visible anatomical changes to account for the condition. Prognosis is grave, and treatment symptomatic.

The case which Mühsam reports falls in the group of five cases reported by Dieulafoy and Charlot-fatal hemorrhage from the stomach in cases of children from infancy up to the age of ten years. In Mühsam's case, the autopsy failed to disclose thrombotic changes in the omentum, although it was carefully examined by the obducent, Dr. Westenhoeffer. Microscopically, a round cell infiltration was made out in the connective tissue of the ulcer; beyond this, nothing. It is reasonable to suppose that the ulcus ventriculi was a fresh one, because gastric ulcer, per se, is rare in children. This ulcer showed a tendency to heal, but not in the direction in which lay the artery which was eroded. It is possible that a piece of apple, which was ingested by the child, had something to do with the erosion of the artery, by rubbing against it.

VALUABLE HINTS FOR THE LIFE INSURANCE EXAMINER.-Circular No. 8, issued by the Boston Mutual Life, arranged by their Medical Director, appears in the December, 1907, issue of The Medical Examiner and General Practitioner. It is well worth perusal by all who. act as life insurance examiners:

I.

WHEN EXAMINING THE HEART, REMEMBER:

To look for the location of the apex beat, and note any deviation from normal on diagrams.

2. To look for signs of interference with the return circulation, such as enlarged veins over the chest, etc.

3. To look for cyanosis, as indicated by the color of the skin and mucous membranes, finger nails, etc.

4. To detect the slightest sign of dyspnoea after exertion.

5. To note the amount of hypertrophy, if any, on the tricuspid areas, indicating location of diagrams.

6. To carefully listen at the mitral, pulmonary, aortic valves, as indicated on the diagrams.

7. To ascertain if a murmur is transmitted to the axilla or carotids. 8. To listen carefully in order to detect intermittency or irregularity in the heart's action, and differences in the length of systole and diastole. 9. To look for pulsations in the epigastrium and other localities. To carefully examine for evidences of arterial sclerosis.

IO.

.II.

To take the pulse for one minute, and record quality, condition of the radial artery, etc., as well as the number of beats per minute. 12. To inquire as to bleeding piles and varicose veins. 13. To inquire as to any swelling of the feet and ankles.

14. To bear in mind that plethoric people with thick necks, inclined to obesity, are prone to apoplexy.

REMEMBER, IN THE EXAMINATION OF LUNGS:

I. To examine the chest without clothing, when possible.

2. To look for bulging of the interspaces, flat chest, and chicken breast.

3. To note condition of skin, as to whether it is unduly moist, cold, clammy, etc.

4. To note the rapidity of the respiration.

5. To note if both sides of the chest rise and fall together.

6. To percuss for dullness from the apex to the base, anteriorly, posteriorly, and laterally.

7. To locate râles, and indicate same on diagram.

8. If pulse is above ninety, for no apparent reason, take the tempera

ture.

9. To note if the voice is strong, steady and firm; to look at the mucous membranes, and observe if they are normal in color.

IO.

be absent.

II.

12.

That in the early stages of pulmonary tuberculosis, cough may

That a phthisical applicant may have rosy cheeks.

To note if clothes fit well. (It often happens that loss of weight is denied, while the fit of the clothing tells a different story.)

13. To ask if he suddenly perspires during the day, and without laying apparent stress upon this incident, ask if he does so at night.

14. To stand in front of the applicant, placing fingers just above each clavicle, and ask him to inspire deeply. If the apices are diseased, applicant will probably show evidence of pain, or soreness, as the inflated lung comes against the fingers.

15. To stand directly in front of the applicant, and place each hand on either side, just below the floating ribs, ask him to inspire deeply, and while he is doing so press firmly. Tenderness will make you suspect pleuritic adhesions.

16. That a prolongation of the expiratory sound is uniform over the chest, and not dependent upon emphysema, should not be recorded.

17. That a few crackles bilateral, at the base, and not associated with dullness, are not necessarily important, but you should give your interpretation.

