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POST-GRADUATE HOSTEL.
494
justifiable without a bacteriological examination. often supposed. lie had seen enormous numbers It was reported that the Streptococcus scarlatinœ of osteomyelitic ulcers in Ireland, but fewer in this persisted for some three to six weeks after the symp- country. The infection started in the bone, extended tonxs had subsided. through the skin, and ended as a chronic ulcer, Sir FREDERICK ANDREWES discussed the question usually associated with sinuses. Another and different whether there was such a disease as scarlet fever type of ulcer was that associated with gangrene. clinically—i.e., whether it was a sharply defined He had seen large numbers of carcinumatous ulcers entity, or whether it shaded off into other strepto- in regions where cancer appeared t" he endemic. coccal manifestations, so that it was difficult to say Malignant ulcers of the tibia were apt to go on for what was scarlet fever and what was not. lIe had a very long time before killing the patient. seen, in 35 years, hundreds of
cases of doubtful scarlet fever from the wards, the origin of the infection being The same sort of difficulty was undetermined. encountered in regard to the bacteriological evidence. Was it always the same kind of streptococcus which caused recognisable scarlet fever ? Dr. Griffith had declared that there were three different serological types of streptococci which could be obtained from the throats of scarlet fever patients, and the two sorts which were commonest in this country were not those which seemed to be commonest in the United States. Might it not be that in scarlet fever there were several different races of streptococci which formed one common toxin ? A lady who was working in his laboratory had last summer got what was, clinically, acute rheumatic fever. She had been given some of Dr. O’Brien’s concentrated antiscarlatinal serum with strikingly beneficial results. When, later, she had a relapse, another dose of it caused the temperature to come down to the normal in four hours and the pain to disappear from the joints. Dr. ALEXANDER JOE agreed that in London, owing -to the mildness of the infection, there was little opportunity for judging of the clinical value of this serum ; in Edinburgh the disease was definitely more Until he came to London he had not realised severe. what serum sickness was; he did not know whether this was due to the greater sensitiveness of the children in the south or to the type of serum supplied for London. He thought a reason why good results did not follow in septic cases was that the serum was generally used too late. As to Sir Frederick Andrewes’s remarks, Dr. Joe had heard a laryngologist say that after mastoid operations his patients often got erysipelas, whereas afterr tonsillectomies a much commoner sequel was scarlet fever. Dr. C. J. MARTIN asked whether there was experience of an epidemic spread of any other form of streptococcal infection, such as occurred in scarlet fever. Dr. J. E. MCCARTNEY referred to the case of a hospital maid who had scarlet fever, and contracted erysipelas when she was partially recovered from the first infection, After that, when the temperature came down, she had pyaemia and a haemolytic streptococcus was isolated from the blood. Much more work was needed before laws cou ,d be laid down about the degree of infectivity of cases of scarlet fever. Much light might be gleaned by a close study of the organisms responsible for the failures. Dr. H J. PARISH described experiments on the titration of scarlet fever antitoxin in rabbits (vide THE LANCET, Jan. 8th, p. 7t). Dr. GooDALL and Dr. O’BRIEN replied.
