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placenta fell away from the tube during the removal, andthe amnion was ruptured.

Routine examination of the right tube revealed a foetusof the same size as that on the left, enclosed in a completeamniotic sac, It in. in diameter, and attached by anamniotic cord about 1 in. long to a fungating placenta-likemass protruding through a hole about 11 in. in diametersituated in the ampulla of the right Fallopian tube. Therewas no haemorrhage from this tube but it was distendedto enclose the placenta, its diameter being about 1* in.The right tube was also removed and its stump invaginated.Examination of both ovaries revealed well-marked

corpora lutea on both sides ; the ovaries were healthyand were left in situ. Blood and clots were removed fromthe peritoneal cavity and the wound was closed. Thepatient recovered rapidly, and within six hours her shoulderpain had disappeared. Twenty-four hours later she com-plained of severe occipital headache and pain in thecervical spine ; this lasted for two days and was thoughtto be due to the spinal anaesthetic. She made a normalrecovery and was discharged on the eleventh day.The pregnancies in the two tubes were of the same

size and development and were identical in all

macroscopic features ; each measured about 5-0 cm.in length. The right foetus was still enclosed in itsamnion and its cord entered through an opening inthe ampulla of the right tube, smaller than the

opening in the left tube, to join the placenta, whichwas still adherent to the interior of tube and whichbulged out through the opening in the tubal wall.The size of the foetus corresponds to about a tenweeks’ gestation : the placenta should not be formeddistinctly until the end of the third month, but inthis case there was a definite, though ragged, placentaon each side. The fact that both ovaries containedcorpora lutea indicated that there must have been

simultaneous ovulation and fertilisation on the twosides.Eden and Lockyer state that, up to 1927, only

28 cases of simultaneous binovular tubal gestationhad been recorded. They classify cases of multipleectopic pregnancy into three groups :

1. Coincident intra- and extra-uterine pregnancy: thecommonest type.

2. Multiple pregnancy in a single Fallopian tube: a

case described by Treub containing quintuplets in one tube.3. Coincident pregnancy in each tube : (a) cases of

consecutive gestation in which there may be symptoms ofattacks of pain first on one side of the pelvis and later onthe other; (b) cases of simultaneous ectopic pregnancy(the rarest type) of which they could only find 28 cases.Doran has shown that in cases of ectopic gestation in

one tube the opposite tube may be the site of a hsemato-salpinx which may be mistaken for an ectopic pregnancyunless subjected to microscopical examination.

This case emphasises the necessity for the examina.tion of the ovaries and tubes on both sides during anoperation for ruptured extra-uterine pregnancy. Theaccompanying photograph, for which I am indebtedto Mr. William Walsh of the radiographic departmentof this Infirmary, shows the two Fallopian tubes withthe attached cords and foetuses ; on the left side theplacenta is lying beneath the site of rupture of thetube, while on the right the placenta is still enclosedwithin the tube. The amniotic fluid from the rightsac, which had been removed intact, began to leakaway while the photograph was being taken.

I wish to thank Mr. Walter Briggs for permissionto publish this report.

1 Eden, T. W., and Lockyer, C.: Gynæcology, London, 1928.

MEDICAL SOCIETIES

ROYAL SOCIETY OF MEDICINE

SECTIONS OF MEDICINE AND SURGERY

THESE sections met on March 7th, with Prof.G. E. GASK, president of the section of surgery, inthe chair, to discuss the subject of

Haematemesis

Dr. ADOLpHE ABRAHAMS said that its most commoncause was peptic ulcer, chronic or acute. About20 per cent. of gastric ulcers and 25 per cent. ofduodenal ulcers caused hsematemesis or melsena orboth. Among other gastric causes were carcinoma,and the rare innocent tumours (papillomata, myomata,nsevi, and angiomata). Haematemesis was a commonand early symptom of cirrhosis of the liver and was acardinal feature of splenic anaemia ; the stomachwas also apt to be the site of bleeding associatedwith a haemorrhagic diathesis.

