T. J. LYNCH, M. D., St. Joseph, Mo. Cases of death from hemorrhage due to a rupture of an extrauterine pregnancy are not infrequent in the literature of the subject, but in so far as the discussion in regard to the immediate versus the deferred operation for the relief of the condition continues to be unsettled, any case reports upon the subject should be of interest.

In reading the statistics of different authors in regard to different conditions, I often wonder if they take into consideration the vast amount of statistical information that does not come under the care of the large hopsital, or well known surgeon. In ectopic pregnancy the deaths from hemorrhage at time of rupture have been estimated at 5 per cent of those diagnosed before death in a large series of cases. If the great number of cases which die throughout the country without a diagnosis being made could be taken into consideration, it would no doubt be astonishing. Formad, formerly physician to the coroner of Philadelphia, reports that in 3,500 general autopsies, he found ectopic gestation to be the cause of death in 35. If it would be possible to obtain the length of time ensuing between the onset of the hemorrhage and the death of the patient it should be extremely instructive in determining the advisability of waiting for the reserve force" to be brought to a higher level. Death can and does ensue in a very few hours.

In performing 162 post-mortem examinations covering a period of eighteen months, I have found hemorrhage from a ruptured ectopic tube to have been the cause of death in two cases. These autopsies being those ordinarily coming under the province of the coroner. They are interesting on account of their similarity, and instructive in that, although we are led to believe that anyone competent to pass a State board examination, should be able to diagnose a condition so emphasized, as a possible case for at least diagnostic exploratory laparotomy three physicians in one of the cases, and two in the other, were given plenty of op

* Read before the Buchanan County Medical Society, St Joseph, Mo.

portunity to make a diagnosis and to suggest at least the possible necessity of a laparotomy, and all failed to do so.

In giving the history of the cases, it is necessary to give it as obtained by me, and to include that portion given to the physicians by the patients themselves before death.

Case I. Mrs. S., age 32; American. Family history not obtainable. Personal history, general. Was married at 20 years of age. Child born two years after marriage, alive and well at present time. Shortly after birth of child was deserted by husband, since then she has made her living by washing, doing house-work and general domestic service. At the time of her ill. ness, she was being cared for by an old man, who made his home with her. Place of illness was at the house of a friend, the inmates of the friend's house being not above reproach, morally.

Patient is a rather small but well developed woman, and to all appearances, was in good health before death.

Was unable to obtain any intimate personal history as to menstruation, etc.

History of Attack.-Patient did a large washing in the morning, and did not complain plain of any ill-feeling; ate a moderate noon meal and then walked a distance of twenty city blocks to the home of a friend, arriving at 2 p.m. Shortly after arriving, at the friend's home, she without any warning "fainted." All hasty efforts made to revive her, being unsuccessful, a physician was called who arrived at 3 p.m., or about one hour after the onset of the attack. While he was in the house, a second physician arrived and they examined the case together.

The woman was partially conscious, enough so that she could be aroused to answer questions. They ascertained that she was of the opinion that she was about three months pregnant, and that she had attempted to produce an abortion upon herself three days before, by introducing a catheter into her uterus. The patient vomited several times and complained of intense pain in her abdomen, while the physicians were present. No diagnosis was made-some pills were left for the patient's use and the physicians promised

to return.

In about an hour the friend of the patient began to look for another physician, on account of the alarming condition of the patient. He arrived shortly before the death of the patient, which occurred at 6:10 p.m., or four hours after the onset of the attack.

Autopsy the following day showed the abdomen literally filled with hemorrhage from a rupture of the right tube, rupture having occurred in the middle third. Pregnancy had progressed to something over three months.

On account of the history particular attention was given the uterus, it was large and soft and revealed no signs of infection or of puncture.

Case II. Age 28, American, single. Family history not obtainable.

Personal History.-Raised in country; came to city about three years ago. Had been the "friend" of one man for past two years.

History of Attack.-Worked at her trade of tent and awning worker during the entire morning; arrived at her boarding house at 12 o'clock noon, apparently in very good health. Ate a large meal and after eating, she ascended a staircase on the way to her room. At the top of the one flight stairway she fell, unconsciousness being complete.

A physician arrived in about thirty minutes, who furnishes the following history: Patient was unconscious upon his arrival, extremities cold, respiration shallow, eye reflexes very sluggish, pupils greatly dilated. After some few minutes patient was aroused to answer questions, but any clear history was very difficult to obtain, on account of the patient frequently sinking back to unconsciousness.

He ascertained that on account of the absence of menstrual flow for the past two months, she had gone to a doctor on the day previous, who had committed an abortion upon her. She complained of pain in the abdomen, but evidently her shock was so profound that the pain was only moderate.

The physician failed to make a diagnosis He left some strychnia pills, instructed those in attendance to give the patient some whiskey at intervals, and left the house, after insisting that the people call the man who had committed the abortion.

A second physician was called in a short time, who, obtaining the same history, gave the same advice and acted as did the first physician.

The first physician returned shortly after the death of the patient, which occurred at 6:15 p.m., or five hours and twenty-five minutes after the onset of the hemorrhage.

