Wm. Porter. 5. Malarial Manifestations in the Upper Air Pas sages, Dr. H. W. Loeb. 6. Malarial Manifestations in the Alimentary Sys tem, Dr. W. G. Moore. 7. Malarial Manifestations in the Nervous System, Dr. F. R. Fry. 8. Malarial Manifestations in the Genito Urinary System, Dr. Bransford Lewis. 9. Malarial Manifestations in the Eye, Dr. C. Barok. 10. Malarial Manifestations in the Ear, Dr. Robert Barclay. 11. Malarial Manifestations in the Skin, Dr. M. F. Engman. 12. Malarial Manifestations in Pregnancy, Dr. W. B. Dorsett. Some Curiosities of Suicide. -The late Sir B. W. Richardson is credited with the following curious information on suicides: The rate of suicides is highest in the last four days of June and lowest in February; more common among Protestants than Roman Catholics and rarest among the Jews. It increases with educa tion and spreads with railways and telegraphs. More men than women are swayed by its influence and the average of suicides is set down at 12 in every 100,000. Graduating Exercises of the St. Louis. Medical and Missouri Dental Colleges. The graduating exercises of the St. Louis Medical Col· lege and Missouri Dental College were held at the Fourteenth Street Theater April 29. The Theater was very tastily decorated with potted plants, and flowers completely studded the front part of the stage. A very large gathering of the friends and relatives of the graduates were there and the speeches were heartily ap plauded. The principal speaker of the evening was Dr. Maurice J. Levi, Secretary of the New York Board of Medical Examiners. He made a very lengthy speech on the subject of "The Evolution of the Doctor." He pictured in eloquent terms the wonderful head way that the profession has made in the last twenty years, and also explaindd the workings of the New York Board of Medical Examiners. After the Doctor's talk the prizes were distributed among the students. Texas State Medical Association. The 13. Therapeutics of Malarial Diseases, Dr. C. Shat- Texas State Medical Association met in annual session tinger. H. W. LOEB, Chairman, R. H. FINLAY, M. F. ENGMAN, at Paris, Texas, May 27-29. The Association was called to order by Dr. R. R. Walker, Chairman of the ComExecutive Committee. mittee of Arrangements. Rev. Dr. Farris, pastor of the First Christian Church, invoked divine blessing upon The Committee upon Permanent Home for the So- the members of the Association. ciety will present its report. St. Louis' Mortuary Record. One hundred and sixty-five persons died in St. Louis during the week ending May 1. This is 12 less than the week before, but two more than the corresponding week last year. The number under 1 year was 33; under 5 years, 47; 60 years and over, 29. Thirty-two died in public institutions, and 24 inquests were held. Dr. Walker introduced Mayor Gibbons, who welcomed the doctors in a few well-chosen sentences. A. P. Dohoney, Esq., followed the Mayor in an address of welcome on behalf of the citizens of Paris. Dr. L. P. McCluston, on behalf of the local association, added his tribute to the work of the Association and indorsed the welcome offered by the preceding speak. ers. Dr. J. C. Loggins, of Ennis, the President of the Association, acknowledged the addresses of welcome on Consumption claimed 17 victims, pneumonia 29, and behalf of the Association. bronchitis 10. Dr. West, the Secretary, called the roll and all presThe births reported were 222. Twelve still-births ent answered to their names. The Secretary then read were not included in the mortality. There was one death from small pox at quarantine, but that is outside the city limits, and the death does not go on the records. The weekly report of Chief Sanitary Officer Francis shows 1 case of small-pox and 1 death; 23 cases of diphtheria, no deaths; 4 cases of croup and 2 deaths; 6 cases of scarlatina; 3 cases of typhoid fever; 17 cases of measles and 1 death; 9 cases of whooping-cough and 1 death. his annual report, and recommendations. The call of the Judicial Council showed two members present be sides the President. Dr. Larendon, the Treasurer, tendered his resignation, he being of the opinion that a man should retire in the zenith of his glory, and in full possession of all his faculties. Dr. Larendon has served as Treasurer of the Association for 25 years, and his resignation was accepted with the understanding that he serve until his successor, be elected. Many interesting papers were read and the meetings were well attended. Congress of American Physicians.