stomach. Annals of Surgery, Philadelphia, vol. 43, pp. 469-72. 13. Idem, 1906: Acute Post-Operative Dilatation of the Stomach, with Report of a Cace Following Nephropexy. Surgery, Gynecology and Obstetrics, Chicago, vol. 2. pp. 13-17. 14. Hamilton, J. A. G., 1905: Acute Dilatation of the Stomach Following Abdominal Section. Transaction Australasian Med. Congress, Adelaide, 1907, vol. 7, pp. 265-68. 15. Knoll, C. A. F. W., 1903: Ueber traumatische Magenerweiterungen, Diss. Berlin. 8. 16. Lee, E. W., 1908: Post-Operative Acute Dilatation of the Stom. ach. Internat. Journal Surgery, New York, vol. 21, p. 20. 17. McEvitt, J. C., 1906: Post-Operative Acute Dilatation of the Stomach. New York State Journal Med., N. Y., vol. 6, pp. 284-88. 18. McWilliams, C. A., 1908: Acute Post-Operatice Dilatation of the Stomach; Report of a Severe Type, with Recovery. Surgery, Gynecology and Obstetrics, Chicago, vol. 7, pp. 294-98. 19. Miller, C. J., 1907-8: Acute Dilatation of the Stomach as a Post-Operative Complication. New Orleans Med. and Surg. Journal, vol. 60, pp. 621-29; also Transactions Southern Surg. and Gynecol. Assn., Phila., 1907. vol. 20, 1908, pp. 33-50. Also Am. Jour. Obst., New York, 1908, vol. 57, pp. 262-65. 20. Mueller. P., 1900: Ueber acute postoperative Magendilatatiɔa etc.). Deutsche Zeitschrift f. Chirurgie, Leipzig, vol. 56, pp. 485-511. 21. Neck, 1905: Die akute Magenerweiterungen. Sammelreferat. Central bl. f. d. Grenzgeb. d. Med. u. Chir., Jena, vol. 8, pp. 529-34. 22. Nicolaysen, J., 1908: Postoperative Ventlikel Dilatation. Forh. i. Kirurg. foren., 1907, Kristiana, pp. 49-63. 23. Rogers, P. F., 1908: Acute Post-Operative Dilatation of the Stomach. Milwaukee Med. Jour., vol. 16, pp. 117-120. 24. Rousseau, P., 1907: La Dilatation aigue de l'estomac postoperatoire. These, 8 Bordeaux. 25. De Rouville, 1908: Dilatation aigue de l'estomac postoperatoire. Montpel. Med., vol. 26, pp. 169-183. 26. Roux de Brignoles, 1906: Sur la dilatation aigue post-operatoire de l'estomac. Marseilles Med.., vol. 43, pp. 422-433. 27. Seelig, M. G., 1907: Post-Operative Acute Dilatation of the Stomach (Gastro-mesenteric Ileus). Inter-State Med. Jour., St. Louis, vol. 14, pp. 517-524. 28. Smith, S. B., 1907: Two Cases of Acute Dilatation of the Stomach Following Abdominal Operation. Jour. A. M. A., vol. 49, p.941. 29. Stewart, J. W., 1903: A Case of Acute Dilatation of the Stomach Associated with Operation; Fatal Termination. Lancet, London, vol. 1, p. 1303. 30. Thoma, F., 1908: Ueber akute postoperation Magen dilatation und ihre Beziehung zum arterio-mesenterialen Duodenal verscluss. Deutsche Med. Woch., Leipzig and Berlin, vol. 39, pp. 501-504. 31. Turner, C. B., 1905: A Case of Acute Dilatation of the Stomach After an Operation on the Kidney. Lancet, Lond., vol. 2, p. 292. 32. Vincent and Bernasconi, 1906: Dilatation aigue de l'estomac a la suite d'une operation de hernie inguinale. Bull. Med. de l'Algerie, Alger, vol. 17, p. 397. 33. Wilkinson, H.,1908: Acute Dilatation of the Stomach Following an Operation for Acute Suppurative Appendicitis. Journal Kansas Med. Soc., Kansas City, vol. 13, pp. 462-465. 34. Beck, C., 1906: Akute postoperative Magendilatation im Kindesalter. Jahrb. f. Kinderkr., Berlin, vol. 62, pp. 102-119. 35. Hunter, J. B., 1887: A Case of Acute Dilatation of the Stomach Following Laparotomy. Boston Med. and Surg. Jour., vol. 62, p. 361. 36. Conner, L. A., 1907: American Journal Med. Sci., March. 37. Simpson, F. F., 1907: Amer. Jour. Obst., September; Halstead, 1907: Surg.. Gynec. and Obst., January. 38. Fenger, Christian, 1898: Clinical Review, Chicago. 39. Appel, Theo., 1908: Philadelphia Med. Jour., October. 43. Bloodgood, Jos. C.: Annals Surgery, November, 1907. DISCUSSION. DR. JESSE E. MYER, St. Louis, Mo.: My experience with acute dilatation of the stomach has been confined largely to its medical aspects. It has been my opportunity, however, to observe dilatation of the stomach following surgical conditions, and I recall in particular two well-pronounced cases. seems to me that the great difficulty has been in the early recognition of this condition. I am firmly of the belief that many cases have been considered • peritonitis which were really acute dilatations of the stomach, and if the condition had been recognized early the trouble might have been arrested. The dilatations of the stomach that occur from a medical standpoint purely, it seems to me, do not differ greatly from those that you meet with following surgical operations. We recognize medically those conditions due to mechanical causes, such as overfilling of