Since a similar discussion ten years ago the

technique of blood transfusion had improved andits therapeutic range had extended. Administrationof iron salts for the secondary anaemia of haematemesishad become more efficient, and the profession hadlearned to accept with comparative equanimity adegree of anaemia which at one time would haveinduced panic, and an urge to some desperate life-saving measure. It was a familiar experience tosee patients with less than 20 per cent. haemoglobinwho showed a tolerably comfortable adjustment toit. The chief discussion must refer to the comparativerisks of haematemesis and of operations on exsan-guinated patients. There was considerable differenceof opinion as to mortality-rates. At Guy’s Hospital

from 1911 to 1920 there were 23 deaths from hsemat-emesis in 600 cases, and Stewart’s figures gave asimilar percentage. It was important to be able toidentify which sufferers would eventually die ifleft without operation, for a proportion of these wouldcertainly be saved by operation. The patients whodied were those who had continued or recurrent

bleeding ; the single large haemorrhage seldom killed.The older the patient, the higher the mortality,males being in the greater danger. One might there.fore say that an indication for operation duringhaemorrhage was the occurrence of bleeding from anulcer in a patient whose arteries were so degeneratethat they were unlikely to contract enough for asatisfactory plugging by thrombosis. Yet the positionwas not so simple ; for were there not other acutelesions in which haemorrhage could not be stopped byso-called medical measures ? Apart from surgicalemergencies, there was the question of operatingto obviate possible future haemorrhages. Somepatients with ulcer seemed to have a special tendencyto bleed, and women, as a whole, bled more readilythan men. Hurst maintained that the liability tohaemorrhage was as great after an operation forpeptic ulcer as after medical treatment. With thathe thought all would agree. At the previous discussionthe chairman, Dr. Robert Hutchison, said he believedthat ten years later the pendulum would have swungtowards surgery-i.e., direct attack on the bleedingpoint. Surgery had no other place in the treatmentof hsematemesis, except when splenectomy was

advisable.Mr. G. GORDON-TAYLOR said that the surgeon

must think very carefully before operating duringan acute haemorrhage from the stomach. An

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enormous array of pathological conditions mightbe responsible for haematemesis, and every care

must be taken to diagnose the cause, for the onlyevent which justified urgent surgery was bleedingfrom a chronic ulcer.

Should surgery be employed to prevent the haemor-rhage of gastro-duodenal ulceration ? The replydepended on the incidence of haemorrhage from

ulcer, the risk to life of such haemorrhage, and thelikelihood of death from operation. Statistics varied

enormously in this respect; whereas Conybearestated that only 2 per cent. of patients with ulcers°which bled died of hsemorrhage, Ernest Bulmer, ofBirmingham, reported that of 249 cases of haemat-emesis due to chronic peptic ulcer, 29 died. Themortality from hsematemesis among cases of chroniculcer of stomach of duodenum which were treatedmedically at Middlesex Hospital from 1924-33amounted to 24 per cent.-a proportion almostidentical with that obtained by A. M. Cooke from theSt. Thomas’s figures ; in the Middlesex cases in whicha second large haemorrhage occurred the mortalitywas 78 per cent. ; with each successive bleedingthe death-rate mounted higher. ’1 his indicatedthe need of surgery before a second ha,,matemosisoccurred. It was more convenient for all to operatebetween the haemorrhages, but there was always theuncertainty whether the haemorrhage would stop andwhen it would cease. Dr. Robert Hutchison, quotingMr. Sherren’s practice, did not advise operationduring bleeding, but recommended it not longer than48 hours after the bleeding had stopped. Finsterer,however, regarded bleeding from a chronic ulceras an imperative indication to operate. In theMiddlesex series no fewer than six died of haemat-emesis while having intensive medical treatmentfor ulcer.When operating for urgent haematemesis the

decision should be made at once, since delay increasedthe risks; and unlimited blood must be available fortransfusion. If possible the operation should be doneunder local anaesthesia. If there was much bloodin the intestine, caecostomy should be carried out, withlavage of the large bowel.From 1919-24 he had operated on 22 cases of active

hsemorrhage from chronic ulcer of the stomach orduodenum, and had saved 20-a mortality-rate of9 per cent. Although the figures had not been sogood in the year or two following, the mortality-rateof all cases of acute haematemesis from 1919-26dealt with by surgery was 19 per cent. His pleawas for closer cooperation between physician andsurgeon in the care of these anxious cases, and thatif anything surgical were contemplated, it shouldbe done in the first 24 or 48 hours. Early enterprisewas the prelude to success.

Dr. T. IzoD BENNETT said he thought it lamentablethat there should still be so little close cooperationbetween the surgeon and the physician when dealingwith these difficult and alarming cases, thoughmany of the difficulties related to diagnosis of thecause of the bleeding. The cases in which surgicalaid should be sought at once were those in whichit was clear that the blood came from a chroniculcer, especially those in which there was stenosisof pylorus or duodenum. The vast majority ofhospital cases of hsematemesis ought not to havebeen admitted to hospital at all; it was a graveresponsibility to have a patient with haematemesismoved to hospital, unless the accident happened inthe street, or the home surroundings did not permitof effective nursing. Statistics of the comparative

