The

of the tube and was in situ when I opened the abdomen. other is the tube stuffed with cotton, and the other is the fetus. There are some points in the case which I believe deserve emphasis, and I will speak of them. The woman is a multipara, thirtyseven years old; mother of five children, the last of them five years ago, and no miscarriages; had considered herself perfectly well. She last menstruated on July 4th for three days, which was her normal period, aud without pain. She did not menstruate again and had no signs or symptoms of menstruation until September 6th, two months and two days from her last menstruation. At that time the period, or attack, was ushered in by severe pain at five o'clock at night. The pain was so severe that she went to bed and stayed for two days, after which she got up and was around for two or three days, when she again had an attack of pain in the abdomen, this time putting her to bed for a day or two. Things went on in this way until September 25th, when she had her third and last attack of pain and at that time she sent for a physician for the first time. He gave her morphin. This was on Thursday, and on Saturday he sent her to me. She came in the street cars to my office and went home in the same way. I made a diagnosis of probable ruptured tubal pregnancy. She went home, and came back again on the following Tuesday to see me and, finally, entered St. Peter's Hospital on Thursday afternoon, unattended. I operated with the probable diagnosis yesterday morning and found this condition. I think there was not more than a pint of blood altogether, both clotted and fluid, in the abdomen. On Monday she did a two weeks' washing.

The interesting point in the case, to me, is the fact that she was able after rupture to go around and do her own work, and did not even call in a physician at first-doing her own housework and taking several trips in the street cars, with a ruptured tubal pregnancy and her belly full of blood, which is certainly contrary to the teaching in these matters; and I believe that the idea that a ruptured tubal pregnancy is always described as a thing marked by extreme symptoms, accounts in large measure for many of these cases being neglected.

When I operated, the pulse was 70, and a normal temperature. The blood was in the free abdominal cavity. It had largely gravitated into the cul-de-sac, but had mixed with the intestines to some extent.

Dr. Jewett I think, with the speaker, that the emphasis generally laid on the severity of the symptoms in ruptured tubal preg

nancy is responsible for frequent failures of diagnosis. This is particularly true of extraperitoneal ruptures. It is also true, to some extent, of intraperitoneal ruptures, for many of the latter class do not bleed as much as the one just reported evidently did. Most difficult of recognition are cases in which rupture has taken place into the broad ligament, with little or no pain, or shock. I operated successfully within a week on a woman with a history of practically no pain, with a doubtful history of pregnancy, and with a large soft tumor at one side of the uterus. The tumor proved to be a fluid blood collection in the broad ligament which was on the point of rupturing into the peritoneum, and it contained fetal structures.

Dr. McNaughton: Is it a fact that patients have less pain in intraperitoneal than in extraperitoneal? that in the latter they suffer more pain, but less shock?

Dr. Jewett: I do not think that is altogether true.

Dr. McNaughton : In the cases I have seen that has been true, that the tearing or separation of the broad ligament where it is extraperitoneal produces pain lasting a long time, while in intraperitoneal there is rupture and they get their shock with it. It is a sharp, quick pain.

Dr. Jewett Pain usually precedes the rupture in two or three paroxysms or more.

Dr. McNaughton: Probably there are slight ruptures or separations occurring at the time they have the pain.

Dr. Dickinson: The question of pain has been brought up. There is a number of cases of threatened miscarriage that may be primarily tubal or interstitial pregnancies, replanting in the uterine cavity. I say this in a very guarded way, because I have not cases enough to make any positive statement, but merely wish to make a preliminary report. You may know that I reported—with drawings a number of cases of early pregnancy, thirty-five in one batch, and others, and I have since had as many more, of the diagnosis of pregnancy in the very early weeks-cases that have been verified by subsequent miscarriage, or by continuance of pregnancy. I made my proportion of mistakes, and the mistakes and cases taken together have taught me this: that the dense spot of which I spoke, which can be identified in one horn or the other of the uterus, in a large proportion of cases, in the eighth or tenth week-sometimes earlier-is not a myth, and whatever be the cause, it is an interesting condition found in certain early pregnancies.

