"Be ready, however, to employ surgical interference should there be a recurrence of the bleeding."

To summarize somewhat. It is generally taught that in cases of tubal rupture in the early months of an ectopic gestation death is almost invariably due to the hemorrhage that takes place, and accordingly the majority of surgeons advocate opening the abdomen as soon as possible and ligating the bleeding vessels. If the total number of deaths could be known that have followed immediate operations for tubal rupture it would be found a considerable one. Particularly is this the case in the country, or in other places removed from the skill of the expert. Therefore when surgeons advise that all such patients should be operated upon immediately, it is easily seen why the treatment might be almost as dangerous as the pathological condition. Naturally the physician in charge of such a patient would feel that an operation should be done at once and that he must do it. Very often, however, such a man has had little or no experience with the performing of an abdominal operation. Under these circumstances the patient's life might be sacrificed simply from the shock of the operation alone. In some instances also a fatal result might follow from the introduction of an infection. For my own part I believe that when we are called to see a patient who is suffering from a tubal rupture, in the great majority of instances the active bleeding has ceased. Now if such a patient is given an anesthetic and an abdominal operation is carried out, the immediate shock of the operation may well be sufficient to cause her death, but to this is added the risk of producing a fresh hemorrhage by the manipulation of the tissues. Undoubtedly in this way a certain number of the immediate or early deaths following the operation may be accounted for. As a rule, after opening the abdomen in such cases, we find a considerable amount of fluid blood present, but it is not often that we see an actually bleeding vessel. When we find spurting or oozing from the rupture in the sac it is generally caused by the blood that has been held under tension in the sac. A large proportion of ectopic gestations are situated in the ampullary portion of the Fallopian tube, and when the embryo passes out through the fimbriated extremity of the Fallopian tube, the amount of blood that is poured out at this time is often not enough to produce a fatal result. Most of these cases, therefore, would undoubtedly recover without any further serious symptoms. For this reason all statistics dealing with the number of deaths

due to a ruptured ectopic gestation are somewhat fallacious. From my experience in the clinical and experimental side of this work for the past three or four years, I feel positive that a fatal result due to the loss of blood alone is exceptional. From our examinations also of a considerable number of ectopic sacs in which a rupture has taken place, we feel sure that it will not often be found that the large vessels, such as the uterine and ovarian arteries, have been torn. During the past four or five years we have carried out with satisfactory results the following method of treating all our cases of ruptured ectopic gestation. If there are signs of improvement in the patient's condition (and this in our experience always takes place), we keep the patient under further observation. The change for the better is brought about by carefully stimulating the patient by means of saline infusions under the breasts, and in some instances also by means of hot saline enemata. If the patient is not vomiting or is not nauseated, we administer a stimulant in small quantities by the mouth. In addition to this we give morphine hypodermically for the pain and the nervousness. External heat is also applied to the body, and the lower end of the bed is slightly elevated. The sulphate of strychnine is also given hypodermically in doses of I-10 to 1-20 of a grain every half hour or so, according to the indications. While this treatment is being carried out the operating room is prepared, so that it can be used at a moment's notice. We have also carried out this treatment in those cases that we have seen for the first time at the patients' homes. Then as soon as the woman had recovered from the shock of the rupture she was transported to the hospital, where an operation could be carried out at any time. that the necessity might arise. Every patient in our series has gradually improved so that after two or three days, and in some instances after twelve days' time, the operative procedures have been carried out with very little if any shock to the patient.

ANALYSIS OF A SERIES OF TWENTY CASES OF ECTOPIC GESTATION.

From an analysis of the twenty cases of ectopic gestation that have come under our personal observation, and received surgical treatment, we may summarize our findings as follows:

Age of Patient.-The youngest patient was twenty-three, the oldest forty-three. Between the second and third decades there were seven, between the third and fourth twelve; one patient was above the age of forty.

2. Previous History.-Fourteen patients had given birth to

children, four were primiparous and ten multiparous (2-6). There were six nullipara.

A history pointing to previous pelvic inflammatory disease was recorded in only three of the cases. Miscarriage had occurred in ten patients.

There had been a cessation of the menstrual flow during a period ranging from five to twelve weeks prior to admission in ten of the patients. In two an irregular flow had been noticed for a short while previous to the acute onset of the illness, and of the remaining seven there had been no menstrual disturbance in four; the history was unsatisfactory in three.

3. Present Illness.-This dated from four days to eight weeks prior to the time of admission. Exacerbations of the primary attack occurred as late as the day of admission in a few cases.

The onset of the attack was in nearly all cases with pain, which was described in thirteen instances as being "sudden and sharp," generally in the lower abdomen, but in one case it was most intense in the epigastrium. In three patients the pain was of a "cramping" or "bearing down" character, while in four it was spoken of as being merely severe. In a number of instances this symptom was chiefly localized to one side of the pelvis.

