ference. Dr. Thomas recites one case "trusted to nature," with With Mr. Tait's wonderful record, the

ultimate recovery. weight of authority is on the side of early interference after rupture, or before if discovered. On what Dr. Thomas has to say upon the treatment of the sac before rupture, hinges its entire value as regards the question of correct diagnosis. In view of the uncertainty of this, to positive surgeons of the Tait type his dictum will have little weight. With these we believe that in competent hands, in case of doubt, the exploratory incision should be resorted to, and if the diagnosis is verified, the sac should be dealt with surgically, as hereafter to be noticed. The use of the electric current is all the less to be recommended in the light of Mr, Tait's successes. At best it only attempts the killing of the fetus, and can promise nothing more. It remains for the reproach of this treatment, that the sac and its contents still remain, and may at any subsequent period menace the life and safety of the patient. Or, in the most favorable event of suppuration and discharge, the comfort of the patient is for an indefinite period interfered with. The treatment appeals more to the electrical experimentist than to the practical surgeon-more to the trier of novelties than to him who is satisfied with nothing less than tangible results.

Mr. Tait's view that, in most instances, the so-called hematocele is a ruptured extra-uterine cyst, is fully substantiated, both by his investigations and those of Bernutz, to whom he gives especial credit.

Bernutz's classification of the possible varieties of intra-pelvic hemorrhage is worthy at this time of great consideration, and is: Hemorrhage caused by the rupture of dilated utero-ovarian veins. (This kind of hematocele occurring sometimes in extrauterine pregnancy, may be said to represent one of the varieties of thrombus in normal gestation.)

2. Hemorrhage caused by the rupture of the ovary. (This we see happen in cases of pregnancy, whether the product of conception occupies the uterus or not.)

3. Hemorrhage caused by the rupture of the Fallopian tube.

4. Hemorrhage from the fetal cyst itself having ruptured. (The largest number of cases fall under this last head; both it and the next are of special interest, because they are peculiar to extra-uterine pregnancy, while the three former belong also to intra-uterine pregnancy.)

5. Hemorrhage within the fetal cyst; (which may end in death without effusion of blood into the peritoneal cavity, and, therefore, may not produce a real hematocele.)

Had these views received the attention they deserve, there would not now be so much conflicting statement concerning the affection, or rather the symptoms they elucidate. Of hematocele due to suppressed menstruation, Bernutz also makes distinct mention. Of this variety Mr. Tait says:

"There are only two causes known to me, one very common, and one relatively rare. The first is sudden arrest of metrotaxis, which may be either normal menstruation, or the pseudomenstruation which occurs so constantly after abdominal operations."

He then goes on to elucidate this condition. The abdominal surgeon who has not studied or considered it, will find much information, and with it much comfort concerning a matter which must often have worried and perplexed him. The second cause of extra-peritoneal hematocele is effusion of blood into the broad ligament from ruptured tubal pregnancy of about the twelfth week. Of this Mr. Tait says it is " much more rare and probably much more fatal, certainly much more serious."

The scheme Mr. Tait has given of extra-uterine pregnancy so well speaks for itself, that there is no need of repeating his argument. It is perfectly plain that, if the primary rupture takes place so as to fall within the folds of the broad ligament, the hemorrhage must be limited. It is also perfectly clear that a further secondary rupture may occur into the peritoneal cavity, and will then be almost necessarily fatal, unless by the merest chance.

Mr. Tait, in considering the question of rupture into the broad ligament, clearly shows that no two cases necessarily have the same history. Some terminate quickly by the death

of the fetus and rapid absorption, others go on in their development for varying length of time, then to die and suppurate, or remain quiescent as lithopedia. Still others may go on until full development, necessitating surgical interference; while others, as has been shown, rupture, and unless promptly dealt with, in the vast majority of instances, terminate fatally.

Of suppurating cysts, Mr. Tait, after calling attention to their various paths of exit-umbilicus, rectum, vagina and bladder-thus sums up:

"In all of these the history helps but little, for the story is seldom more than that of obscure pelvic trouble, ending in abscess, bursting and continually discharging into the rectum, and it is not till the arrest of some sharp spicula of fetal bone in the anus declares the true solution, that the nature of the case is discovered. . The mortality is doubtless quite what is asserted by Parry, though I never saw a fatal case. All that have come under my own care have been easily cured by the complete emptying of the sac."