mortality of operation and medical treatment weremisleading because of the great variation in the cases.In the last ten years he had had 7 fatal cases ; inabout 300 cases which he had seen in that periodthe indications for surgery were very rare. Haemat-emesis must always be regarded as a grave emergency,and the patient should be treated as carefullyas if he had undergone a severe abdominal operation.Not until a week had passed should the physicianfeel anything but anxiety ; yet often such cases

were treated with a lack of care which amounted tolevity. The first step in the treatment was discon-tinuance of food or drink by mouth, if the case was atall dangerous, for 36 to 48 hours ; next the patientshould be given some drug of the morphia group,in quantities sufficient to induce twilight sleep, andbe kept in a state in which not only was he not

suffering from absence of food or drink, but did notnotice that they had been withdrawn. Saline shouldthen be given rectally, and the nursing should becontinuous, the amount of liquid and food dependingon the regular examination of stools for occult blood.Very rarely was a surgical operation indicated.It was better to face the risk of recurrent haemor-

rhage without moving the patient than to movehim to hospital with the view to operation. Whencommencing to give fluid by mouth, it should notbe milk, nor glucose and lemonade, but isotonicsaline.

Mr. JOHN MORLEY (Manchester) held that treatmentof bleeding from an acute ulcer was the provinceof the physician ; surgical intervention would deprivethe patient of his chance of recovery. Only in dealingwith chronic ulcer was there a difference of opinion.Of 330 patients with acute ulcer bleeding treated inManchester Royal Infirmary in ten years, 40 died,a mortality of 12-2 per cent. Of all cases of chroniculcer admitted to hospital for haematemesis, about10 per cent. died. What should the surgeon do whenhe had a patient who was vomiting blood profuselyfrom a chronic ulcer or was collapsed from a recenthaemorrhage ? The question could not be answeredby a recourse to statistics, but post-mortem examina-tions on these cases usually showed that a largevessel, usually an artery, had been eroded and wasopen on the ulcer front. Patients did not usuallydie after their first haemorrhage, but succumbed toa series of severe bleedings. He did not think operationshould be done on collapsed or exsanguinated people ;and yet the surgeon should not resign these cases tothe physician with the intimation that, if all wentwell, he would do something operative in two or threemonths’ time. After severe haemorrhage, operationshould be done as soon as it was reasonably safe.He agreed with Mr. Gordon-Taylor that operationshould consist of a direct attack-no such measuresas gastro-enterostomy. The surgeon alone hadthe experience which enabled him to judge whena patient could stand operation. Lives were some-times lost by cases of this gravity having been leftfor hospital residents to deal with. In cases of post-operative haematemesis he found the usual cause

was that the sutures had been placed too far apart.Remote post-operative haemorrhage was usuallyfrom an anastomotic ulcer. He did not operate onthese cases until the anaemia from the haemorrhagehad been cured.

Dr. R. S. AITKEN spoke on the treatment of gravehaematemesis. When a patient had vomited so muchblood that he seemed likely to die from exsanguination,there were three main lines of treatment : (1) purelymedical-i.e., complete rest, morphia by mouth but

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nothing else ; (2) medical plus transfusion ; (3)surgical. Of 253 cases of haematemesis from gastricor duodenal ulcer treated at London Hospital, 25

died, a mortality of 10 per cent. For statisticalpurposes mild cases which did not cause anxietyshould always be separated from the severe ones.

The figures he had been able to collect gave himthe impression that in grave cases with a red cellcount of less than two million, especially if the

bleeding continued, with the patient at rest in

hospital, transfusion should be done, if necessary,more than once. Operation should be regarded as alast resort.

Prof. C. A. PANNETT differed from those whobelieved that surgery should be reserved for caseswith repeated haemorrhages. When the patientshad got worse and worse, when they had lost 80 percent. of their haemoglobin, then surgery should beabsolutely excluded. When a man was known tohave gastric ulcer, surgery should be considered fromthe beginning of the haematemesis ; by which he didnot mean that every case should be operated onearly, but that a deliberate choice should be madebetween medical and surgical treatment. An exsan-

guinated patient was not in a position to standan operation. When the patient had lost half hisblood, operation might be done, but not in the

collapse immediately following a big haemorrhage.Dr. GEORGE GRAHAM said that in cases of very

severe haematemesis it might be necessary to givetwo or three transfusions of blood ; one of his patientshad had six. When a person had lost much blood andthe haemoglobin was below 40 per cent., blood mustbe supplied. On the day after the transfusion thehaemoglobin might have dropped to 33 per cent. oreven 29 per cent., but that, he thought, was becausethe patient had been able to dilute his blood.

