up to or through the later months of pregnancy—a rare

Occurrence.

The previous and intermediate conditions and variations between these extremes are many.

The Period of Tubal Pregnancy prior to Rupture.

The first few weeks, six or eight, the evolution of the ovum goes on within the tube without incident, or at least in the majority of cases, without sufficient deviation from the normal symptoms of pregnancy to lead the patient to seek medical advice.

As a rule, the first symptom to awaken anxiety is pain, mild to terrific, in one or the other tubal region, followed usually by nausea, faintness, slight to complete syncope, pallor, ending in complete exsanguination and death.

Prior to this onset of menacing symptoms, the most fortunate occurrence which can take place is the death of the

ovum.

At this period I know of no agent which can be so accurately and effectively applied as a lethal current of electricity. But alas, how rarely at this opportune time is the patient within the physician's grasp so that he may make a diagnosis. In every case of tubal pregnancy which has come. under my observation this golden opportunity has been lost, simply because nothing was known of the condition until the violent symptoms incident to rupture appeared. One of my earliest cases was treated with electricity; the patient recovered and is alive and well at the present time. It is my candid opinion, however, resultant from riper experience, that recovery was from the fortuitous kindness of nature rather than skill in diagnosis or selective treatment, for there is now no question in my mind but that rupture had already occurred.

In concluding this portion of the subject, we may summarize as follows:

1. Electricity is the agent par excellence for the destruction of the ovum in the early weeks of tubal pregnancy prior to rupture.

2. Practically it is very rare for the conditions to be within.

the physician's grasp, to be treated by any method at this time, hence electricity from natural limitations holds but a small place in the treatment of tubal pregnancy prior to rupture.

It is a question not decided whether rupture through the upper segment of the tube into the abdominal cavity ever occurs unaccompanied by hemorrhage. It is known that hemorrhage incident to such a rupture varies in rapidity and

In some cases it is so free and copious that fatality supervenes before medical or surgical aid can be summoned, and in other cases days elapse following the first symptoms of rupture, and the patient still lives on, though showing positive exsanguination, the loss of blood slowly going on all this time.

Reasoning from analogy it seems plausible that such rupture may occur without hemorrhage, for we have positive evidence that it occurs this way sometimes downward into the folds of the broad ligament, with perpetuation of the child's life for a longer or shorter time.

Another mooted point is whether incident to such rupture upward the ovum ever continues to live and develop. Theoretically it seems more reasonable to believe that it always dies, for bereft of covering of the maternal parts (the wall of the tube), the only envelope remaining to cover and protect the fœtus is the foetal membranes (the chorion and amnion).

We must admit, however, that nature's ways and resources are sometimes marvellous and startling, and it may be possible that an ovum thus ejected into the abdominal cavity can engraft itself upon neighboring peritoneal tissues and continue to live and develop.

This does not seem a physiological possibility. It appeals more strongly to one's reason to believe that if such a sequel ever does occur, the ovum remains adherent to the tube at the original site, that the patch of tubal mucous membrane exposed at the point of rupture furnishes the placenta with a suitable soil in its early development and later it spreads widely over surrounding viscera. If such ever does occur it

explains the old ideas regarding so-called abdominal pregnancy. If, mayhap, an ovum has survived and gone on to the seventh, eighth, or ninth month the surrounding parts must have become so changed, displaced, and buried under the placenta and membranes that no landmarks remain to indicate that it ever was a tubal pregnancy.

My personal experience in all the cases of this class with which I have had relation has failed to corroborate such theory. As far as I have been able to judge, the foetus, placenta, and membranes have always been extra peritoneal. However high in the abdominal cavity the developing fœtus has risen, there is still above all and outside all a peritoneal covering. Obviously this would not be the state of matters if the ovum escaped from the rent in the tube and became engrafted upon the peritoneal surface. We have no positive knowledge of the growth and development of an ovum upon any other matrix than cylindrical epithelium, such as is normally found lining the uterus and Fallopian tubes.