Autopsy showed that death had been caused from a rupture of the right tube, rupture occurring in the distal one-third of the tube, the fetus being free in the abdominal cavity. The abdomen was filled done the uterus, in the attempted abortion, with blood. No apparent damage had been as it was free from puncture or infection.

oc

In presenting these cases, I wish to call attention to the fact that the history of attempted abortion seem to be the excuse of the attending physician in failing to make a correct diagnosis. We should realize that no woman of the social status, cupied by these particular patients, becomes pregnant without endeavoring in some manner to have an abortion occur. Also that while a history of gonorrheal infection was necessarily not obtained, that in all probability both patients had been. infected at some time.

Both of the cases could be classed as ruptures of the distal portion of the tube, the portion which we have been led to believe gives the better chance of recovery, but both patients died within five hours.

With a proper diagnosis and an immediate operation, it would seem as if these patients could have been given a chance. 801 Felix.

A St. Joseph Poetess.

"TWILIGHT SLEEP."

BENJ. E. DAWSON, A. M., M. D., Kansas City, Mo. President of American Association of Orificial Surgeons.

Why does a foreign label promptly invest a product or procedure with authority and potency, slowly acquired by our own? Only today I received a sample of medicine, which bore in conspicuous letters, Manufactured in Switzerland," as though this were a guaranty of its efficacy.

This Twilight Sleep," so aggressively lauded by certain lay magazines, as of German origin, and something new under the sun, has been used by many intelligent, progressive physicians in this country for a number of years. It is true, a much larger number of physicians has not used it, presumably, because it originated at home; it did not possess the foreign label.

Nearly a decade since, I was called one night to wait on a farmer's wife in confinement, and was asked at the time, if I would use chloroform. I replied that I would use something far better. I gave the lady a half-strength table of Abbott's H-M-C, hypodermatically, and repeated it in an hour or so. This was my first experience with this remedy in obstetrics. I was delighted and so was my patient with results. Her comment was: "No more chloroform for me. In my previous confinements I was given chloroform, and thought I could not do without it, but this beats chloroform. I imagined, during my pains, that I was assisting another woman who was in labor, by pushing down with my own strength, but was free from any suffering." She and the baby got along nicely after the accouchement.

Since then I have used this wonderful combination in almost every obstetrical case, with very gratifying results. I believe it safer and better than scopolamine.

If it become necessary to use forceps, often chloroform can be dispensed with, or, if used, very little will be required. Like all powerful remedies, it should be used with intelligence and watchful caution.

The Dietetic and Hygienic Gazette, which is just completing the thirtieth year of its existence, has been purchased by The Critic and Guide Company, and beginning with January, 1915, will be consolidated with The Critic and Guide, and the combined journals will be under the editorship of Dr. William J. Robinson. The offices of publication are at 12 M. Morris Park, W. New York City.

Gastric Aphorisms

J. M. BELL, M. D., St. Joseph. Mucus which has been swallowed is not incorporated with food stuffs, that which is gastric in origin has the appearance of having been triturated with the food.

Pernicious anemia from prolonged autointoxication, and chronic gastritis are, like cholelithiasis frequently met in large, apparently well fed individuals.

Glenard's "belt test," as quoted by Kemp, is worth remembering. If one stand behind the patient, and encircling him with the arms, lift up and support the lower abdomen, and this gives relief, it suggests enteroptosis.

¶ The one point of most value in determing enteroptosis, if tumor can be excluded, is, that the discomfort is relieved by the recumbent position, to reappear upon rising or a few hours after.

A case of persistent and chronic salivary ation showed it to be associated with hypersecretion was met recently. Examingastric hypersecretion. Both conditions were evidently a reflex from a dilated and prolapsed colon. They disappeared within two weeks following a correction of the colon disturbance.

The diagnosis of chronic gastritis is more often made because of lack of knowledge or lack of examination, than it should be. It is a blanket term made to fit chronic diseases of the stomach of unknown etiology. Yet there is one factor, easily detected upon examination. It is pathognomonic, viz., mucus. The mucus of chronic gastritis is often so thick and ropy that it cannot be aspirated by a tube. When suspected, irriThe gate the stomach with salt solution. mucus will be vomited around the tube rather than pass through it.

Intestinal autointoxication is a common cause of neuritis. In these cases the indican test is very high. When such a condition exists, neither heat nor electricity have any influence on the pain.

It would be well if we would regard the X-ray as merely one avenue of information toward making a diagnosis of alimentary canal diseases. Unfortunately there are those who consider it the one means of diagnosis.

Not all cases of gastric hyperacidity are due to ulcer. The latter diagnosis should not be made without a positive string test, repeated two or three times and a positive benzine test.

DECEMBER 2, 1914.

Regular meeting of the Buchanan County Medical Society held at their rooms Wednesday evening, December 2, 49 members present. Dr. J. J. Bansbach in the chair. The minutes of the previous meeting were read and approved.

The application of Dr. Lyda Hillyard was voted upon and failed of election, the vote being a tie, and according to our constitution a two-thirds majority is required.

The report of the Banquet Committee was received and referred back to the committee with instructions to carry out the programme as reported.