POST-GRADUATE HOSTEL. THE final meeting of the Hostel was held at the Imperial Hotel on Feb. 24th, when Sir D’AR,cy PowER opened a discussion on
Chronic Ulcers of the Tibia. grouped into non-infective, infective, and malignant. Of the non-infective, he said, the commonest were the traumatic and the varicose. Less often seen, and nearly always in women, was the small rather punched-out ulcer which gave very great pain, probably because there was a nerveending in the centre. These could be cured by blistering or painting with silver nitrate. First among the infective was the tuberculous, for the syphilitic was by no means the commonest, as was These he
Treatment. Dr. G. F. STEBBING spoke of his experience of ulcers in a Poor-law hospital where very large For over 15 years numbers were encountered. his institution had kept a ward of 90 beds for nothing else. The important points in treatment were cleanliness and early attention. An injury might heal quickly, but the resulting scar often had not enough blood-supply to stand active life ; every little knock started the trouble again and finally periostitis set in. Such cases did best if the scar were excised and the area grafted on to the deep fascia. Much more difficult to treat were ulcers arising on a leg with faulty circulation, as with varicose veins and phlegmasia. One-third of his cases had been in women with a history of "white " leg after parturition, and in such women he had seen ulcers extending from knee to ankle and all round the leg. Amputation was the only treatment for most of them. but even ulcers of this class might heal after a time with the leg at rest in a raised position and with antiseptic dressings which were not changed too often. The complication of conservative treatment was that stasis produced adhesions in the tendon sheaths, with the result that the ankle appeared ankylosed, though really the lameness was due to matting of the tendons. Therefore it was not really worth wasting time healing up the ulcer if amputation could be performed. Some of the cases had septic infection through the deep fascia, and pus poured from the ulcer. The varicose ulcer was often associated with only a very slight degree of varicosity. but the circulation was always poor. The ulceration seemed to depend largely on the recurrent phlebitis that affected the varicose veins. It healed quickly and the leg kept well if the patient could be persuaded to sleep and spend a part of each day with her foot raised. The pain was ischaemic in nature and was greatly relieved by a wedge under the mattress, 9 inches high at the broad end. Hoskins Dr. Stebbings made a special bed for such cases. thought that parathyroid was not of much use. An elastic stocking was better than bandages if the patient could afford to have a really well-fitting If there were one, renewed about twice a year. varicose veins about the knee the stocking must be in two pieces so that bending the knee did not produce ! anaemia. Unfortunately patients had to earn their living, the leg got knocked, and the ulceration returned. The Poor-law officer, Dr. Stebbing continued, saw very little tuberculous ulceration, and syphilitic ulcers, like all tertiary syphilitic phenomena, were rarer and rarer. He had seen many of the so-called gangrenous ulcers, but they were not in the ordinary sense of the term. The condition began as a little spot which rapidly spread over the leg until the skin sloughed and left This healed well and rapidly if treated an ulcer. with antiseptics, but if it were treated as an indolent ulcer for a long time and got a hard edge it would do badly, and matting of the tendons would probably occur. Osteomyelitic ulcers were becoming more uncommon as treatment improved ; nowadays they were more often seen over the femur than over the tibia. One type of malignant ulcer began as a papule and grew without previous ulceration, starting apparently as a true carcinoma of the skin ;-, a commoner form began on the site of a varicose ulcer and was seen also on the foot, even on the great toe, at the site of some chronic sepsis such as a bunion.
becoming gangrenous
495 Dr. P. F. WATKIN said he had found lotio calaminse very useful, and for tropical ulcerations lie recommended irrigation by dropping methods or by soaking the leg for hours in a bath. The chief features of treatment were cleanliness, rest, and the application of an antiseptic, such as perchloride with a little salt. Dr. STEBBING agreed that the probletn was how to keep the part clean. The bath was not very comfortable, and he had found boric compresses better when once the skin was clean. All kinds of hyperæmic methods were useful-kaolin, glycerine pastes, radiant heat, massage, and electricity. If the scar were soft and could be pinched up recurrence
1 c.cm. was far too in the second stage of labour. large a dose. If pituitrin was given at all, two or three minims should suffice, and it should only be given in selected cases. The CHAIRMAN agreed that when a patient came to hospital in a condition of shock, as in this case. there was nothing to be gained by laparotomy. Most of these cases, if they did not die of He mentioned the died from sepsis within ten
days.
