favor of an early operation in every case where a diagnosis has been made.

The little incision, the safe, speedy and permanent recovery from an early appendicitis operation,--these are surgical triumphs that United States surgeons may well be proud of. Delayed surgery, chronic pathology and multiple complications are synonymous with extensive procedures, permanent destruction of the organ involved and often irreparable injury to structures in the vicinity of the original lesion.

The diagnosis of a ruptured tubal pregnancy is, as a rule, easy if the history is gotten carefully and systematically. All questions, in getting a history, should be asked with an object in view, and the patient should be made to answer in a concise manner.

To ask a question directed to bring out or dispel a suspicion which the physician may have formed, as to the existence of a certain disease, and to have the patient or her friends give the history of the ailments of some distant relative is confusing, and will surely lead to a scrambling or hashing of the truths. To separate from this confusion the facts wanted will be found a difficult task.

The menstrual history in the case of an extra-uterine pregnancy may be negative, yet in the typical cases this part of the clinical feature is very valuable. The typical ectopic menstrual history is about as follows:

Having been perfectly regular up to a given time, the woman noticed that she did not flow quite as profusely as formerly, and not quite so long, but that at the end of two weeks a "show" was noticed, this lasting a few days. At her next regular period her flow was more profuse, and clots were noticed to pass, and shreds of membrane (decidua) passed, accompanied with pains very much like those of a miscarriage. It is about this dime that the tube ruptures in most instances (eighth to tenth week) and the pains of a slight rupture with a menstrual flow and decidua passing certainly resemble an early abortion. At this time the menstrual flow usually continues until the diseased tube is removed. The flow may cease for a few days, but usually a "prune-juice flow" will continue for weeks. I had one case where the flow continued for six months after the primary rupture and the walling in of the ruptured tube and its escaped contents.

Bland Sutton calls attention to this feature of old ruptured

tubal pregnancies, and likens it to the retained placenta of a miscarriage. The location of a pain in the first or second rupture should be exactly defined by closely questioning the patient. The character of the pain differs entirely in the different ruptures from the pain of an early abortion.

The prostrating nature of the suffering can usually be brought out by cross-questioning the patient. The intensity of the collapse (shock) primarily, and the alarming nature of the syncope are usually out of all proportion to the small amount of blood lost per vaginam. The quickened pulse, the sub-normal (early) temperature, the gasping for breath-all these go to make up a picture of acute cerebral anæmia so typical that the recognition of the condition requires no great skill or experience. One experience in witnessing a case presenting these features is sufficient to indelibly impress its import on one's memory.

No question in getting a history should be ever asked in a leading manner. It is too often the case that the doctor asks and answers the question in the same sentence in getting a clinical history. A history elicited in such a manner usually confirms the doctor's previously conceived idea of the case, and in most instances that opinion is not a correct one. Guess diagnoses may be correct occasionally. It is not the infrequent that the clinician and surgeon most desires, but the most accurate and exact. Much guessing in surgical diagnoses is an excuse for repeated so-called exploratory incisions. All diagnostic resources should be brought to bear on any contemplating an operation. In the clinical history of the cases here reported attention is called to some special and interesting feature of this frequent and dangerous condition. During this present year, up to June 1st, I operated upon eight cases of ruptured tubal pregnancy.

case

Mr. Tait I am sure is wrong when he says that all cases of interstitial pregnancy prove fatal by intra-peritoneal rupture before the fifth month, and the following case will prove my

assertion.

Mrs.

ago.

-, aged 24, gave birth to a full-term child one year Nothing unusual, excepting that she did not nurse the baby. She menstruated at the end of the third month following her confinement, and continued regular up to ten weeks ago. At

that time she ceased menstruating, and all evidences of pregnancy soon developed. At four o'clock A. M. she was taken with pains of an intermittent character followed by bleeding per vaginam. These pains continued up to ten o'clock, when a fœtus and its membranes was expelled. The flowing ceased, the pain subsided, and all seemed serene up to 10 o'clock P. M., when she had a most terrific pain in the region of the left tube. This was quickly followed by collapse. The pulse ran up to 160 and the temperature dropped to 96.5 and all evidences of a concealed hemorrhage were present. Following the severe pain above referred to, a few natural uterine contractions expelled a second foetus completely enveloped in its membranes. The condition of the patient at this time was such that I was called in consultation. I found her with a pulse of 160, sub-normal temperature, and gasping for breath.