the stomach, and those conditions which may arise without any mechanical cause. These cases have been met with in typhoid fever and pneumonia especially, also in infants with acute gastritis, and upon several occasions cases of acute dilatation of the stomach have been reported in persons who have simply had an acute indigestion, and the intense vomiting resulted in an acute dilatation of this organ. Many of the surgical cases have been attributed to acute gastro-mesenteric ileus. It has been shown very clearly by Kemp and Connor that many cases of acute dilatation of the stomach following surgical operations can be directly attributed to the tension of the intestines upon a long mesentery, the intestines falling into the pelvis without the mesentery being long enough to enable them to rest upon the floor of the pelvis. That being the case, it seems to me it would be well in these cases to consider the condition of the patient prior to operation, namely, as to whether or not they are individuals with typical enteroptotic habitus-with relaxed abdominal walls, in whom long mesenteries usually exist, and in whom enteroptosis can be demonstrated prior to operation. It seems to me that if the surgeon would consider the existence of this condition, and would bear in mind the effect that the exaggerated Fowler position might have upon these patients, together with the application of a very tight binder, prophylaxis might be employed. It seems some of these cases might be prevented. I have not been able to learn from the cases I have reviewed whether or not cases of gastroptosis and enteroptosis have been more prone to dilatation of the stomach than others. The stomach-tube should be applied as soon as the patient spits up small quantities of stomach contents instead of waiting for actual vomiting to begin. I have seen cases in which I felt that an acute dilatation of the stomach had been averted through the prompt and effectual use of the stomach-tube. It is unnecessary to say that in those cases in which a disturbed motility of the stomach can be demonstrated prior to the operation, the stomach should be emptied by the use of a stomach-tube prior to operation, whether the operation be done on the gastro-intestinal tract or upon other portions of the body. If a careful, painstaking examination of the gastro-intestinal tract were made prior to every surgical operation, and the stomach emptied where necessary, acute dilatation of the stomach might be obviated in some of these cases at least. DR. DANIEL N. EISENDRATH, Chicago, Ill.: Any one who has ever operated on a clean case-for instance, a case of gall-bladder trouble-or has done any operation at all in the abdomen, and seen the horrible picture of an acute gastric dilatation come like a bolt of lightning from a clear sky, would be impressed as by nothing else in surgery. To every one who operates a good deal, this experience comes without warning, even in patients who did not have, as a rule, any enteroptosis. I have seen it occur in children and in young healthy adults in whom there could be no question of the existence of enteroptosis. It is a condition which, unless you recognize it early, is very apt to prove fatal. What causes it? It is caused by an enormous displacement of the diaphragm and heart, so that they cannot find room to move, thus interfering with cardiac pulsation. One of the first causes of acute dilatation of the stomach I had was that of a man upon whom I operated for gall-bladder trouble. These cases are undoubtedly toxic. It is not necessarily in the least the fault of the operator that this condition of acute dilatation of the stomach occurs, but it seems to be a toxic condition associated with infection of the bile passages that causes paralysis, in all probability. There are two theories that have been brought out in this connection, and one is a paralysis of the muscular wall of the stomach, resulting in this enormous dilatation, so that the stomach reaches down as far as the umbilicus at times. This occurs especially in gall-bladder cases. We have made a study of some ten or twelve cases of this kind occurring at the Michael Reese Hospital, and we found some characteristic changes. In the first place, we found that in association with the acute dilatation of the stomach there seemed to be multiple hemorrhages from the mucous membrane of the stomach into its contents. This is one of the most characteristic symptoms or signs of acute gastric dilatation following operations upon the bile passages. This man whose case I have just mentioned was a healthy