18. That as we grow older the respiratory sound becomes harsher, and less vesicular, and may be increased in intensity, or diminished. (If these conditions are uniform in an elderly person, and are not due to emphysema, they need not be noted.)

How to Measure the Chest Place the tape at lower angle of the shoulder blades, and when it is brought around it will fall just below the

nipple. The applicant is requested to stand erect, without muscular strain or rigidity, and told to draw in slowly and steadily a long breath until the chest is thoroughly inflated. Chest circumference at inspiration is thus obtained. The applicant is then asked to count from one onward until the demand for inspiration becomes urgent; chest measurement at expiration is then recorded. (Note if inflation is uniform over entire area.)

OF

THE CLINICAL IMPORTANCE OF THE UNEVEN DISTRIBUTION HYDROCHLORIC ACID IN GASTRIC CONTENTS.*-Albert E. Taussig, M. D., and William H. Rush, M. D., of St. Louis, Mo., state that the fundamental assumption that underlies nearly all the work that has been done on the acidity of the gastric contents, is that the latter represent a fairly homogeneous mixture, so that if a portion is obtained by means of the stomach tube its acidity represents fairly well the acidity of the total stomach contents. This is an error. The gastric contents are not homogeneous, and the acidity of the portion obtained for analysis does not always represent the average acidity of the entire contents. If the stomach contents are obtained in two portions, first in the erect, and then in the prone posture, the acidity often varies widely, the difference being greatest with solid or semi-solid test-meals, and least with liquid ones. Moreover, it is impossible, by any means at our disposal, to obtain the entire contents, and the acidity of the unobtainable residue may differ from that of both portions examined.

I. When the stomach contents are expressed and aspirated, in the usual manner, as completely as possible, the patient sitting erect, only a comparatively small portion of the gastric contents can be obtained.

2. After any of the usual test meals, the acidity of the portion so obtained can not be assumed to represent the acidity of the stomach contents as a whole.

3. If, after this portion of the stomach contents has been removed, the patient is made to lie down, it is usually possible by means of aspiration, inflation, and the like, to obtain a further considerable quantity of stomach contents. This second portion often differs considerably in its acidity from the first portion.

4. Even after this second portion has been removed, the stomach still contains considerable unobtainable residue. The amount of this is apparently independent of the total quantity of gastric contents, and probably varies from one to three ounces. Of its degree of acidity we can know nothing; certainly we have no ground for the assumption that it is identical with the acidity of the contents obtained for examination.

5. The quantitative determination of the acidity of the gastric contents is thus seen to be subject to a grave source of error. This will be

*Author's abstract of Monograph read to Section on Internal Medicine, St. Louis Medical Society December 14, 1907, Weekly Bulletin, St, Louis Medical Society.

diminished if the contents obtainable in the prone position are also examined. It will be further lessened if the acidity of the two portions does not differ very widely, since then we may assume that the acidity of the unobtainable residue will, itself, not be very different.

6. It follows that, in practice, trustworthy results can be obtained only if the following precautions are observed: The stomach contents must be obtained separately in the erect, and in the prone posture; the acidity of each portion must be determined, and diagnostic conclusions drawn only if the two acidities correspond fairly well, or if the total quantity of gastric contents obtained is so great that the unknown acidity of the unobtainable residue may be neglected.

7. Indeed, the entire concept of degree of acidity of the stomach contents seems not to correspond to anything real. Different portions of the stomach contents have different degrees of acidity. We may speak of the acidity of the contents at the fundus, or near the pylorus, or, at most, of the average acidity of the total contents. It is this last that clinicians have attempted to determine, with what scanty success, it has been the object of this paper to show.