Pain continuous or increasing in severity to the time of admission was noted in nearly every case of tubal rupture, whereas in cases of tubal abortion there was usually a history of recurring attacks of pain at intervals of a few hours to a day or so.

Fainting attacks had occurred in four instances, two of which were cases of tubal rupture, the other two of tubal abortion and pelvic hematocele respectively.

Five patients had had nausea and vomiting.

A bloody vaginal discharge, varying from slight to a profuse flow, and beginning with the onset of pain or some time afterwards, was noted in fifteen instances.

4. Condition on Admission.-In five of our patients the condition was regarded as serious and contraindicatory to immediate surgical interference. All of these showed evidences of shock, and a marked anemia was present, the lowest hemoglobin record (Tallqvist) being sixty per cent. The general condition of the remaining fifteen patients was "fair" to good, none exhibiting symptoms, however, that called for immediate operation.

Signs on bimanual examination pointing to a probable ectopic gestation were noted in eight of our cases.

The temperature was normal or above in eighteen patients, the highest being 101.4°, not definitely given in one. One patient in collapse had a temperature of 96° F.

5. Time of Operation.-No patient was operated upon earlier than the day after admission (18 to 24 hours), and there were only three who came to operation so soon. In one of these patients a diagnosis of pelvic abscess was thought to warrant an early vaginal puncture. The other two patients were in sufficiently good condition to undergo a laparotomy at the time.

The remainder of our patients were operated upon at periods ranging from three to twelve days after admission, the average being five days, eight of the seventeen on the third day.

Of the five patients, who were in grave condition at the time of admission, operation was not considered advisable until the third, sixth, eighth, and twelfth day afterwards, respectively, in four instances, the other patient being the one mentioned above as coming to operation on the day after admission.

6. Condition at Operation.-It will suffice to say that of our five serious cases all but the one operated upon the day after admission showed considerable improvement in their condition over that when first seen. The usual measures of stimulation and keeping the patient quiet had been employed.

7. Operation. There were fourteen patients treated primarily by abdominal section, four in whom only a vaginal puncture was done, and two in whom vaginal puncture was followed by abdominal section, in the one case immediately, in the other twenty-four hours later on account of a suspected continuance of hemorrhage. Of these latter two cases one was an instance of tubal rupture, the other of ovarian pregnancy.

Tubal rupture was found at operation in nine cases, six times. on the left side, three times on the right side.

Tubal abortion had occurred in four instances, three left sided. An intact tubal pregnancy was met with twice, on opposite sides. Pelvic hematocele was the diagnosis in four patients.

The unusual case of an ovarian pregnancy has been mentioned. Adherent structures on the two sides called for a bilateral salpingooophorectomy in three patients. A unilateral salpingo-oophorectomy was done in eleven instances, and the opposite tube removed in nine. Both tubes were removed in two cases.

The appendix was found involved four times; once it was ad

herent, and in three instances was deeply congested. It was removed from eight patients.

Clotted blood or bloody fluid or the two together in a large quantity were found in the peritoneal cavity in seven of the abdominal sections (six tubal ruptures and the ovarian pregnancy). Where an estimation of the quantity is given, the figures vary from 700 to 1,500 c.c.

We wish to here raise the question whether one can judge of the actual loss of blood to the patient from the amount of bloody fluid present in the abdomen, as some of the latter is probably a serous exudation resulting from an irritation of the peritoneum by the blood that escapes into the abdominal cavity.

Drainage was employed in three of the abdominal section cases, once by the vagina in a primary section, once through both abdomen and vagina, and once per vaginam alone, respectively, in the two celiotomies that followed vaginal puncture.

8. Convalescence and Results.-Eleven patients made an uninterrupted recovery-nine of the celiotomies and two of the vaginal punctures. In two of the section cases, one for an ovarian pregnancy, the other for tubal rupture, convalescence was slow; in both of these patients there was a marked anemia, and a left brachial thrombophlebitis developed in one of them.

There were evidences of a right popliteal phlebitis in one section case. In another bronchopneumonia was a complication.

Following abdominal section for tubal abortion a concomitant uterine pregnancy ended in abortion on the fourth day after operation.

Infection of the abdominal incision took place in one instance. -a tubal rupture.

Two of the patients treated by vaginal puncture for hematocele had a considerable elevation of temperature during the first twelve to fifteen days, and one of them a good deal of abdominal pain. Both were discharged free from pain, but with adherent pelvic

structures.

There was one death in our series. This occurred in a patient whose convalescence from a celiotomy for tubal rupture had progressed favorably to about the tenth day, when signs of ileus began to manifest themselves. The abdomen was reopened on the next day; a volvulus and intestinal adhesions were found present. Death ensued one hour later.

9. Pathologic Findings.-There were two specimens of intact