The attending physician was of the opinion that a part of the membranes of the first child was retained, hence an anesthetic was given, and the curette introduced, which, to my surprise, passed upward, without meeting any resistance, for eight inches. It was quickly withdrawn and the finger substituted, when the true pathology was revealed. The left cornua was dilated and funnel-shaped, the apex of the cone being some part of the Fallopian tube. At the tubo-uterine junction there existed an opening torn through into the peritoneum. It was through this tear that the curette found exit. An iodoform gauze pack was introduced as a temporary procedure trusting that nature would close the rent by uterine contraction, and thereby control the bleeding as well as prevent the invasion of sepsis from the vagina and uterus into the peritoneum. This case, fortunately, made a good recovery. This treatment would not be the best to use in all similar cases.

The pathology of extra-uterine pregnancy which most concerns the practitioners as well as the surgeons is the clinical pathology, as it may be termed. Theoretical pathology, while invaluable to the scientific phase of this topic, is of little value at the bedside. Facts leading to a correct diagnosis and proper interpretation of well marked operative indications are the truths we should seek. It matters little to the patient or the surgeon whether or not a patch of the tube is denuded of its celliated epi

thelium, and especially is this true when the ovarian or uterine vessels are ruptured by the contents of that tube.

A tube once ruptured (primary rupture) will certainly continue giving trouble even if a secondary rupture does not occur. The dangers incident to delay while trusting to nature's efforts to cope with a ruptured tubal pregnancy far outweigh those of timely surgery.

A diagnosis of tubal rupture forms a positive indication for surgery, it matters not whether the rupture has taken place into the broad ligament or peritoneal cavity. A number of deaths have been recorded as having taken place while the surgeon was debating the question of the exact location of the rupture, and whether the hemorrhage was going on intra or extra-peritoneally.

The following is a case of extra-uterine pregnancy: Mrs. G., aged 44. This lady had several children by her first husband, and was then a widow for several years. Has been married to her present husband for five years; no children and no miscarriages. Health good. Menstrual periods regular up to her present illHer last menstrual period was on April 28. In the early part of June she had a little flow, lasting for two days, passing at that time shreds of membrane (decidua). No nausea or breast changes. She attributed her irregularity to the "change of life" working on her, and thought but little of it.

ness.

On June 20, Dr. Brosius was called to see her, and found her having severe pains in the lower abdomen, continuous in duration and of almost prostrating (hemorrhage) character. She had fainted two or three times (acute cerebral anæmia) and was sweating profusely and calling for air. Strychnia was given and warmth applied to the body. Under this treatment she improved slowly, and in two or three days was able to sit up in bed. June 28, one week later, the doctor was again called, and found her very much in the same condition (secondary rupture). The same treatment was resorted to, and I was called to see her, the doctor recognizing the case as an ectopic pregnancy with a tubal

rupture.

On

my

On

arrival I found her as white as an unpainted wax fig ure with a pulse of 140, but with a temperature of 100°. (Septic fever, possibly the fermentation fever of Bergman and Senn.) An examination revealed a "boggy" mass in the vaginal vault

or

and filling the pelvis. The feel of blood clots in the vault is different from any other sensation to the examining finger, presenting a peculiar crackling or quivering sensation. The mass of clots and débris filled the pelvis and extended half way up to the umbilicus, pushing the intestines upward and leaving a dullness from iliac spine to iliac spine. I was as gentle in my examination as possible, yet this careful manipulation disturbed the clots (nature's poor ligatures) and started up a fresh hemorrhage, or intensified that which was certainly going on when I arrived. She soon went into a state of collapse of the most alarming character, so much so that she went on to the table without a pulse. Hurried preparations were made for an operation, and little time was lost in opening the abdomen.

An enormous amount of fluid blood and many firm clots were found. Quickly working my fingers down to the uterus, and from there to the ruptured tube, which proved to be the left one in this case, the specimen was delivered, and grasped with a pair of large tissue forceps, and the bleeding that was going on was quickly controlled. The clots were broken up and removed from the pelvic cavity and the cavity flushed and cleansed so that I could make sure of getting my ligatures below the point of the rupture. The tube had ruptured very close to the uterus. The foetus was found in this case.

A drainage tube was introduced and the patient was put to bed without a pulse. The foot of the bed was raised, and a quart of normal saline solution (45 gr. chloride to a pint of sterilized water) was injected into the rectum, and 24 ounces of the same solution was thrown under the mammary glands and glutei muscles. Strychnine, atropine and whiskey were given hypodermically. In a few hours a good pulse for that particular case was developed.

The shape of the mass in extra-uterine is almost characteristic where the bleeding has been going on for several days. The clot of an extra-uterine is at the bottom of the pelvis, and is built up cone-shaped towards the umbilicus, and the clot receives layer after layer of coagulated blood, the fluid part of the blood draining into the costo-iliac cavities. In many instances very few clots form at all, as the peritoneal fluid and the absence of air prevent coagulation. I have noticed that peculiar feature, the cone-shape