rupture has occurred. There may be a secondary hemorrhage, and if the primary hemorrhage is at all considerable, the blood-clot may never be absorbed, and infection and suppuration may finally result.

While some of our surgeons report cases of ectopic pregnancy diagnosed and operated upon before rupture, these cases are so infrequent in the experience of most surgeons, that they may be considered rare exceptions. This, however, may finally in a degree be different, if the general practitioner is taught to be more careful in the observance of the symptoms that indicate the probability of ectopic pregnancy. I do not remember to have operated upon a case before tubal rupture.

If cases are operated upon with any degree of promptness after rupture and before infection has occurred, there is no serious condition in the pelvic or abdominal cavity that is followed with more successful results. In about one hundred operated cases by both the abdominal and vaginal routes, I do not now recall but three deaths. One was in the primary intra-peritoneal rupture at about the sixth week, with much hemorrhage, operated upon in Jefferson County with bad aseptic surroundings, and before we knew so well how to guard against infection. The patient died three days after the operation, from septic peritonitis. Another case was where the operation was performed for an enormous intra-peritoneal hemorrhage, followed by profuse shock, which had occurred ten days previous, and in which placenta and membranes were removed. While this woman had no diffuse peritonitis, she probably died of some sort of infection. This may have developed in the uterus, for before and after the operation, there was a profuse discharge from the vagina, and seventy-two hours after the operation, she expelled from the uterus a decidual mass two inches long, one inch wide and one-half inch thick, which may have been the remnant of a uterine abortion. uterus was the size of a two and one-half months' pregnancy.

The

While most of these cases should probably be operated upon by the' supra-pubic route, many of them may be operated upon with entire success by the vaginal route. I formerly did much of my work by the latter method, having operated in this way upon about forty cases, with one death, but I now in most cases prefer the supra-cubic method.

As ectopic pregnancy seldom continues until the child is viable, I wish to report this evening a case operated on two weeks ago, where I removed a fully developed dead child with the placenta and all the membranes, and give briefly the treatment indicated in these cases with both the living and the dead child.

I did not see the woman until the day before the operation, and obtained no definite history that indicated a pregnancy of any kind, in fact did not get from the patient a detailed history of her trouble, as the doctor who brought her here from Shelby County said the abdomen began to enlarge on the left side about two years ago, but it had not increased much in size for fifteen months. The abdomen was symetric

ally enlarged and free of nodular projections, and gave to the hand the sense of touch that is diagnostic of a large smooth myoma. greatly emaciated, and without the tumor would not weigh seventy pounds. Her pulse was 130 per minute. She had no elevation of temperature, but I was not able to learn if she had any since the tumor appeared. When the abdomen was opened the appearance of the tumor and the sense of touch were diagnostic of a myoma, with extensive central degeneration. There were firm adhesions to the anterior abdominal wall, the omentum and the sigmoid flexure, and upper part of the rectum. After the anterior adhesions had been separated, a gallon of pus was drawn from the tumor through a large canula, and when an incision was made into the tumor, this full-grown child was removed. I then knew I was operating for an extra-uterine pregnancy that had developed to full term, and that I must remove the placenta and the

surrounding fetal membranes. In addition to the physiological attachment of the placenta to the pelvic structures and the colon and rectum, and the development of the gestation capsule for the ovum, which had unfolded the layers of the left broad ligament, and the mesentery of the sigmoid colon, extensive and firm inflammatory adhesions had formed, which required difficult and prolonged dissections to separate. The ovum had also dissected the peritoneum from the pouch of Douglas and the posterior pelvic and abdominal wall, thus remaining retro-peritoneal, with an anterior, superior and lateral capsule of peritoneal and connecting tissue.

The sac and placenta, as you will see from this specimen, were dissected out of the capsular attachment, leaving much of the pelvic cavity and the lower half of the posterior abdominal cavity divested of peritoneum, with broad lateral, thickened peritoneal wings.

The large arteries and veins on the posterior wall were uncovered and exposed, and the right ureter was entirely separated from its attachment for about eight inches, and was carefully examined by the fingers and sight to see if it had been torn. No positive evidence of injury of the intestines, ureters or blood vessels could be found, and the operation

was practically bloodless. The lateral wings of the peritoneal covering were sewed together in front of the spinal column, to below the pelvic brim, and the remaining capsule was sutured to the peritoneum in the lowest part of the abdominal incision. A large gum tube and a strip of iodoform gauze were introduced to the lowest point of the pouch of Douglas. I might also have drained through the vagina, but the woman's feeble condition would not permit of a prolonged operation. She was returned to bed with some increase in the rapidity of her pulse, but with no shock. Her resistence was much weakened by the long continued use of large doses of morphia, and a protracted diarrhoea. Notwithstanding the fact that the diarrhoea continued, and morphia in large doses is still required, she has gradually grown stronger and better, and barring unexpected complications, will recover.*

Since the operation I have learned that she had all the symptoms of extra-uterine pregnancy, and that about nine months after her period ceased, she had what she supposed were labor pains, which were finally relieved by large doses of morphia, after which all movements of the child ceased. I am unable to get the exact date of these supposed labor pains, but it was from twelve to eighteen months ago.

The report of Dr. E. S. Allen, from the pathological laboratory, of the pus surrounding the fetus is as follows: "Pus cells abundant, streptococcus pyogenes, staphylococcus pyogenes aureus and colon bacilli present. Pure cultures of colon bacilli were made. Infection evidently

a recent one."