- About A Victim of the Dispensaries and Their five hundred members of the medical profession, among Rival -A pitiful tale is told in the London Daily them some of the most distinguished specialists in the Telegraph, of the straits to which the humbler members country, attended the Fourth Triennial Congress of of the medical profession in that metropolis are reduced American Physicians and Surgeons, which convened at by the multiplication of dispensaries and the growing Washington, D. C, May 4, 5 and 6. The Congress evil of club practice. Among other instances it is reopened with a business meeting of the Executive Com-lated that "one fully qualified man, who is said to have mittee, following which the Chairman of the Commit passed his examinations with brilliancy, has descended tee, Dr. Landon Carter Gray, called the general body to a lower depth than even the sixpenny doctor. He to order. Dr. William H. Welch, the retiring Presi. has settled in one of the poorest districts of St. George's dent, delivered the triennial address, and later a recepin-the-East, and outside his surgery is painted in bold tion was given the delegates by the members of the Roman letters: 'Advice and Medicine, 44d. Superior local society at the Arlington Hotel. The Congress is ditto. 6d. Where the three-half-pennyworth of superidivided into fourteen distinct associations, each of ority lies is a puzzle to the more thoughtful inhabitants whose president is ex officio president of the Congress. cal Times says that "when a leading London daily of the district." Commenting upon this case, the Medi These associations held daily sessions at their respec tive headquarters in addition to the regular meetings of paper draws attention to conduct of this kind on the the Congress. A large number of interesting and im- part of members of an honorable profession, it affords portant papers were read and discussed. A statue of convincing evidence of the degradation to which many the late Prof. Gross was unveiled Wednesday afternoon. of our poorer brethren have been reduced. It is not The statue is erected in the grounds of the Smithsonian reasonable to suppose they can choose such work, and Institution. Annual Banquet of the Alumni of the St. Louis Medical College.-The annual banquet of the Alumni of the St. Louis Medical College was held April 28, at the Southern Hotel. Plates were laid for eighty, and the banquet hall and tables were hand somely decorated with flowers. The members of the graduating class of '97, who have been elected members of the Alumni Association, were all present. Dr. Wil lis Hall, President of the Association, presided, and Dr. Joseph Grindon acted as toastmaster. There was no set programme of responses, but the toastmaster called upon a number of gentlemen, who made remarks. Dr. Semple delivered the class speech, Dr. Henry H. Mudd responded for the Faculty, Dr. Hall for the Alumni Association. Dr. E. C. Runge, Superintendent of the Insane Asylum, was also called upon and made a brief response. New Rule for Shipment of Corpses.-Undertakers are protesting over a new rule the railroads have made relative to the shipment of dead bodies. Heretofore when an undertaker desired to ship a corpse out of the city he was compelled to buy two tickets for it, and it was transported as a regular passenger. friend could accompany the remains on one of those tickets if he so desired, but no body would be carried by any railroad for less than two regular fares. Now the railroads have refused to carry dead bodies except as express matter. The express companies are more particular about receiving corpses than the railroads used to be, and refuse to accept any body until the offi cials have issued a permit. Before bodies can be sent away the undertaker is required to obtain permits from the Health Department, so that they have to get two permits now instead of one. it can only be presumed it is the res angusta domi that forces them thus to drag in the dirt their professional dignity." The causes for this "degradation" enumer ated by our contemporary are the old familiar ones of competition with lodge doctors, unqualified practition ers, dispensaries, and patent medicine makers - Medical Record. PUBLISHER'S DEPARTMENT. Fastest Service to the West.-The Missouri Pacific Railroad runs five daily trains to Kansas City and Western points. Through service to Carthage, Joplin, Southwest Missouri points, Leavenworth, Atchinson St. Joseph, Lincoln, Omaha and the North. Also, unexcelled service to Wichita, Pueblo, Denver and the West. See that your ticket reads "Via the Missouri Pacific Railroad." Full particulars, time tables, illus. trated pamphlets, etc., may be procured on application to representatives of the company, or H. C. Townsend, General Passenger Agent, St. Louis. Buggy Lamps.