The following bills were allowed:

Lon Hardman, printing....$ 8.15
Sam Wilcox, attorney........15.00
W. F. Goetze, postage and

various other matters....16.99 The Library Committee, through Dr. Morton reported that the society's subscription to the medical journals at the library had expired and requested that they be renewed for the coming year; the committee was given power to proceed with the necessary action to secure their renewal.

A communication from Dr. J. A. Adcock, secretary of the Missouri State Board of Health, was received and the communication was ordered to be filed for future reference. This communication concerned the physicians reporting miscarriages, as births and deaths and whether they are compelled by law to be buried in a cemetery. Dr. Adcock interpreted the law giving the relatives discretion to select their own burial place.

The following officers were elected to serve for the year of 1915: President, Dr. J. F. Owens; 1st vice-president, Dr. W. J. McGill; 2d vice-president, Dr. A. R. Timmerman; secretary, Dr. W. F. Goetze; treasurer, Dr. J. M. Bell; censor, Dr. F. H. Ladd; delegate. Dr. H. S. Forgrave; alternate, Dr. J. J. Bansbach.

The hour being late Dr. A. L. Gray's paper was deferred to be read at the next meeting.

There being no further business to come before the society the meeting adjourned.

DECEMBER 16, 1914.

Regular meeting of the Buchanan County Medical Society held at their rooms Wednesday evening, December 16. Seventeen

members present; Dr. J. J. Bansbach in the chair. The minutes of the previous meeting were read and approved excepting a change made in the announcement vote on Dr. Lyda Hillyard, which was changed to read, failed of election.

A letter was read from Dr. S. F. Carpenter, resigning from our society as an active member on account of ill health. On motion of Dr. F. H. Ladd, the society elected Dr. Carpenter an honorary member and the secretary notified to inform him.

The application of Dr. H. S. Conrad, received its first reading and was referred to the Board of Censors for their action.

The Public Health and Legislative Committee, through Dr. Ladd, requested further time for a report, and very earnestly solicited the co-operation of the members in the way of reporting cases and patients handled by non-registered and unethical physicians.

An acknowledgment of the testimonial and flowers sent to the family of Dr. O. B. Campbell, was made in a letter from Mrs. Campbell.

A very interesting and enjoyable paper was read by Dr. A. L. Gray on "Pituitary Extract and Its Uses." The paper was discussed by the following members: Drs. Owens, Ladd, Willman, Stamey and Beck.

There being no further business to come before the society, the meeting adjourned. W. F. Goetze, Sec'y.

THE PRESIDENT-ELECT.

Dr. James Frank Owens, the newlyelected president, was born on February 23, 1870, near Camden Point, Platte County, Mo. Received his early education in public. schools and Gaylord Institute, Platte City. Was graduated in medicine from the Northwestern Medical College in 1892, and

received degree from New York Post Graduate School in 1910. Commenced practice in St. Joseph March, 1892, in the office with Dr. S. F. Carpenter, that association con

DR. JAMES FRANK OWENS

tinuing for three years. Since that time has continued in practice alone. Dr. Owens held chair of Materia Medica and Therapeutics in Central Medical College, and when the consolidation took place, he continued to lecture in the Ensworth for a period of four years. Dr. Owens has been active in local politics, having held the office of jail physician for two years, city health officer two years, and county physician for two years. He was married to Miss Laura Esther Brock, of Los Angeles, Cal.. in 1895.

Dr. Owens is a faithful attendant at the medical society meetings, takes a deep interest in his profession, is loyal to his friends, painstaking and careful in his attention to patients, and will make an excellent presiding officer. We predict a successful year for the society.

cer, president; Dr. Leroi Beck, first vicepresident; Dr. Charles Geiger, second vicepresident; Dr. F. X. Hartigan, secretary; Dr. J. T. Stamey, treasurer; Drs. P. I. Leonard, F. H. Ladd and J. J. Bansbach, board of censors.

Dr. H. S. Forgrave read an excellent paper on "Local Anesthesia.'

THE PRESIDENT-ELECT.

The president of the Academy, and subject of our sketch, Dr. Floyd H. Spencer, is another Missouri product, and one of the most popular of the younger surgical set in St. Joseph. He was graduated from the Central Medical College in 1900, and attended the Chicago Post-Graduate in 1903; served four years as assistant to the late Dr. O. B. Campbell. For past five years Dr. Spencer has limited his practice to surgery and consultation. He is professor of intestinal surgery, St. Joseph Veterinary College, and has charge of the experimental laboratory in this institution; he took special work in Berlin and Vienna last summer, and attended surgical clinics. Dr. Spencer is secretary U. S. Pension Examining Board; a fellow of the A.M.A.; member of Clinical Congress of Surgeons: Buchanan County, Missouri State, Medical Society of the Missouri Valley; for four years 1st Lt. and assistant surgeon, N.G. M. We are pleased to present below an excellent portrait of the Academy's new

THE ST. JOSEPH ACADEMY OF SUR

GEONS.

At the annual meeting of this young and progressive society, held at the St. Francis Hotel, the following officers were elected for the ensuing year: Dr. Floyd H. Spen

DR. FLOYD H. SPENCER