individual. He had come all the way across the Atlantic from Berne, Switzerland, to be operated on. He preferred to be operated on here rather than in Switzerland. He came across with a septic gall-bladder, a gall-bladder which showed areas of gangrene. He was operated on by me, and everything went smoothly; his bowels moved the morning after the operation, so that he was feeling first-class. About four o'clock in the afternoon the nurse reported to me that he had vomited. She showed me the vomitus, and this is a characteristic of post-operative acute gastric dilatation, namely, the vomitus is never in small quantities. It is always from eight to sixteen ounces or a quart at a time, and the moment you have vomiting of this character a brownish, sour vomitus in large quantities-look out for acute dilatation of the stomach. Further examination verified the other points which have been made by Dr. Walker. If you percuss the upper epigastric region, you will find it is enormously distended. If you percuss the heart, you will find that heart dullness is almost obliterated. Dyspnea is extreme, as is also cyanosis. The pulse runs up to 150 or 160, till the patient gets relief from lavage and other methods. This patient had four vomiting spells in quick succcession, vomiting a considerable quantity each time. Our first thought or idea was that perhaps we had a general peritonitis to deal with. How shall we make a differential diagnosis? That was brought out by Dr. Walker. A differential diagnosis between post-operative obstruction and acute gastric dilatation may be made in this way. If the patients improve rapidly, as they usually will the moment you perform gastric lavage, there will be magical improvement. If you wash out the stomach and the patient does not improve considerably, then you may reasonably conclude that you have to deal with an acute gastric dilatation. Following postFollowing postoperative ileus or post-operative peritonitis, the entire abdomen is distended. Of course, it is hard to make a differential obstruction high up and an acute gastric dilatation. In general, these forms pertain to the small intestine, in which there is uniform distension of the abdomen. In peritonitis the pulse does not jump up suddenly from the time the temperature rises, but it has been going up to 80, 90, 110 and 120, and it is not surprising that the patient should vomit. A rapid pulse does not accompany the vomiting. One patient vomited after the stomach was emptied with the stomach-tube; the patient passed a small quantity of gas and a small quantity of feces. These patients will not do that in all probability, especially twice in succession, if they have peritonitis or ileus. Now, in regard to the etiology. The condition occurs, as we know, from a medical standpoint, in cases of typhoid fever. I saw a case in consultation in which there was supposed to be a perforation from typhoid fever with general peritonitis. The case terminated fatally. Autopsy showed an enormous acute gastric dilatation. In regard to the treatment, it is said that gastric lavage should be undertaken immediately after the operation. In discussing this subject at a meeting of the Western Surgical and Gynecological Association last December, Dr. Chas. Mayo made a statement which impressed itself upon my mind, namely, that their interne every afternoon made the rounds with a stomach tube thrown around his neck, so that he was ready to use the tube immediately. In addition to lavage, position is very important. Position has been brought out lately by a writer in one of the German medical journals. He emphasizes in his article the importance of the prone position of the patient. I have tried the right-sided position after the suggestion of Kehr, the idea being to empty the stomach better, but the prone position is one well worth a trial. DR. J. E. GILCHRIST, Gainesville, Texas: I have been very much interested in Dr. Walker's paper and in the discussion and would like to mention one case that came under my observation. I operated on a man last June for chronic appendicitis. He had attacks of vomiting before the operation. The operation went off about as usual; the patient did well until the afternoon of the second day after operation, when he reached out and got a pitcher of water that was lying on the washstand near his bed and drank considerable water. That night he began to complain of his stomach and of belching a little. When I saw him early the next morning he commenced spitting up this dark-colored fluid, and he was constantly regurgitating this fluid, but not vomiting. I