-We are in receipt of a complete catalogue of buggy lamps from R. E. Dietz Co., 60 Leight Street, New York. This firm is manufacturing one of the vest best, and we would urge our readers to procure this catalogue before they purchase elsewhere. They are also manufacturers of bicycle lamps, street lamps, doctors' office lamps, etc, and will send you full particulars and a description of their goods on applicacation, mentioning this journal. Colorado and the West.-Through service via the Missouri Pacific Railway from St. Louis to Pueblo, Colorado Springs and Denver. See Company's representatives for full particulars, tickets, time table and descriptive literature, or address H. C. Townsend, General Passenger Agent, St. Louis. MEDICAL REVIEW, VOL. XXXV. A WEEKLY JOURNAL OF MEDICINE AND SURGERY. ST. LOUIS, MO., MAY 15, 1897. ORIGINAL: ARTICLES Extra-Uterine Pregnancy Occurring Twice in the Same Fallopian Tube.1 BY T. F. PREWITT, M.D., ST. LOUIS, Professor of Principles and Practice of Surgery and Clinical Surgery, Missouri Medical College; Surgeon to St. John's Hospital, Etc. This would seem a startling heading for a case of ectopic gestation and in view of our preconceived ideas of the etiology, evolution and terminations of this accident would scarcely seem possible. If we admit its occurrence in the case I report, it is certainly unique, as I am not aware of any similar case having been re. ported. In paper read by me before the State Medical Association of Missouri, at Sedalia, on the 19th of May last, on the subject of Extra-Uterine Pregnancy, I reported, among others, the case of Mrs. T. D., then 26 years of age and the mother of three children, who, after passing her regular monthly period of four or five days, commenced to flow, which she regarded as simply de layed menstruation. This continued for four or five days, when on November 15, 1895, it suddenly stopped. She supposed she had taken cold, especially as she had some pain. On November 18, she was taken with severe pain in the left pelvis, which "doubled her up," as she expressed it, accompanied with faintness and also diarrhea. I saw her in the afternoon. There was still pain, tenderness very great upon digital examination, and supra pubic palpation especially marked in left pelvis, with quick pulse, etc. I made a diagnosis of tubal pregnancy, with rupture of sac, and advised celiotomy, which she emphatically declined. In the meantime, there was a return of the bloody flow. Her temperature rose to 103° F., and her 1Read before the St. Louis Medical Society, Saturday Evening, February 20, 1897. The Discussion on this paper appeared in the MEDICAL REVIEW of April 10, 1897, page 259. NO. 20. pulse to 130 per minute, with great abdominal tender ness. The flow continued for about three weeks. There was a gradual subsidence of the more acute symptoms, but a distinct tumor or swelling with great tenderness remained for months. About December 13, 1896, she consulted me and stated that she should have been un. well about the 10th, but had had only a slight flow, and as she had been perfectly regular up to that time, she was apprehensive she might be pregnant-a condition to which she was very averse. I suggested it might be only the effect of cold and that the next period might come around all right, and advised her in any event to let the matter alone. On January 21, 1897, I was called to see her about 9 P.M., and found her suffering great pain. She gave me the following history: On January 14, she was taken with a profuse bloody flow coming on with a gush, like the flow from a hydrant. On the first or second day of the flow she noticed a membranous, fleshy something, but did not preserve it. The bloody discharge continued quite free without marked pain up to the 21st, when, in the afternoon, she was seized with violent pain in the left pelvic region with faintness and vomiting. When seen by me, the pain was still very severe, and the pain in the supra. pubic region great, and upon digital examination a distinct tumor in the left pelvic region could be felt. It was clearly not connected with the uterus, there being a distinct interval between. It was excessively painful to the touch, seemed about as large as a small fist and somewhat elongated. I thought I could detect indistinct fluctuatiou. She had no fever but a quickened and rather depressed pulse. I was somewhat puzzled to account for the condition. Under other circumstances I should have unhesitatingly made a diagnosis of tubal pregnancy with rupture of the sac. With a previous history and a group of symp. toms that clearly indicated an extra uterine pregnancy with a rupture of the sac in the same tube, I hesitated. I explained to her that some serious accident had happened in the pelvis and that it