(From the Obstetrical and Medical Services, Misericordia Hospital) THE patient, B. R. L., 23 years old, unmarried, Canadian, was first seen in the Prenatal Clinic of Misericordia Hospital on Aug. 29, 1950, with the chief complaint of amenorrhea of 4 months' duration. Although she denied previous pregnancies it was learned subsequently that she had given birth to a normal baby in 1946. She also gave a history of an appendectomy in 1943 and the usual childhood diseases. She had an attack of rheumatic fe.ver at the age of 13 years with bed rest for 9 months. Shortly thereafter she was treated for diabetes mellitus for 7 months, and required 15 units of insulin daily for several months. The insulin was discontinued on the advice of her local doctor and never resumed. During July, 1945, she spent eight days in another hospital with the complaint of weak· ness and malaise and, from the history and facts given, the most probable diagnosis was pyelitis. Her next admission to the same hospital was in August, 1945, for two weeks. At this time she was found to have a 3 plus sugar and a 4 plus acetone on several urine examinations. Diagnosis at this time was diabetes and psychoneurosis. Physical examination on her first visit to the Obstetrical Outpatient Clinic was normal except for a uterus enlarged to the size of a 17 weeks' gestation. Her pelvic measure· ments were reported adequate. Laboratory findings were as follows: Group A, Rh positive, serologic examination negative, red blood cells, 4.4 million, hemoglobin 81 per cent; urinalysis showed a very faint trace of albumin, otherwise negative. During the next month, the patient was observed at frequent intervals in the Outpatient service. She had numerous complaints of headache and back pain, but was objectively well. On Oct. 1, 1950, she was admitted to the hospital because of nausea and vomiting of four days' duration, Routine physical findings on admission showed a short untransmitted diastolic murmur at the apex, and a uterus enlarged to 3 em. below the umbilicus. Fasting blood sugar was 58 mg. per cent. On symptomatic treatment the nausea and vomiting subsided and she was discharged after six days. One week later, Oct. 13, 1950, the patient was readrnitted with the complaint of nausea and vomiting of six days' duration. In addition she complained of anorexia, malaise, headache, chills, and fever. Physical findings were as before except for right costovertebral angle tenderness. No cardiac murmurs were noted at this time. Temperature was 100° F., hemoglobin 93 per cent, blood pressure 130/85, fasting blood sugar 57 mg. per cent, glucose tolerance tests normal. Initial impression was beginning toxemia of pregnancy. She was treated with vitamins, phenobarbital, and intravenous fluids. Within a few days she improved but the vomiting persisted and was not relieved by any of the usual remedies. On Oct. 19, 1950, it was noted that she was cyanotic and a systolic murmur at the apex was heard. The cyanosis increased progressively. Definite systolic and diastolic apical murmurs were heard. There was no edema, the liver was one fingerbreadth enlarged, the spleen not palpable and there was no demonstrable ascites. An electrocardiogram revealed right axis deviation and inversion o:f T waves in Leads 2 and 3, right heart strain indicating myocardial damage. Liver function tests were essentially within normal limits. The patient continued to vomit and to run a bizarre temperature ranging from normal to 103° F. with no definite. pattern. Circulation time was within normal limits. Repeated blood cultures were found sterile. On Oct. 23, 1950, a macrocytic type of anemia with 3.5 million red blood cells, 74 per cent hemoglobin, and 13,850 white. blood cells was reported. Dur-