shock,
statistics published by Doderlein from cases of rupture of the uterus at the clinic at Munich during the last 50 years, when there had been 50 cases. Seven of the cases had been untreated and had died. Ten had had laparotomy performed, and of was unlikely. Dr. A. P. BERTWISTLE said that traumatic ulcers these 60 per cent. had recovered. The other cases resulted from bruises and abrasions which were had been treated in various ways. Eight of them so insignificant that they were neglected. The had been treated in a way similar to that described bv Dr. Solomons and three had recovered. On the causes of chronicity in an ulcer were : Poor (1) the average of recovery had been between blood-supply. The deep fascia, the duty of which whole 40 and 50 per cent. during the last 50 years. He was largely to carry and support blood-vessels, in this case the large amount of pituitrin that thought with the of the tibia over its periosteum joined subcutaneous border, so that there were few vessels which had been given was probably responsible for If cases were not too shocked he in the area. (2) Such ulcers became fixed at an the condition. they were better treated by laparotomy ; early stage to the bone, which cut off the vascular thought but a great deal depended on the method by which supply to their base. If periostitis did not occur the shock had been brought about, and also on the as the result of the blow, it would develop later. time which has elapsed since the rupture had taken The militated rest. against position (3) exposed and when the patient was seen. (4) The absence of fat in the subcutaneous fascia place Mr. W. PEARSON said that it was very difficult cushion to break the there was no that meant of a blow or make the case to decide what to do after the primary part elastic. (5) The in this had impact It was a question of been overcome. dependent position was not conducive to a good shock either or intestinal obstruction. It proved, peritonitis he should be allowed said, blood-supply. Abrasions, an obstruction, and the patient had to be however, to dry, the resulting eschar being the best protective After that time for them. In America they had tried electric drying done fairly well for a fortnight. the had and risen the abdomen had temperature If dirt were as in shampooing. ingrained hydrogen become distended and but it was plain that it soft ; for a after which the was beneficial day peroxide wound should be allowed to dry. Lotio calaminæ was not an obstruction, as the bowels moved if worked like a charm in some cases. Rest in bed purgative or enemata were given. There was a good Iodoform deal of dullness in the right iliac fossa, extending was essential if there were varicose veins. to the middle line, and the probability was that clisguised the smell of putrefaction, but iodine was across The abdomen Boric ointment in it was a case of mild peritonitis. bad and caused much pain. and was was there was found; opened, peritonitis a paraffin basis was useful at certain stages. a great deal of turbid fiuid and also adhesions the whole way across to the abdominal wall. Dr. CANNON said that these cases were rare. ROYAL ACADEMY OF MEDICINE IN He personally had only come across two. One was caused bv the injudicious use of pituitrin, and the IRELAND. baby had died. The other was a case of spontaneous rupture from a previous scar. He did not think that SECTION OF OBSTETRICS. there was any great danger of sepsis if the gauze A MEETING of this Section was held on Feb. 4th, was left on for 10 or 15 days. He thought that if Dr. Louis CASSIDY (in the absence of the President) the foetus was completely in the peritoneal cavity in the chair, when Dr. BETHEL SOLOMONS read a com- it would be difficult to deliver the baby, unless the munication entitled scar was extended ; and it would add to the shock to deliver the baby per vaginam. In these cases he Rupture of the Uterus Treated by Plugging the Rent. The patient was aged 35 and had had three normal thought laparotomy should be done. Prof. DAVinsoN asked where the rupture was in labours. During the second stage of labour her doctor had given her 1 c.cm. of pituitrin and as there was no advance this case ; was it in the uterus or not ? He had had after an hour had applied forceps and delivered a stillborn three cases of rupture of the uterus, two following child. Efforts to express the placenta and to remove it version and one following a breech. In the first manuallv had failed. case the rupture had been discovered when trying On admission she was pulseless and in a condition of the placenta ; the rupture was in the profound shock, just conscious. Routine treatment showed to extract The placenta was removed by traction of little reaction and the placenta was sought for. The cervix fornix. the cord and the hand was never inserted at all. was closed, but on following the cord it was found that the uterus was separated from the fornix on the left side and He thought that this was a very good point in techthat the placenta was among the intestines ; it was removed. nique, as in this way it might be possible to avoid Intestines appeared at the vaginal vault and the rent was introducing sepsis into the abdominal wall. In all plugged with a large tampon of iodoform gauze. Two his cases the wound had healed. He asked if there later of intestinal obstruction days symptoms appeared, and the gauze was removed. For 14 days she got on well, was any possibility of the collection of fluid in the but there was always some distension without absolute abdomen being urine, as he thought perhaps the rigidity. Symptoms of slight peritonitis then appeared ’, bladder had been injured by the rupture, as sometimes and the abdomen was drained ; two pints of foul sero- the bladder was concerned in cases of ruptured uteri. sanguinous fluid escaped and a drainage-tube was inserted. Dr. SOLOMONS, in reply, said that he had met three Since then, said Dr. Solomons, she has progressed cases of rupture of the uterus in the past three monthswell, but there was still some discharge from the the one he had reported, which lived ; one of quiet wound. which it was hoped would clear up with rupture which died ; and another one which occurred ultra-violet rays. This patient would have died had on the previous day where there was a spouting laparotomy been done ; she had lived after the uterine artery. In this last case hysterectomy had treatment of plugging. Plugging was a valuable been necessary and the patient was still alive. Plugaid to obstetrical teclmique and could be carried ging was the best treatment when possible, but there out by the general practitioner. The rupture had were some cases in which laparotomy alone could occurred probably from the overdose of pituitrin be done. The practitioner must choose his case for .