indicated extra-uterine pregnancy, and that a laparotomy ought to be done To this she again objected. at once. I gave her a hypodermic injection of gr. morphine to relieve the great suffering and left her, with instruc tions to send for me at once if any urgent symptoms stitched up with silkworm-gut, with flushing or drainage. arose. The next morning, January 22, in response to an early telephone message, I saw her again, and found that she rested pretty well during the night, but that some pain had again set in in the morning. She was quite pale, with a pulse 120 beats to the minute and depressed, but there was no rise in temperature. Digital examination revealed the same excruciating pain and the same swelling to the left of uterus. I explained to her that the rupture of the sac of an extra-uterine pregnancy had occurred, that the condi tion was an exceedingly critical one, that if she survived the immediate dangers, she must expect to go through the same ordeal of suffering and ill-health as before, and advised her to submit to an operation. After much hesitation, she consented, but not until late in the afternoon. C L Aided by my assistants, Drs. Geitz, Schlueter and Rohlfing, I proceeded to open the abdomen making an incision through the peritoneum of about two inches. Passing in two fingers I found blood to well up from the pelvis and readily recognized extensive adhesion. The uterus was retroverted and held by bands-the left Fallopian tube and ovary were somewhat prolapsed and firmly bound down. A rounded tumor could be felt about two inches to the left of the uterus in the track of the tube, which, upon attempting to raise it, came loose and dropped away into the pelvis. Upon getting it out, it proved to be a firm mass, made up mostly of clotted blood as large as, or larger than a walnut. With my fingers I endeavored to detach the adhe. sions from the tube and ovary, but only succeeded in part. In fact I was compelled to make a pedicle of a mass of adhesions that bound the ovary down, too firm to be detached. The tube and ovary were then removed, the pelvis sponged out with sterilized gauze and the abdomen A large rent was found midway of the Fallopian tube from which the clot the size of a walnut escaped in the early manipulation. The fimbriated extremity was closed hermetically, and the tube presented the appearance as though two sacs existed, the one from which the clot spoken of had escaped, and a larger one at the outer end of the tube, with something of a constriction between. No fetus was found, but no careful search was made to find it in the fluid of the belly. That a similar accident had occurred more than a twelvemonth before, involving the same Fallopian tube, the history of the case, the identical group of symptoms in each case, and the pathological conditions found, clearly demonstrated. If it be admitted that the accident in November, 1895, was tubal pregnancy with rupture of the sac, how could a second pregnancy occur in the same tube? That it did occur, I think is certain. It might be contended that the failure to find the fetus at the time of operation leaves a doubt as to the diagnosis of ruptured tubal pregnancy. Upon this subject, Mr. Tait says: "I have never seen an intra peritoneal hematocele that was not due to ruptured tubal pregnancy, and when we find a tube dilated into a sac until the distension had caused its rupture, followed by an extravasation of blood in quantity, what other conceivable explanation can be given when we know that in many similar cases the fetus has been found? "The criticism might have more weight if applied to the first accident, since actual rupture of the tube was not verified and it might have been an extra-peritoneal hematocele (intra-ligamentum), though such a condition is scarcely possible in view of the evidence of peritoni tis found to have followed. "In what condition was the tube left after its rupture after the peritonitis set up in connection with it after the absorption of the blood poured out at the time of the accident and the cicatrization and repair of the rent in its walls? "It must be conceded that in accordance with the scheme of tubal pregnancy as at present understood, the tube should be patulous from the uterus to the morsus diaboli to permit of the passage of the ovum upon the one hand and the spermatozoa upon the other. "According to Bland Sutton, while the tube is expanding from the enlargement of the ovum within it, and the mucous membrane is stretched and its glandu. lar folds effaced, curious alterations are taking place at the abdominal ostium, which in most cases gradually bring about its occlusion, an event usually completed by the eighth week. During