For instance, there was a single patient who weighed

ninety pounds and whose abdominal walls are as thin as my coat, over whose pelvis I can follow the blood-vessels, and who has been kind enough to be three times pregnant and twice to miscarry. She has a great deal of pelvic pain, and had a very bad retroversion. Here one can work out every detail of the conformation of the uterus and of the condition of the ovaries. Being able to study both ovaries, I have found in the three pregnancies that an ovary and tube of one side, not previously enlarged, was, in the early weeks of these pregnancies, always enlarged. At one time it was one tube; at the next time it was the opposite tube; at the third time it was the same tube and ovary together as the first time, which may tend to prove, when there are cases enough accumulated, that there is an enlargement of the ovary and tube on the side from which the ovum comes. But the point which I wish to make is that in a number of cases-as yet small, and which I do not propose to publish in detail until more can be brought together-we find this condition:

If this (indicating) is the shape of the normal uterus, the uterus of pregnancy is supposed to enlarge mostly in the body and to enlarge more or less symmetrically. Now, in a large proportion of cases, this (Fig. 1) is the shape in which the uterus does enlarge. It seems to show that either a number of uteri are cordiform in shape or slightly of the uterus-bicornis shape, or that there is a very little septum left. A number of uteri enlarge thus (Fig. 2)a horn growing very much larger than its fellow; eventually, as the uterus assumes a more globular shape, the whole becomes symmetrical; but I am speaking of the early weeks. Now, there is a considerable number of cases in which that (Fig. 3) form is detected, in which the globular protuberance is almost outside of the uterus proper. Occasionally the uterine body can be felt pointing over to one side, and a globular protrusion more or less nodular, detected alongside in the middle line. Dr. Garrigues has been mildly laughed at for a case which he mapped some what clearly, and in which he said he had a gestation in the tube near the uterus, and she had a threatened miscarriage and the enlargement disappeared, the uterus became globular, and she went on to full term. It has been supposed that those must be interstitial cases. They may be interstitial cases, or it may be the ovum enlarges well out in the cornu. There is hardly the possibility of getting a specimen at such a time. There are one or two frozen specimens bearing on the matter, like Pinard's and Varnier's, but they are all antero-posterior sections and none of

them sections from tube to tube, which would throw light on my statements. It may be that the tube will lodge an ovum and then empty it into the uterus. The position of the ovum in ordinary tubal pregnancy is further from the uterus, and not favorable for such action, but elaborate study may develop that occasionally the ovum does not develop in the uterine end of the tube.

Dr. Palmer: How early in pregnancy can you detect that? Dr. Dickinson: It is rarely detected before the twenty-first day

Compressible

FIG 1.-Gravid womb of the early weeks, of a not uncommon form. The division of the fundus into two lobes is rarely symmetrical; the dark shading of the junction of body and cervix is intended to show the firm core in this compressible portion.

FIG. 2-Asymmetrical development; left cornu contains bulk of ovum ; in later stage it begins to occupy entire cavity of body of uterus; miscarriage confirms the findings of palpation.

after an isolated coitus, and as the fruitful coitus is in the week following menstruation, the patient comes to you ordinarily five or six days after she has missed her period, and then you can sometimes detect these changes; but I am speaking now of the changes after the second period, usually between the sixth and ninth week.

I will make one further statement: that it is very common to all of us to find in curetting the uterus, with the finger in the uterus,

this condition: that the finger runs much deeper into a cornu on one side, in which are the remnants of decidua and possibly placenta. This supports the belief that development of the ovum. in the cornu, the development of the ovum in the tube as it passes through the uterine wall (interstitial pregnancy), and even the development of the ovum in the uterine end of the tube are not infrequent.

Dr. McNaughton: In connection with this subject may I relate a case? This is where there was a globular mass; there is no

FIG. 3.-Four stages of development of pregnant uterus wherein the ovum may have been first implanted in the tube. That it was finally attached chiefly in the extreme angle was shown by the finger within the uterus.

question about that. The patient was thirty-six years old; she has been married ten years and had two children, nine and five years respectively, and one miscarriage four years ago. She menstruated first at ten years of age-I think that is a mistake, though it may not be. She last menstruated on July 13, 1896. From August 1, 1896, she had a slight pain on the left side of the pelvis, and on August 24th had five or six separate and distinct discharges of blood from the vagina, bright red in color, with considerable increase of pain, and on the 25th, which was the next day, she had several attacks of sharp, stabbing pain in the left side of the pelvis, extending down the left leg. These attacks continued for several days; her physician examined her on September 17th and asked me to see her with him. We found that the left side was perfectly normal so far as could be determined, while on the right side was a mass of considerable size and the uterus felt as if it were impregnated, and of course, the diagnosis was, naturally,