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 siightly 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.

Hunter

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. 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."

Landinski (Am. Jour. of Ob., January, 1908), in his report of one hundred and seven cases with one death, which occurred on third day, and was in a case of hemophilia, says: "It is my firm belief, and the results obtained by me in the cases of extreme collapse justify my contention, that no matter how profound the collapse of the patient, the urgent indication is to check the hemorrhage; and if the operation be performed with the ease and rapidity that is possible in expert hands, the additional shock will be so slight that it can not be held responsible for a single death. I can not agree with the theoretical reasoning, nor is my experience in accord with the practical deductions of the writers who advocate delaying operation in profound shock."

In making statistics, some objections may be made to any case that has not been proven to have existed by an operation or autopsy.

Simpson (Surgery, Gynecology and Obstetrics, November, 1907), says: "What to do when suddenly confronted by deep-seated hemorrhage sufficient to cause alarming symptoms, is a question which always commands serious consideration."

Many writers say delay till patient has rallied from shock is permissible. Davis says: "It is true, however, that some cases sometimes recover by the spontaneous and gradual cessation of bleeding. Immediate operation is the best and safest treatment, and the physician should be content with nothing less, when an operation can be performed."

Boldt has had quite a number with tubular abortion recover completely without an operation. The expectant treatment should not be merely an advice to keep the bed, but absolute rest should be insisted on; no vaginal examination, no palpation of pelvic region, or rectal interference, is allowed. The patient should be absolutely quiet, with the foot of bed elevated. Anything that would elevate blood pressure is not allowed.

Another question arises: Is the increased shock following the cases of operation due to the operation per se, or to the anesthetic? It is my belief that the cases would suffer less from shock if operated on with local or no anesthetic, and all unnecessary handling and delay done away with.

Simpson says: In conclusion, it seems to me that the indications for immediate operation are definite, and that the indications for deferred operation with careful preliminary operation are equally definite. The essential feature in either case is to save life. If the patient's condition is not desperate at the time of rupture, operation may be done with safety. It then possesses the advantages of a shorter convalescence and fewer and less firm adhesions. On the other hand, if the margin of reserve strength is reduced to a very low limit, operation or any other severe depression may readily wipe it out with a fatal termination. In such cases, the very desperate cases, it seems to me that we are to think of life alone

and not of the question of convalescence. The objects of operation at any time may be:

(1.) To control bleeding which is in progress.

(2.) To prevent the recurrence of bleeding which has ceased, or, (3.) To remove the debris incident to tubal abortion or rupture.

1. Regarding the first indication for immediate operation, it has been said, I think truly, that in the vast majority of instances hemorrhage has already ceased long before the abdomen is opened. This may readily be believed, especially as to operate in two hours from the time of rupture would be an unusual achievement.

2. The prevention of recurrent bleeding, where hemorrhage has already ceased, can with safety be effected by quieting the patient with morphine and insisting upon absolute rest. This means of preventing a return of bleeding is far more simple and safe than adding the depression incident to an abdominal operation.

3. An operation designed for the removal of pelvic pathology or abdominal debris should, if possible, be done at a period of election. That period is not at a time when the margin of reserve strength is at the lowest point, but after the victim of hemorrhage has regained sufficient energy to pass through the ordeal of operation with comparatively little risk.

It seems to me that in the case of immediate operation the following combination of conditions is an absolute requisite of uniform success: 1. Slight hemorrhage which does not reduce the margin or reserve strength to a very narrow limit.

2. A competent operator.

3. Skilled assistants and attendants.

4. Appropriate surroundings.

5. And adequate preparation.

On the other hand, it seems to me that any one of the following conditions will render deferred operation safer and hence preferable:

I. Profound depression due to serious hemorrhage, with or without other associated lesions.

2. Or an unskilled operator.

3. Or inadequate assistants, attendants or facilities.

4. Or hasty or inadequate preparation.

5. Or the need of transferring the patient to hospital, thereby seriously increasing the risk of continued or renewed bleeding.

THE PROPHYLACTIC VALUE OF VACCINATION.-Passed Asst. Surg. Henry S. Mathewson, Public Health and Marine-Hospital Service; United States Public Health Report, January 31, 1908.-Reports to the Surgeon-General, Public Health and Marine-Hospital Service.-Small-pox

is supposed to have originated in Africa, in prehistoric times. The first historical reference to the disease is an account of an epidemic of small-pox which developed in the Abyssinian army besieging Mecca, in the year 571. From Mecca it spread over Asia and Europe. Procopius, in his history of the Eastern Empire, describes small-pox as present in epidemic form in Constantinople in 581, and Gregory of Tours records its presence in Southern France in the same year. Throughout the Middle Ages references to small-pox are few and misleading, as it was much confused with measles and syphilis. The very name small-pox shows its confusion with and final differentiation from syphilis, or the pox, as syphilis was commonly called at that time. By the year 1600 small-pox had assumed epidemic form throughout Europe, and in the following two hundred years it continued its ravages unchecked, save by the exhaustion of the susceptible following years of great epidemics. Various mysterious. causes have been assigned for the rise of certain infectious diseases to epidemic form at varying intervals, but the simple explanation suffices, that in the interval a new generation is born, and grows up and furnishes new fuel for the flame.

In England the disease was always present, and but I person in 25 escaped an attack of small-pox. From 1761 to 1800, there died in the city. of London an average of 2,037 persons yearly from small-pox.1 Its omnipresence is shown by the common proverbial saying, "That few escape love and small-pox." It confined its assaults to no class, and royalty suffered equally with the peasant and the pauper, thus clearly indicating that differences in sanitary surroundings did not influence the incidence of the disease. It is estimated that in the 100 years from 1700 to 1800, an average of 600,000 persons died yearly from small-pox throughout the world." Among preventive measures, prior to the discovery of vaccination, inoculation with the disease deserves a brief mention. Among the Turks it had long been practiced, and it was introduced into England in 1721 by Lady Mary Wortley Montagu, who returned in that year from a period of residence in Constantinople. The advantages of inoculation were that one could by this means have the disease when young, when in good health, at a favorable time of the year, and often in a mild form. Many among the educated availed themselves of this practice, but it never became popular among the masses, as death not infrequently followed inoculation.

In the same year, 1721, Dr. Zabdiel Boylston, of Boston, introduced inoculation in America. During this year an epidemic of small-pox was present in Boston. Of Boylston's 286 inoculated cases, 6 died, a percentage of 2.09. During the same period, of 5,759 cases acquired by contagion, 844 died, a percentage of 14.6. During the colonial period smallpox was very prevalent, and scarcely a personal description is found in the

1 Second Report Royal Vaccination Commission, 1890, p. 290.

2 Welch and Schamberg, p. 18.