the first four weeks the congestion of the parts causes turgescence of the fim. briæ as well as of the muscular and serous tissues adja. cent to them. When the parts are thus swollen the margin of peritoneum adjacent to the ostium is very In the specimen I present the complete closure of the fimbriated extremity is well shown. Admitting the correctness of my diagnosis in Mrs D.'s case in the first instance, we must suppose that one of two things occurred: 1. Either the rupture in the first case occurred before the closure of the abdominal ostium leaving the MEDICAL REVIEW. L. T. RIESMEYER, M.D., Editor. DEPARTMENT EDITORS: DR. F. J. LUTZ, General Surgery. PUBLISHED UNDER THE AUSPICES OF THE By O. H. DREYER. lumen of the tube after the repair of the rent still patu-YEARLY SUBSCRIPTION, $3.50. SINGLE COPIES, 10 Cents. lous. 2. The fimbriated extremity having been closed, an ovum must have passed down the right tube, became impregnated in the uterus and been forced up by mus. cular action into the left tube in the manner suggested by Tylor Smith and Kussmaul. (Referred to by Play fair). TO CONTRIBUTORS AND CORRESPONDENTS. All letters whether intended for publication or not must contain the writer's name and address, not necessarily for publication. No attention will be paid to anonymous com munications. Secretaries of medical societies will confer a favor by keepng us informed of the dates of the meetings of their respective societies, and of officers elected. Members of the profession who send us information of matters of general interest to our readers will be considered as doing them and us a favor, and we shall take pleasure in nserting the substance of such communications. Communications, Medical Books for review, and all letters lication, subscription, or advertising department of the REVIEW, must be addressed to O. H. DREYER, Publisher 112 N. 4th Street, St. Louis. Since the above paper was written my attention has been called through the courtesy of Dr. J. B. Ross, of this city, to a most interesting paper by Dr. H. C. Coe, of New York, in the American Journal of Obstetrics and Disenees of Women and Children for June, 1893. In this article he reports one case of his own of un-containing business communications or referring to the pubdoubted double tubal pregnancy in which an old unrup tured tubal sac containing fetal bones was situated near the uterus and another of recent development near the fimbriated extremity which was patulous. The more Entered at the St. Louis Postoffice as Second-Class Matter. recent sac had ruptured and contained a living fetus of four months. He cites also Hayden's case clearly, also a double tubal pregnancy in which was an old sac containing fetal bones lying apparently just outside free extremity while a second sac developed near the fim briated extremity has ruptured. He has kindly furnished me the following references 1876. Herman-British Medical Journal, Vol. 11, p. 722. The following is the report of the microscopic examination of the clot, by Dr. Carl Fisch, of this city: EDITORIALS Hemorrhage From Healthy Kidneys Angioneurotic Hematuria. Among those affections of which it is often difficult to determine whether they should be classified as belonging to the domain of surgery or medicine, hemorrhage from a healthy kidney is a most interesting as well as a representative condition of such, with regard to the mentioned classification, borderline cases. It is only recently that the occurrence of hemorrhage from a healthy kidney has received closer attention. There are a number of cases on record, where, on account of hemorrhage, kidneys have been removed by surgeons of world-wide fame, and where, after the operation, no pathological condition whatever could be "The clot you handed me for examination was care fully examined in every direction, but it was not possible to demonstrate the presence of an ovum or of its remnants. There were, however, several places, where chorionic villi could be shown in great numbers, some torn off and single, while others formed small groups detected in the extirpated organs. The kidneys have connected by parts of the membrane. "A number of these villi showed evident signs of maceration and disintegration, others were quite intact and normal in appearance. In the latter vascular struc tures could be plainly made out, showing that the embryo must have been older than two weeks." also been incised, almost completely bisected, for such conditions, and the organs found to be healthy upon close inspection. If, upon a cystoscopic examination, blood wells forth. from one ureter with the urine and in the characteristic manner in which that excretion passes from the ureter |