If extra-uterine pregnancy continues until after viability of the child, an operation should be performed before the death of the fetus, in the interest of both the mother and the child. This enables us to remove a living child, and also protect the interests of the mother, for the dangers of suppuration, sepsis, etc., and of an operation-which must ultimately be performed-combined, exceed the dangers of the primary operation before the death of the child. In the primary operation the entire gestation sac and the placenta should be enucleated, and this is much more easily done than in the delayed cases where inflammatory adhesions and exudations have developed. To do otherwise would be unsurgical. The real danger in the primary operation is hemorrhage, but by the proper use of forceps and gauze pressure, this may usually be successfully controlled. The vessels that bleed freely when torn, contract quickly, and the current is relatively feeble.

* Recovered and left Hospital at the end of fourth week; cured of diarrhea, and is taking no morphia.

DISCUSSION.

DR. ABELL: I am certainly grateful to Dr. Wathen for the exhibition of this most interesting specimen. Personally I have never met with one so far advanced, and consequently have been greatly interested in the case. I do not wish to discuss it, but prefer to listen to some of the older gentlemen who have had a richer experience.

DR. MARSHALL: I cannot discuss the case. I know absolutely nothing about it. I have had quite a large experience in obstetrics, but have never met with a case of extrauterine pregnancy. I hope I never will. One point that strikes me about these cases is that you cannot theorize in abdominal work as you can in other parts of the body, and that when once in you have to keep on going until you see a way to get out.

DR. IRWIN: This is one of the cases that the general practitioners see first, as the Doctor has said, but the interest attached to this case is far greater than any ordinary one, in view of the fact that such a condition as this can and does occur. We have an absolute demonstration here of one of the most interesting facts that could be brought before any society, and within these walls we are making history in exhibiting that which in a lifetime we may never see the like of again—a full-grown child developing within the abdominal cavity outside of the uterus, living sufficiently long to have attained a full term, normal size, and then dying, 'and at the end of eighteen months after conception this child is removed from its abode outside of the uterus.

The skill required to do such an operation reflects great credit upon the abdominal specialists. An operation of this kind fifty years ago would have been heralded by the Associated Press throughout the entire world as one of the greatest achievements that had ever been accomplished. To-day it is not common. Others have done similar things, but that does not lessen the magnitude or importance of this operation. This surgeon has saved the life of the woman after this child had been in the abdominal cavity for eighteen months.

There is one point that I would like to have Dr. Wathen to tell us about and which is of great interest to us general practitioners, and that is what are the diagnostic symptoms of ectopic gestation before rupture occurs. We would like to be able to make a diagnosis. There are so many diseases with which an ectopic gestation may be confounded that it would be interesting to know if there is any one diagnostic point before the more dangerous condition of rupture occurs.

DR. ED. GRANT: I have been greatly interested in the paper and also in the discussion. This teaches us as general practitioners the importance of studying the symptoms of rupture in extrauterine pregnancy. I have unfortunately met with two cases in the course of my career as a practitioner, and they have impressed upon my mind the importance of studying these symptoms carefully, and avoid brushing them aside with

little thought, thinking that they are hysterical women or that they are suffering with colic. We must think of the symptoms of ectopic pregnancy when these cases present themselves, and in that way we will be able to save lives. Dr. Irwin has said that the operator has saved the life of this individual, but the general practitioner might have saved the life of two people. The life saved has already been wrecked, and she has become a morphine habitue, and if she gets over this her life will be of but little value compared with what it might have been had this condition been discovered by the general practitioner at the proper time.

DR. GRIFFITHS: I want to thank Dr. Wathen for his paper and the presentation of this very rare and most interesting specimen.

DR. MCMURTRY: I am very glad of the privilege to have heard the paper and to have seen the specimen, and I think that the remarks of Dr. Irwin and the other members are very appropriate, as the specimen would elicit the interest of any society in the world.

The subject that the essayist introduced is a very comprehensive one, and the condition he describes presents itself in a great variety of ways. Our knowledge of this subject, as you all know, is comparatively new.

Two eminent French surgeons, Bermutz and Goupil, by a postmortem investigation, discovered this pathological condition and reported it. The report was translated into English, but the subject attracted no attention until Lawson Tait did the operative work, and since then it has been one of the greatest triumphs of modern pelvic surgery. I might say that very often a case of ruptured tubal pregnancy cures itself. These are the cases that were known in the old literature as cases of hæmatocele. There may be a rupture of the tube with a moderate amount of hemorrhage into the peritoneum, the hemorrhage is disposed of by the peritoneum, which, we know, has a wonderful capacity for disposing of effusions, and the woman gets well. Rarely the foetus may develop and the child escape at full term into the abdominal cavity. We have an extreme illustration of this variety in the specimen exhibited this evening.

In cases of primary rupture it is wonderful what diversity they present. One of the most beautiful actresses ever known on the stage was riding in the suburbs of Paris, and she stopped at a little shop to get a glass of buttermilk. She became faint and fell. She was carried across the street to the office of a physician and died in a few hours. A postmortem was made by an eminent physician in Paris, and he announced that she died of uterine apoplexy. This illustrates how a postmortem, with all the facts lying before us, may be without profit. She had an abdomen full of blood and a ruptured Fallopian tube. This illustrates the extreme cases, and are very rare. It is wonderful what some of these women will stand. With a ruptured tube and an extensive blood-clot in the abdomen, they will be transported two or three hundred miles, or will go about their house work. I recall a case last September of a woman with a ruptured tube and a blood clot in the abdomen for eight weeks.