In conclusion, then, of this, the second division of our subject, we may assume, as far as our present knowledge warrants, that: —

Rupture upward or through the superior segment of the tube results in :

(a) Hemorrhage (slow or rapid) and death of both mother and fœtus.

(b) Absence of hemorrhage, probably death and absorption of fœtus, continuation of life of the mother.

(c) Possibly, but in extremely rare instances, continued life of the ovum, constituting the old so-called abdominal pregnancy.

The most urgent condition to be met at this turn of affairs is the hemorrhage. Manifestly there is but one remedy for it, namely, abdominal section, exposure of the ruptured tube, ligation and removal.

No one knows how frequent an upward rupture of the tube unaccompanied by hemorrhage occurs, for the very reason that beyond an attack of pain, which might pass as colic, no further symptoms would be likely to occur, unless

it be the rare chance of continued life of the foetus, which I personally gravely doubt and which would not become manifest until later, through enlarging abdomen, steady localized pain, placental souffle, etc.

Under the conditions above described, then, and at this stage of tubal pregnancy, the remedy must be the knife.

I cannot comprehend how any discussion of the propriety, nay, urgency of operation under the given conditions can

arise.

After a diagnosis of ruptured tubal pregnancy has been made, place your patient in the most favorable environment and proceed to an operation without delay. If you find the abdomen full of blood and a two months' old tubal gestation from which the lifeblood of your patient is slowly but surely oozing away, you will breathe a prayer of gratitude that you have saved your patient's life in the quickest and safest way known to science.

Rupture of the Tube Downward, with or without Hemorrhage between the Broad Ligament.

This may well constitute another division of our subject, for the conditions are totally different from the preceding. Of immediate danger to the patient's life there is little. The hemorrhage, if such occur, is received between the folds of the broad ligament and may dissect up the peritoneum for a considerable distance, even to the opposite side, and thus bury to obscurity all the pelvic organs. In all cases of this kind, however, the hemorrhage finally spontaneously ceases, because the resistance of the surrounding tissues. becomes greater than the pressure of blood. Extravasation is never sufficient to produce syncope. As far as I can judge, it has never exceeded a pint even in the worst cases which have fallen into my hands.

The symptoms incident to rupture of the tube are frequently overlooked or escape scrutiny and are forgotten, especially if none of the early indications of pregnancy have been present. Once the tension of the tube be relieved by rupture, with escape of the ovum into the broad ligament, pain ceases or at least becomes greatly mitigated, and the

fears of the patient are allayed. Often this phase of the situation is passed through without medical aid being summoned. There persists, however, a feeling of uneasiness, fulness, and subdued pain in the pelvis which does not yield to expectancy or domestic remedies.

A physician is finally consulted and on vaginal examination finds the pelvis occupied in part, or wholly, with a diffuse, tense, bulging tumor impinging closely upon the uterus, or it may be burying it, and reminding him, in its feeling of elasticity, of a pelvic abscess. This is the true pelvic hæmatocele.

Careful analysis of the history of the case will probably disclose the fact that the patient has missed a period, has had morning sickness, has herself had an idea that she is pregnant, and has had severe to agonizing pain in one or the other tubal region, which she has called "colic," and has also been without elevation of temperature.

Unfortunately the clinical picture may be far from so complete as thus described; indeed, it has been frequent that I have been able only to elicit a history of pain, normal temperature, and pelvic tumor, upon which to base a diagnosis.

With such an extravasation of blood the fœtus dies and is lost in the clots which engulf it. The treatment of this condition is open to the widest discussion and personal choice.

I. Patients never die from this condition even if let alone; at least I have never known or heard of a fatality. The blood is gradually absorbed, the tumor diminishes and finally disappears altogether.

2. It would be quite within the bounds of propriety to make abdominal section, clear the clots from the pelvis, and remove the ruptured tube. With the present scientific accuracy of surgery this would be a safe procedure, and bring about a much more rapid convalescence than the first course mentioned.

3. The bulging tumor may be opened in the posterior cul-de-sac and the blood and clots washed and curetted out. This is followed by rapid collapse of the tumor and recovery.