F. Henrotin operate (in the Chicago Policlinic in 1896) after removing the child, which was fully developed, but dead, he sutured the margins of the sac to the abdominal wound and put in a large Mikulicz drain. The patient made a good recovery, although she had to remain in the hospital for about six weeks.

The use of modern aseptic methods of operating has reduced the mortality when the child is still alive from 93% to 31%. The death of the foetus renders the operation much less dangerous to the mother. Some authorities, therefore, recommend the injection of about gr. of morphine sulphate into the foetal sac which, it is stated, is sufficient to kill the foetus, but does not affect the mother. The operation should be delayed for six or eight weeks after the death of the foetus in order to allow the maternal blood spaces in the placenta to become obliterated, thus facilitating its removal without hemorrhage. In such cases, however, should the patient develop any dangerous symptoms, immediate operation is indicated.

Case of Repeated Tubal Pregnancy: August 19, 1902, I was first called to see patient. The following is briefly the history of the case:

Mrs. C., married, age 32, mother of one child, a boy 12 years of age. No normal pregnancy since. About one month previ. ously was taken with severe pain in lower abdomen. She had been treated medically without any, except temporary, relief. The temperature was at times as high as 102°. A bi-manual pelvic examination showed a mass in the region of the right tube which was quite painful on pressure. I advised operation and patient was sent to the hospital and operated August 21, 1902, by Dr H. D. Niles and myself. The right tube was ruptured and incorporated in an inflammatory mass of exudate. Large blood clots were in the abdominal cavity. The right tube and ovary was removed, normal salt solution was given the patient sub-cutaneously while she was on the operating table. She made a very satisfactory recovery and left the hospital September 6th, two weeks after the operation. Her health was good for over a year and a half. March 22, 1904, I was again called to see her. She complained of pain in the lower part of the abdomen and there was a discharge of blood from the uterus, and she gave rather indefinite symptoms of pregnancy. The pain persisting, I made a pelvic examination March 28, 1904, and a mass was found in

region of left tube. Temperature normal or slightly below. Ectopic tubal pregnancy being suspected, I again advised her to go to the hospital and on March 29, 1904, I, assisted by Dr. Jackson, did a second laparotomy on her. I removed the left Fallopian tube, but did not remove the left ovary. The left tube was ruptured about the middle and there was considerable black clotted blood in the peritoneal cavity, which was removed by thoroughly flushing with warm normal salt solution. The patient again made a satisfactory recovery and left the hospital in three weeks.

In conclusion I wish to emphasize the following points:
(1) Take a careful history of all cases.

(2) Do not depend on the patient's statements entirely, but make a thorough pelvic examination.

(3) Operate promptly.

References: Williams' Obstetrics; M. Herzog, F, Henrotin, International Text Book of Surgery; Kelly's Operative Gynecology; Pryor's Gynecology.

VOMITING IN TUBERCULOSIS.

By DANIEL S. NEUMAN, M. D.

Denver.

For the proper rational therapeutics in vomiting of tubercu losis, one must carefully analyze the cause of its production. Vomiting in itself is only a symptom of some morbid process and should be treated according to the cause.

Taking into consideration the fact that the already lessened vitality of the tubercular patient demands a proper amount of nourishment, which is impossible at the time vomiting occurs, it has to be controlled as soon as possible, as it has a demoralizing effect on a patient, and prevents a good many, from fear of its occurrence, from eating a proper amount of food.

It is my intention carefully to separate the causes of its production and give its differential diagnosis and treatment.

Morning Vomiting. Due to irritation produced by overfilled bronchial tubes from sputa collected over night.

Vomiting very seldom occurs during the day. This type of vomiting by itself is only physiological, as it tends to empty the respiratory passages and upper part of the alimentary canal.

Treatment: Increase of expectoration during the day must be encouraged. A glass of hot milk in the morning and a cup of weak tea may often facilitate the removal of the source of irritation.

Saline draught, inhalations of Comp. Tr. Benzoin, every morning and evening often beneficial (before retiring to bed and soon after patient is awake in the morning). (Nothnagel.)

I often obtain good results from the following mixture:

Misce. Signa: Tablespoonful in water every three hours. Vomiting in Hypochlorhydria-Due to insufficient amount of hydrochloric acid in gastric juice.

This type is easily recognized, as vomiting invariably follows after the introduction of food into the stomach.

Marked by profuse anemia; all secretory organs are disturbed.
Sometimes violent hiccoughs precede vomiting.

Fermentation (gas and dry eructations) and constipation are often present. The stools are foul, tongue pale, patient refuses to eat, and the mouth is dry, owing to diminished secretions. To determine the quantity of hydrochloric acid in the stomach, it is best to examine the gastric juice three or four hours after ad; ministration of the Leube-Riegel test meal.

Misce. Signa: Tablespoonful in water (through glass

tube) one-half hour before eating (Hemmeter).

If constipation complicates, I use the following prescription:

R:

Caffeinae citratis

Acidi hydrochlorici diluti

Ext. cascarae sagradae aromatici

0.30

10.00

102.00

Misce. Signa: Teaspoonful in water one-half hour be fore eating.

The tendency of salines is to deplete the circulating blood; hence they are unsuitable in these cases.

Dyspeptic Vomiting.-(Due to catarrhal gastritis). Associ ated with pain, eructations, anorexia and constant nausea.

Pain, as a rule, is relieved by the act of vomiting and increased by taking food. The tongue is usually furred, and in some cases a red line on the gums occurs.

Absolute aversion to the taking of meals.

The earliest and commonest symptom is loss of appetite. Vomiting occurs in short time after introduction of food and is preceded by nausea.

Treatment: Out door exercise, hydrotherapy and massage are always of value. We should exclude hot breads, cereal foods, stews, preserved fish, cheese, etc., from the patient's diet (Noth. nagel).

If fermentation is present give small doses of resorcin.

Misce. Signa: Teaspoonful in water three times a day

immediately after meals.