made an examination and found that he had a large stomach, the stomach reaching considerably below the umbilicus. I introduced a stomach tube and got at least a quart of this dark-colored fluid. It was much darker than Dr. Walker has described as being the usual color of the fluid coming from the stomach in these cases. We recognized the condition and elevated the foot of the bed, but we did not use the stomach tube as often as we ought to have done at first. We used it every six or eight hours. He would begin to vomit each time before we used it again. We used it then every three hours and in that time, not taking anything into his stomach, we would get between a pint and a quart of this dark fluid out of the stomach after introducing the tube each time. We continued washing his stomach after getting the fluid out of it. We ran normal salt solutions through his stomach, and it took a gallon and a half before it would come out black. This man's pulse remained from 80 to 100, but at one time it was 120. He did not suffer a great deal of pain, but the distension of the abdomen was enormous for three days when he began to get better. We made use of lavage every three or four hours, keeping his stomach washed out, and after the third day he began to improve and has made a good recovery. DR. EDWIN WALKER (closing the discussion): I read this paper not with a view to offering anything new, but to call the attention of surgeons to this condition, as I am satisfied it will lead to an early recognition of these cases which is the most important thing. Where there is any doubt after operation I believe we should resort to lavage, and I, for a while, would allow the patient to drink large quantities of water and wash out his own stomach. But, of course, that is not so effectual as the stomach tube. This condition occurs much more frequently than we have supposed in the past, and I have seen a number of mild cases where there was distinct dilatation in the epigastric region, which disappeared after lavage, but which would have been serious if not recognized. I have had the opportunity of watching a severe case which followed an injury. The man was in a ditch and a large quantity of dirt fell in and he nearly died of suffocation. Afterwards he had a distinct dilatation of the stomach and on lavage he spat up gallons of greenish fluid. By repeated lavage and the prone position he recovered promptly. The prone position is more suitable in this particular condition than any other, and in many of our drainage cases it is more suitable than the Fowler position. I have used it to advantage lately in some cases of appendicitis as well as in some cases of peritonitis. THE average man on the street seems to feel that his knowledge about stovaine is quite the equal of what his family physician knows about the anesthetic. JAPANESE physicians are restrained by law from advertising their skill through the press. SOME REMARKS ON LIFE INSURANCE polyuria, persistent low specific gravity, and the EXAMINATIONS WITH REFERENCE TO URINALYSIS AND TUBERCULIN REACTIONS. BY CLARENCE W. LEIGH, M.D., Professor of Phthisiotherapy in the Illinois Post-Graduate IFE insurance examinations are intended to ascertain if applicants for insurance are, in all respects, first-class risks or not. The presumption that individuals are insurable or not is based on statements made by them relating to their personal and family history, and on the physical and laboratory findings of the examining physician. By requiring the medical examiner to question and record all the facts relating to the first part of the examination, it is believed more accurate data may be elicited than if done by the solicitor. Information relating to personal and family history will characterize the risk, and can best be obtained by the examiner, and properly should be a part of his duties. The method usually pursued, however, is to read rapidly the various interrogatories, and enter the replies as briefly as possible. The applicant certifies to the correctness of the statements, and the physician attests his signature as a witness, with date and place of examination. There are good reasons for having this work done by the examiner, but, as a matter of fact, it is generally conducted in the perfunctory manner described. It is regarded by him also, and not without reason, as an onerous and more or less clerical duty, and therefore of less value to the company in determining insurability. It would seem the time required in performing labor not strictly medical might with better reason and profit be devoted to