justifiable without a bacteriological examination. often supposed. lie had seen enormous numbers It was reported that the Streptococcus scarlatinœ of osteomyelitic ulcers in Ireland, but fewer in this persisted for some three to six weeks after the symp- country. The infection started in the bone, extended tonxs had subsided. through the skin, and ended as a chronic ulcer, Sir FREDERICK ANDREWES discussed the question usually associated with sinuses. Another and different whether there was such a disease as scarlet fever type of ulcer was that associated with gangrene. clinically—i.e., whether it was a sharply defined He had seen large numbers of carcinumatous ulcers entity, or whether it shaded off into other strepto- in regions where cancer appeared t" he endemic. coccal manifestations, so that it was difficult to say Malignant ulcers of the tibia were apt to go on for what was scarlet fever and what was not. lIe had a very long time before killing the patient. seen, in 35 years, hundreds of
cases of doubtful scarlet fever from the wards, the origin of the infection being The same sort of difficulty was undetermined. encountered in regard to the bacteriological evidence. Was it always the same kind of streptococcus which caused recognisable scarlet fever ? Dr. Griffith had declared that there were three different serological types of streptococci which could be obtained from the throats of scarlet fever patients, and the two sorts which were commonest in this country were not those which seemed to be commonest in the United States. Might it not be that in scarlet fever there were several different races of streptococci which formed one common toxin ? A lady who was working in his laboratory had last summer got what was, clinically, acute rheumatic fever. She had been given some of Dr. O’Brien’s concentrated antiscarlatinal serum with strikingly beneficial results. When, later, she had a relapse, another dose of it caused the temperature to come down to the normal in four hours and the pain to disappear from the joints. Dr. ALEXANDER JOE agreed that in London, owing -to the mildness of the infection, there was little opportunity for judging of the clinical value of this serum ; in Edinburgh the disease was definitely more Until he came to London he had not realised severe. what serum sickness was; he did not know whether this was due to the greater sensitiveness of the children in the south or to the type of serum supplied for London. He thought a reason why good results did not follow in septic cases was that the serum was generally used too late. As to Sir Frederick Andrewes’s remarks, Dr. Joe had heard a laryngologist say that after mastoid operations his patients often got erysipelas, whereas afterr tonsillectomies a much commoner sequel was scarlet fever. Dr. C. J. MARTIN asked whether there was experience of an epidemic spread of any other form of streptococcal infection, such as occurred in scarlet fever. Dr. J. E. MCCARTNEY referred to the case of a hospital maid who had scarlet fever, and contracted erysipelas when she was partially recovered from the first infection, After that, when the temperature came down, she had pyaemia and a haemolytic streptococcus was isolated from the blood. Much more work was needed before laws cou ,d be laid down about the degree of infectivity of cases of scarlet fever. Much light might be gleaned by a close study of the organisms responsible for the failures. Dr. H J. PARISH described experiments on the titration of scarlet fever antitoxin in rabbits (vide THE LANCET, Jan. 8th, p. 7t). Dr. GooDALL and Dr. O’BRIEN replied.
