superficially. As a last resort the median basilic vein at the left elbow was opened and fourteen ounces of very hot salt solution were injected, with the happy effect of restoring her pulse, color and respiration, and though her recovery was extremely tedious and characterized by many crises, she had the good fortune to regain her previous excellent health.

Many points in this case were most interesting, but two of them were so pronounced as to deserve special mention, as they should be remembered in connection with the differential diagnosis of these interabdominal diseases. Both of the features were noted in some of the other cases in this series, and I have frequently observed them before, though prominence is not given them in the books treating of the subject. The first of these was the epigastric pain complained of by the patient, though the source of the pain was deep in the pelvis. In cases of appendicitis, I have frequently noted that the first pain, and sometimes the only pain complained of by the patient, is at the epigastrium, though, as in this case, the point of tenderness to pressure is over the seat of the disease, i. e., over the appendix, or tube, or in the vaginal vault.

This is another evidence of the untrustworthiness of pain alone as a guide to the location of disease, and a corroboration of the value of localized tenderness on pressure.

The second point of diagnostic significance was the constant complaint of rectal tenesmus and desire to go to stool without being able to expel anything from the rectum, a symptom caused by the pressure of the mass of blood and clots about the rectum in Douglass' pouch.

This symptom was noted in most of the other cases of this group, indeed, I believe in all of these advanced cases where considerable blood had accumulated. This is a very significant sign and one easily corroborated by vaginal and rectal examinations with the finger.

These symptoms taken in conjunction with the irregular menstrual history, faintness, pallor, colicky pain, low temperature, often subnormal at first, and the early signs of pregnancy make a characteristic clinical picture that should never be mistaken.

In two cases of this series the diagnosis was made by the

2. Anterior wall (interior view) of the gestation sack, probe point protruding from the uterine end of the oviduct and eye from the oviduct at the point of rupture. The mass is made up of the anterior fold of the right broad ligament surmounted by the oviduct and traversed by the round ligament, the face being covered with smooth (normal) peritoneum.

3. The fœtus. Length when straight 51⁄2 inches.

Illustration half normal size.

attending physician before I was called, though in each instance it was the first case of ectopic gastation he had ever seen, which is a remarkable tribute to the progress of medical science when we recall that less than a generation since the condition was seldom recognized by the most expert gynecologists, and a report of eight cases operated by one individual in eight months with seven recoveries is a still greater triumph for modern methods of diagnosis and treatment.

The foetus, placenta, vermiform appendix and portions of the gestation sack from this patient are shown in the accompanying photograph. The foetus was at about the fourth month of gestation, and was about five inches in length, as may be seen by the tape.

Another advanced case was operated upon November 11th, the pregnancy dating from the menstrual period of the previous May. The patient had felt life distinctly for nearly two months, she insists, and she is doubtless correct, as life is apt to be felt earlier and more vigorously when the foetus is outside the uterus. She was treated much as the first case had been, and ultimately made a perfect recovery. It is a remarkable coincidence that these two patients should have advanced ectopic pregnancies at the same time, one from May and the other from the June menstruation, the first being operated in November and the second in October; that they should live in adjoining houses and quite by accident occupy adjoining rooms at the same hospital, at the same time, and happily both make good recoveries in the face of most unfavorable conditions.

The photograph shows the fœtus (ten inches in length), placenta and portions of the gestation sack. The placenta was five inches in diameter, and was attached to the posterior face of the uterus and the left broad ligament. The head of the fœtus lay at the very bottom of Douglass' pouch and crowded the uterus forward and upward out of the pelvis. A large aspirating needle, which had been thrust through the vaginal vault for diagnostic purposes, produced some queer cheesy looking material that proved very confusing till it was found that this was brain substance, the needle having perforated the head of the foetus.

The third advanced case died immediately on being returned

to bed after operation, the hemorrhage evidently being freshly started by the manipulation incident to the vaginal examination and incision, and before she could be turned on the table and the abdomen opened and the bleeding point grasped, she was so exsanguinated that she did not rally. This experience has been and shall be my last in the operative treatment of ectopic gestation by the vaginal route, for had I operated this case with the same detail and method followed in the others cited, i. e., by the abdominal route and with free use of normal salt solution, the result might have been different.

The remaining five cases were in the earlier weeks of pregnancy, one being a tubal abortion, one rupture of tube near the cormua with the expulsion of the unruptured amniotic sack containing a foetus less than half an inch in length. All made prompt and perfect recoveries.

In three of the cases the gestation being in the right tube, the vermiform appendix was adherent to or involved in the inflammatory mass and was removed along with the oviduct.

The impressive features of this series of concurrent causes are mainly those of differential diagnosis and details of operative treatment. The diagnostic points have been referred to in sufficient detail and their importance will doubtless be conceded, for after all it is about the diagnosis of this condition that the greatest interest centers.

In operative detail I have fixed upon certain principles that now seem to me to be correct, and I am happy to be able to report most excellent results from their adoption.

I. For reasons that seem quite sufficient, but chiefly because of the impossibility of controlling hemorrhage, as in my fatal case, and dealing satisfactorily with adhesions and complications, as in the adherent appendix cases, I operate all cases of ectopic pregnancy by the abdominal route.

II. Irrigation of the abdominal cavity for the purpose of washing out clots and blood is unnecessary and undesirable; wiping and sponging is better.

III. Hot salt solution, intravenously, by hypodermoclysis and in the abdominal cavity for stimulation and to fill the de