Of the fatality of cases opening into the bladder, Mr. Tait agrees with Parry, that they are much more fatal than those opening in the other directions. Mr. Tait has never seen one

of these cases in its early stages, but expresses the belief that the correct method of dealing with them is by abdominal section. He says:

"I feel quite confident that if these cases were dealt with by opening from above in their earlier stages, much of their mortality would disappear, and the patients would be spared years of suffering. I would treat them as I do pelvic abscesses, and if the peritoneum were opened I should close it in my usual fashion, by stitching the opening in the walls of the cavity of the broad ligament to the opening in the parietal peritoneum, after emptying the decomposing debris and cleaning out the cavity. I have now done over fifty operations of this nature, and not only has there been no mortality, but the cures have been so rapid, complete, and permanent, as to give me perhaps more satisfaction than almost any other class of my work."

For a complete discussion of what Mr. Tait terms the minority of the minority of cases, i. e., where the ovum survives and grows toward full time, the reader must follow minutely the

argument of the author. To do it full justice, almost a complete reproduction would be necessary. Jessop's remarkable case is cited at length, as the only instance of the so-called "abdominal" pregnancy on record. pregnancy on record. Mr. Tait, rightly we agree, refuses to accept those collected by Parry. The difficulty of diagnosis, in broad-ligament cases, approaching maturity, is thoroughly discussed. Conditions conducing to error are, extreme thinness of the uterine walls in normal pregnancy, displacement of the normally pregnant uterus, during the early months of pregnancy, complicated with fibro-myoma or cystic diseases of the uterus, and more rarely pregnancy in one-half of a double uterus. The greatest difficulties in diagnosis are met, according to Mr. Tait's experience, after the death of the child, or, at least, when the time of the expected confinement has passed so long that if there is a child, it is sure to be dead. 'No history," says Mr. Tait, "however complete, is of sufficient weight to establish a diagnosis, unless there be some distinct physical signs in support of it." Quoting from Campbell's curious work, referred to by Ramsbotham as "a publication full of most valuable facts and deep research," he cites the following passage, showing how little trust can be placed in histories :

"In many instances of the different varieties of misplaced gestation, the catamenia are suspended; frequently, however, they appear regularly in each of the early months; in some cases they flow at uncertain periods; and in other examples they are either profuse or limited in quantity. In many cases, at an uncertain period of gestation, we have hemorrhage, uterine effusions, the extrusion of coagula, of bodies which resemble moles, or portions of placenta. These appearances have occasionally led to the belief that the patient has aborted, so that the ovum was originally not extra- but intra-uterine, and had escaped through a rent in the uterus into the peritoneal cavity, the extruded body, in either case, being viewed as the placenta. Cases attended with much uterine excitement, whether arising from unusual exertion, or some external injury, are most likely to be accompanied by these later phenomena."

Two symptoms are regarded by Mr. Tait as invariable in extra-uterine gestation which has gone past the period: a "show"

during false labor, and a diminution of size after false labor. This opinion is fortified by Parry's authority, which is regarded throughout as especially weighty.

As to the treatment of these extra-uterine fetal cysts, Mr. Tait leaves no doubt or question as to his position. Tapping is condemned, as a diagnostic procedure. The author says: open the abdomen and make out the condition." The use of the trocar in diagnosis, as shown by Parry, is simply a record of mortality, and cannot be too strongly condemned. The treatment by electricity, at or near full time, in order to kill the child when viable, is condemned by Mr. Tait in the strongest terms, especially as its death does not bring safety to the mother. His own experience has shown that, by operation both may be saved, and his argument cannot be refuted. The treatment by electricity has been referred to before. Mr. Tait has no place for it. Dr. Buckmaster's case is cited at length. Mr. Tait here clearly has the best of the argument, and sums up his belief as follows:

"It is by no means clear from experience which we have had in this method, that the current is without harm, whether the diagnosis be correct or not, and it is equally without proof that it is sufficient to produce the effect desired."

In reply to the assertion that it is sometimes impossible to complete these operations, the following strong statement is made: "The rule ought to be that all such operations should be completed, and any man who has such want of skill and pluck as to stop in the middle of one of them, ought not to attempt them. THEY CAN ALL BE COMPLETED." It may be well to give the author's concluding creed in reference to the operation to save both mother and child :

He says, " I, therefore, advocate the principle of saving a child who has survived the catastrophe of the primary rupture of the tube by being extruded into the broad ligament. If its existence is recognized during life, the mother ought to be carefully watched till the false labor sets in, just as we watch for a case of puerperal hysterectomy and seize the onset of labor or its early stage, as the most favorable time for both mother and child. From this point of view, therefore, neither the time