POST-GRADUATE HOSTEL. THE final meeting of the Hostel was held at the Imperial Hotel on Feb. 24th, when Sir D’AR,cy PowER opened a discussion on
Chronic Ulcers of the Tibia. grouped into non-infective, infective, and malignant. Of the non-infective, he said, the commonest were the traumatic and the varicose. Less often seen, and nearly always in women, was the small rather punched-out ulcer which gave very great pain, probably because there was a nerveending in the centre. These could be cured by blistering or painting with silver nitrate. First among the infective was the tuberculous, for the syphilitic was by no means the commonest, as was These he
Treatment. Dr. G. F. STEBBING spoke of his experience of ulcers in a Poor-law hospital where very large For over 15 years numbers were encountered. his institution had kept a ward of 90 beds for nothing else. The important points in treatment were cleanliness and early attention. An injury might heal quickly, but the resulting scar often had not enough blood-supply to stand active life ; every little knock started the trouble again and finally periostitis set in. Such cases did best if the scar were excised and the area grafted on to the deep fascia. Much more difficult to treat were ulcers arising on a leg with faulty circulation, as with varicose veins and phlegmasia. One-third of his cases had been in women with a history of "white " leg after parturition, and in such women he had seen ulcers extending from knee to ankle and all round the leg. Amputation was the only treatment for most of them. but even ulcers of this class might heal after a time with the leg at rest in a raised position and with antiseptic dressings which were not changed too often. The complication of conservative treatment was that stasis produced adhesions in the tendon sheaths, with the result that the ankle appeared ankylosed, though really the lameness was due to matting of the tendons. Therefore it was not really worth wasting time healing up the ulcer if amputation could be performed. Some of the cases had septic infection through the deep fascia, and pus poured from the ulcer. The varicose ulcer was often associated with only a very slight degree of varicosity. but the circulation was always poor. The ulceration seemed to depend largely on the recurrent phlebitis that affected the varicose veins. It healed quickly and the leg kept well if the patient could be persuaded to sleep and spend a part of each day with her foot raised. The pain was ischaemic in nature and was greatly relieved by a wedge under the mattress, 9 inches high at the broad end. Hoskins Dr. Stebbings made a special bed for such cases. thought that parathyroid was not of much use. An elastic stocking was better than bandages if the patient could afford to have a really well-fitting If there were one, renewed about twice a year. varicose veins about the knee the stocking must be in two pieces so that bending the knee did not produce ! anaemia. Unfortunately patients had to earn their living, the leg got knocked, and the ulceration returned. The Poor-law officer, Dr. Stebbing continued, saw very little tuberculous ulceration, and syphilitic ulcers, like all tertiary syphilitic phenomena, were rarer and rarer. He had seen many of the so-called gangrenous ulcers, but they were not in the ordinary sense of the term. The condition began as a little spot which rapidly spread over the leg until the skin sloughed and left This healed well and rapidly if treated an ulcer. with antiseptics, but if it were treated as an indolent ulcer for a long time and got a hard edge it would do badly, and matting of the tendons would probably occur. Osteomyelitic ulcers were becoming more uncommon as treatment improved ; nowadays they were more often seen over the femur than over the tibia. One type of malignant ulcer began as a papule and grew without previous ulceration, starting apparently as a true carcinoma of the skin ;-, a commoner form began on the site of a varicose ulcer and was seen also on the foot, even on the great toe, at the site of some chronic sepsis such as a bunion.
becoming gangrenous
495 Dr. P. F. WATKIN said he had found lotio calaminse very useful, and for tropical ulcerations lie recommended irrigation by dropping methods or by soaking the leg for hours in a bath. The chief features of treatment were cleanliness, rest, and the application of an antiseptic, such as perchloride with a little salt. Dr. STEBBING agreed that the probletn was how to keep the part clean. The bath was not very comfortable, and he had found boric compresses better when once the skin was clean. All kinds of hyperæmic methods were useful-kaolin, glycerine pastes, radiant heat, massage, and electricity. If the scar were soft and could be pinched up recurrence
1 c.cm. was far too in the second stage of labour. large a dose. If pituitrin was given at all, two or three minims should suffice, and it should only be given in selected cases. The CHAIRMAN agreed that when a patient came to hospital in a condition of shock, as in this case. there was nothing to be gained by laparotomy. Most of these cases, if they did not die of He mentioned the died from sepsis within ten
days.