REPORT OF AN INTERESTING CASE OF DOUBLE ECTOPIC GESTATION.Charles H. Dixon, M. D., St. Louis (Weekly Bulletin, St. Louis Medical Society, January 30, 1908), gives this history of the patient from whom he removed this specimen:

Mrs. H., age twenty-one, first menstruated at fourteen; regular, lasting six days, painful first two days. No serious illness; no leucorrhoea. Married May 4, 1907. Menstruated May 19th, regular; June 16th, regular; July 18th, four days over time. August 8th, flow again appeared, accompanied with severe pain in the side; was very profuse, lasting fourteen days. No large clots were passed. September 20th, again menstruated, lasting eight days, but little pain. October 16th, flow started again; more pain than usual; no large clots passed, and has continued to the present time. November 2d, in the afternoon, had first attack of severe pain in the abdomen, radiating to pelvis. She became cold, and had quite a profuse sweating. On November 4th, in the evening, had second attack of pain, similar to the first in location and character; also was slightly nauseated. Five hours later had a third attack of pain, lasting over two hours, with previous symptoms, only more severe and accompanied with considerable shock. There has been frequent micturition since November 1st. Examination: Uterus slightly enlarged, normal position, os soft. Small mass to the left of the uterus, tender to pressure, size of the thumb; mass in cul-de-sac soft, size of an egg. Considerable bleeding from the os. Abdominal muscles slightly rigid, no flatness, but slight tenderness in left inguinal region. Patient anemic, pulse weak, slight temperature. Operated November 7th; both tubes involved, showing ectopic gestation. Some bleeding in abdominal cavity; some hemorrhage from right tube.

I had two objects in view in presenting this specimen to you this evening: First, because it is a little out of the usual, although cases are on record where twin and even triple pregnancies have occurred in the same tube, and also ectopic and entopic conditions have existed at the same time. The other object was to bring up the question: When should we operate in ruptured ectopic gestation?

Formad states that this condition exists in one per cent of all pregnancies. Schauta, in 1900, in his celiotomies on women, found it to exist in five per cent of the cases.

Werder, in Bovee's Gynecology, page 706, says: "No matter how much collapsed, and blanched the patient may be, even when in a pulseless condition, an attempt should be made to save her life by at once, without delay, opening the abdomen." Montgomery, Reed and Webster recommend immediate operation. Hirst says as soon as diagnosis is made, operate, rupture or not. "The patient's only hope lies in immediate operation." Noble, who separates his cases, reports forty-two per cent of deaths on immediate operation, to eleven per cent on all cases.

Ihm, in his statistics of mortality in cases treated on expectant plan, gives Winkle's and Winter's rate as nil, Thorn one per cent. Hunter Robb, in twenty cases treated expectantly, had one death.

Penrose says: "It is unwise to wait for reaction." Ashton says: "Operate without unnecessary delay; we must not wait for reaction from shock or collapse to set in before operating, as the patient may perish in meantime from loss of blood."

Fowler says: "Operative interference is indicated in all cases except only in those instances in which the patient is moribund from intra-abdominal hemorrhage. The more rapidly progressive the collapse, the more urgently immediate operation is demanded."

Hartog, of Landaus' clinic, in a complete review of German statistics, says that not more than five per cent of the victims of ectopic pregnancy died from hemorrhage at the time of rupture. In speaking of death following hemorrhage, Ewald says that deaths from gastric hemorrhage are comparatively rare. Osler says that hematemesis rarely proves fatal. Moynihan says: "For a time symptoms may give rise to serious alarm, but a rally is seldom long delayed."

Riegel: "Cases in which hemorrhage is so severe as to cause death are rare."

Pepper: "A single hemorrhage is rarely so profuse as to cause death.” Tyson: "Very rarely will a patient bleed to death." Fatal hemorrhage from lungs, either in early or late phthisis, is rare, according to Loomis, Thompson, Strumpel and Delafield.

Recovery may take place after the loss of a large quantity of blood. Gastric hemorrhages, where patients have lost from two pints to a few quarts, are on record; intestinal bleeding in typhoid up to six pints with recovery; and post-partum to three quarts with recovery.

Stillwagen (Am. Jour. of Ob., January, 1908), says: "Treatment of terminated ectopic pregnancy is of serious importance, owing to the frequency of its occurrence, because of its high mortality, and on account of the almost universal teachings, which teachings I believe to be based upon a fallacy and to be exceedingly dangerous."