Mr. H. J. PATERSON contended that very few of thecases of severe haematemesis from ulcers proved fatalif given adequate medical treatment. At the previousdiscussion he reported a series of 120 severe casesof acute or chronic ulcer haemorrhage with no deaths ;they were under the care of Dr. J. Porter Parkinsonand Dr. Soltau Fenwick, and the latter declared hehad never seen fatal haemorrhage from gastric orduodenal ulcer. Since then, however, the speakerhad had three fatal cases. One was a haemorrhageten years after a gastro-enterostomy for duodenalulcer; the patient came in with severe melaenaand died, and the autopsy next day revealed no causefor the haemorrhage. Another patient came to

hospital after two or three severe haemorrhages, andwas doing well under medical treatment, when hereached for something off the floor, had a severehaemorrhage, and died in a few hours. These patientsshould not only have complete physical rest, but alsorest to the stomach. Recurrent haemorrhages wereadmittedly dangerous, but under adequate medicaltreatment there should be no repetitions of h2emor-rhage. Bleeding from an eroded ulcer was very rare ;mostly the bleeding arose from a general stomachoozing. Surgery in the face of acute haemorrhage wasvery rarely justifiable.

KENT AND CANTERBURY HOSPITAL.-The numberof patients admitted last year was 2256, an increaseof nearly 10 per cent. There were 137 available beds,and the average daily number occupied was 113-5.Residence averaged 16-5 days, a fall of two days on thepreceding year. The average total cost of each patientwas :S6 15s. 6d., and the average weekly cost of each

in-patient 2 12s. ld.

MEDICAL WOMEN’S FEDERATION

AT a meeting held on Feb. 20th, with Prof. M. F.LUCAS KEENE in the chair, Dr. ANDREA ANDREEN-SVEDBERG opened a discussion on theSwedish Approach to the Problem of DiabetesThe first thing she did with her diabetic patients,Dr. Svedberg said, was to tell them that they werenot ill, but that theirs was a condition which

developed into illness if they failed to follow certainrules. They could be healthy provided they adaptedthemselves to their peculiar metabolic circumstances.One result of telling them that they were not illwas to make them realise that they were meant tobe useful members of society. They could beeducated and could work and earn a living just aboutas well as anybody. True the patients with severediabetes who needed much insulin were less welladapted than ordinary people for heavy work, becauseit was difficult to arrange a constant balance betweenthe amount of work and the insulin supply. Dr.

Svedberg had begun to use the clinical laboratoryof the Board of Health of Stockholm as an out-patientclinic for diabetics, she said. in order that these patientsshould not have to spend hours in waiting at mixedclinics, with the loss of wages and perhaps employ-ment. The clinic was opened in 1925, and in 1927all the patients attending, with the exception of a fewvery old ones, were in work. Now, of course, few ofthe men were in work except boys under the age of 18,who received lower wages. Most of the women wereemployed, but as a group these patients were hardhit by unemployment because they were not first-class material. Diabetic children should be allowedto take part in sports and gymnastics.Although they were not ill, diabetic patients must

be reminded of certain weak points. They wereliable to become infected early and often severely,and infections tended to make the diabetic conditionworse. The beginning of diabetes could not generallybe traced, but sometimes it clearly started in connexionwith an acute infection, and was associated withpains of pancreatic origin. One of Dr. Svedberg’scases had entered hospital suspected of appendicitisand had left with diabetes. Sugar often appearedin the urine of a controlled case of diabetes followinga cold, and the pathological process in the pancreasfrequently seemed to progress with each cold. Adiabetic patient with a cold should go to bed for acouple of days. Special care must be taken of theteeth and of all small wounds and abrasions, particu-larly of the feet.

If the urine of a patient contained sugar but no ketonebodies, Dr. Svedberg told him to return the next morning,fasting, and with a 24-hour sample of urine. She generallystarted mild cases with a fast-day, this often workedmiracles in cases with itching eczema and a high blood-sugar. The patient spent the day in bed and drank asmuch water, tea, or coffee as he wished, and a little broth.This method was not suitable for severe cases whosetreatment should not be ambulatory at the outset, or forchildren or young patients who would easily get acidosis.In cases of intermediate severity it was often possiblefor a visiting nurse to give the insulin injections at first.Evidence of a " liver-rhythm " had not withstood criticism,and the most that could be said was that the blood-sugarof mild diabetics and normal people fell during the nightand the blood-sugar of severe diabetics rose, owing to theprolonged fast. It was therefore advisable for severe

diabetics to take their morning insulin an hour or twobefore they took any food. Otherwise insulin could be

given just before a meal.In arranging the diet the aim was to keep the urine