shock,
statistics published by Doderlein from cases of rupture of the uterus at the clinic at Munich during the last 50 years, when there had been 50 cases. Seven of the cases had been untreated and had died. Ten had had laparotomy performed, and of was unlikely. Dr. A. P. BERTWISTLE said that traumatic ulcers these 60 per cent. had recovered. The other cases resulted from bruises and abrasions which were had been treated in various ways. Eight of them so insignificant that they were neglected. The had been treated in a way similar to that described bv Dr. Solomons and three had recovered. On the causes of chronicity in an ulcer were : Poor (1) the average of recovery had been between blood-supply. The deep fascia, the duty of which whole 40 and 50 per cent. during the last 50 years. He was largely to carry and support blood-vessels, in this case the large amount of pituitrin that thought with the of the tibia over its periosteum joined subcutaneous border, so that there were few vessels which had been given was probably responsible for If cases were not too shocked he in the area. (2) Such ulcers became fixed at an the condition. they were better treated by laparotomy ; early stage to the bone, which cut off the vascular thought but a great deal depended on the method by which supply to their base. If periostitis did not occur the shock had been brought about, and also on the as the result of the blow, it would develop later. time which has elapsed since the rupture had taken The militated rest. against position (3) exposed and when the patient was seen. (4) The absence of fat in the subcutaneous fascia place Mr. W. PEARSON said that it was very difficult cushion to break the there was no that meant of a blow or make the case to decide what to do after the primary part elastic. (5) The in this had impact It was a question of been overcome. dependent position was not conducive to a good shock either or intestinal obstruction. It proved, peritonitis he should be allowed said, blood-supply. Abrasions, an obstruction, and the patient had to be however, to dry, the resulting eschar being the best protective After that time for them. In America they had tried electric drying done fairly well for a fortnight. the had and risen the abdomen had temperature If dirt were as in shampooing. ingrained hydrogen become distended and but it was plain that it soft ; for a after which the was beneficial day peroxide wound should be allowed to dry. Lotio calaminæ was not an obstruction, as the bowels moved if worked like a charm in some cases. Rest in bed purgative or enemata were given. There was a good Iodoform deal of dullness in the right iliac fossa, extending was essential if there were varicose veins. to the middle line, and the probability was that clisguised the smell of putrefaction, but iodine was across The abdomen Boric ointment in it was a case of mild peritonitis. bad and caused much pain. and was was there was found; opened, peritonitis a paraffin basis was useful at certain stages. a great deal of turbid fiuid and also adhesions the whole way across to the abdominal wall. Dr. CANNON said that these cases were rare. ROYAL ACADEMY OF MEDICINE IN He personally had only come across two. One was caused bv the injudicious use of pituitrin, and the IRELAND. baby had died. The other was a case of spontaneous rupture from a previous scar. He did not think that SECTION OF OBSTETRICS. there was any great danger of sepsis if the gauze A MEETING of this Section was held on Feb. 4th, was left on for 10 or 15 days. He thought that if Dr. Louis CASSIDY (in the absence of the President) the foetus was completely in the peritoneal cavity in the chair, when Dr. BETHEL SOLOMONS read a com- it would be difficult to deliver the baby, unless the munication entitled scar was extended ; and it would add to the shock to deliver the baby per vaginam. In these cases he Rupture of the Uterus Treated by Plugging the Rent. The patient was aged 35 and had had three normal thought laparotomy should be done. Prof. DAVinsoN asked where the rupture was in labours. During the second stage of labour her doctor had given her 1 c.cm. of pituitrin and as there was no advance this case ; was it in the uterus or not ? He had had after an hour had applied forceps and delivered a stillborn three cases of rupture of the uterus, two following child. Efforts to express the placenta and to remove it version and one following a breech. In the first manuallv had failed. case the rupture had been discovered when trying On admission she was pulseless and in a condition of the placenta ; the rupture was in the profound shock, just conscious. Routine treatment showed to extract The placenta was removed by traction of little reaction and the placenta was sought for. The cervix fornix. the cord and the hand was never inserted at all. was closed, but on following the cord it was found that the uterus was separated from the fornix on the left side and He thought that this was a very good point in techthat the placenta was among the intestines ; it was removed. nique, as in this way it might be possible to avoid Intestines appeared at the vaginal vault and the rent was introducing sepsis into the abdominal wall. In all plugged with a large tampon of iodoform gauze. Two his cases the wound had healed. He asked if there later of intestinal obstruction days symptoms appeared, and the gauze was removed. For 14 days she got on well, was any possibility of the collection of fluid in the but there was always some distension without absolute abdomen being urine, as he thought perhaps the rigidity. Symptoms of slight peritonitis then appeared ’, bladder had been injured by the rupture, as sometimes and the abdomen was drained ; two pints of foul sero- the bladder was concerned in cases of ruptured uteri. sanguinous fluid escaped and a drainage-tube was inserted. Dr. SOLOMONS, in reply, said that he had met three Since then, said Dr. Solomons, she has progressed cases of rupture of the uterus in the past three monthswell, but there was still some discharge from the the one he had reported, which lived ; one of quiet wound. which it was hoped would clear up with rupture which died ; and another one which occurred ultra-violet rays. This patient would have died had on the previous day where there was a spouting laparotomy been done ; she had lived after the uterine artery. In this last case hysterectomy had treatment of plugging. Plugging was a valuable been necessary and the patient was still alive. Plugaid to obstetrical teclmique and could be carried ging was the best treatment when possible, but there out by the general practitioner. The rupture had were some cases in which laparotomy alone could occurred probably from the overdose of pituitrin be done. The practitioner must choose his case for .