a more rigid scientific physical and laboratory examination. Present methods are somewhat obsolete. Unless there are good reasons for doing so, examinations should not be made at the applicant's place of business or residence, or in the presence of other than the examiner and his assistants. It would be better that examinations were made in an office especially equipped for this work, and a good laboratory is the most important part of the equipment. The examiner should also be a competent laboratory man. Chest examinations should be made in a room as free from noise as possible, and all applicants be required to bare the chest. It is ridiculous to assume chest examinations can be made under other circumstances. Urinalysis, as generally conducted, affords but meager information. For example, sugar may be found in the urine, and, while highly significant, may not be necessarily associated with diabetes. A chronic interstitial nephritis may exist without the presence of albumin in the urine, and the only evidence of the disease is found in a history of finding under the microscope of a few hyaline casts. On the other hand, albumin may be found due to the presence of pus from a pyelitis. Again, a pyelitis may exist with only traces of albumin, the quantity depending on the amount of blood and pus. To state that the urine is acid or alkaline, conveys no further definite information. The acidity may be normal, or of a high degree and due to metabolic disturbances. In acute cystitis acidity is the rule, but microscopic examination shows blood, pus and epithelium. Chemically, albumin is also present. In chronic cystitis it is alkaline, and contains bacteria, triple phosphates, albumin and large quantities of epithelium. A condition known as acidemia or acidosis may be present, due to auto-intoxication, and is often associated with pulmonary tuberculosis. Harrower, in a recent communication, emphasizes his belief in the frequency and importance of acidemia as a complicating factor in this disease. Many individuals having the appearance of being in excellent health harbor incipient tubercular foci. There may be no suspicious findings. Much has been said about the early diagnosis of tuberculosis, and the writer desires to state emphatically that while it is possible, it is not at all probable, that the disease in its strictly incipient stage can be diagnosed except by reaction. Under these circumstances it is necessary to resort to some one of the various tuberculin tests, which at least tend to corroborate or disprove the existence of the disease. It is true a tuberculin reaction alone, whether ocular, subcutaneous, or percutaneous, is not to be regarded as absolute evidence of tuberculosis. Considered, however, in conjunction with other signs and symptoms, it is highly significant and sufficiently conclusive to be of positive practical value. Wolff-Eisner believes ocular reactions occur only in the presence of active and not latent tuberculosis. Other observers object to this view, and insist that both the latent and active forms react to the test. However, this method of application is sometimes followed by serious results to the eye, and, as a rule, shoudl not be employed by the general practitioner. While it may be the most reliable, the subcutaneous method is not practical, as applied to life insurance examinations, owing to the necessity of keeping the individual under close observation and strict control, together with an accurate record of the pulse and temperature for several days prior and subsequent to injecting. In the hands of physicians who have had but little experience with tuberculin the subcutaneous. method is also not without danger. In fact, the possibility of converting a chronic into an acute type of the disease is never altogether eliminated, even in the hands of competent and trained men. The value of the Von Pirquet reaction may be questioned because it so frequently occurs in indi viduals apparently free from tuberculosis. A negative result, however, should be regarded as important evidence against the existence of the disease. As to the comparative merits of the Von Pirquet and Moro or percutaneous method, it would seem that the latter, in addition to being the more convenient, is also the more reliable, especially in adults, as fewer reactions result in apparently tubercularfree individuals. However, failure to react from any tuberculin test is of great importance in determining the existence or non-existence of tuberculosis. The Moro reaction may be safely used by any one. It exhibits itself with constitutional disturbances, either general or at the site of lesion; it is simply and readily applied, and without the necessity of preliminary pulse and temperature records for purpose of comparison. Autopsies confirm tuberculin tests in a large percentage of cases examined, and, next to the discovery of the tubercle bacilli, are probably the most reliable methods at hand for diagnosing tuberculosis in its early stages. When a reaction occurs, the most positive evidence to the contrary must be adduced to justify us in dismissing the case as not tubercular. It is surprising that these tests are so seldom used, not only in life insurance examinations, but in private practice. Society Proceedings. OBSTETRICAL SOCIETY OF PHILA- Stated Meeting, Thursday Evening, November 4, DISCUSSION. I DR. WM. S. WADSWORTH (by invitation): I have seen many cases of death from hemorrhages into the abdominal or pelvic cavities. Some of them might throw light on the present discussion. have never seen a case of furious hemorrhage from a corpus luteum, though I have seen small hemorrhages from a ruptured ovarian cyst and several from a post-ovulation cyst. The hemorrhage cases that come to my mind were mostly following injuries due to falls or other violence, occasional cases from ruptured aneurism and varicose veins, and a few in cases of purpura which were toxemic in nature; with these a limited number of cases of extrauterine pregnancy. Without the history in these cases it would have been difficult at the time of death to distinguish between hemorrhage from extrauterine and other causes. The history in most cases renders definite diagnosis possible. There is in most cases of extrauterine pregnancy a tendency to intermittent hemorrhages, which is not so commonly found in the other cases. When the case was one of extrauterine pregnancy seen in the first hemorrhage, it would be difficult, because such cases are often thought by the patient or family to follow some strain or violence. When violence has been done to the uterus in attempting to produce abortion in the early months of pregnancy, such as "opening the womb" with a knitting needle or hatpin, when a misleading history had been given, much difficulty might be found in ascertaining the cause of the hemorrhage. In the cases of extrauterine pregnancy I have been able to study, the effects of the hemorrhage, including shock, have been more suddenly developed and out of proportion to the injury reported. In nearly all the cases when external violence caused hemorrhage which was slow enough to allow of treatment being applied, the hemorrhage has been more gradual, often taking hours to make a fatal termination. In purpura there would be a history of infection, fever, chills, or other symptoms, though I had a case of a foreign woman who could not speak English, who died of malignant malaria with severe internal purpura, though the case was reported as a suspicious one by two physicians who had attended the woman. Neither these physicians nor those at the hospital where the woman died had thought of malaria, and it was only after great trouble that a clear history of her case was obtained. Hemorrhage from any sort of cyst that has ruptured might simulate that from extrauterine pregnancy, but all these cases call for immediate opening of the belly, so that the matter of accuracy in diagnosis before operating is of relatively little importance except in aneurism of the large vessels. DR. RICHARD A. CLEEMAN: I recollect quite an extraordinary case, not in my own practice; I saw the woman after she was dead. She was in about I the eighth month of pregnancy; another doctor had been in attendance all night and was called away. The patient got so much worse that they sent for me, but she was already dead when I arrived. opened the abdomen to see if I could save the child, which, however, was dead. The whole abdomen was full of blood, which I suppose came from a rupture of blood-vessels somewhere in the broad ligament. DR. GEO. M. BOYD: I have never seen a case of pelvic hemorrhage or pelvic hematoma other than from ruptured ectopic gestation. DR. J. M. BALDY: The subject bears rather closely upon the present agitation of operation or no operation in ectopic pregnancy, and would seem to conflict considerably with the views of those who are inclined to hold their hands in such cases. DR. B. F. BAER: I think all of the cases of hemorrhage within the abdomen or pelvis I have met with have been the result of ruptured ectopic pregnancy. I have seen slight hemorrhage from ruptured hematoma, but not enough to amount to shock. |