patient was much easier, no vomiting and pulse slightly more perceptible. On examination still no hemorrhage could be detected, though a thorough examination could not be made on account of tenderness of entire abdomen, especially marked on right side in region of appendix and on account of general bad condition of patient. Hot normal salt solution was kept up every four hours by bowel, everything by mouth interdicted and morphine given from four to six hours hypodermically for forty-eight hours. Temperature ranged from 96 to normal and then began to rise gradually, reaching on seventh day 103.5. Pulse was almost imperceptible for forty-eight hours, then began to show improvement. On second day after rupture an ill defined tumor could be made out on the right side in region of appendix, which was gradually enlarging. Now, leaving out the history of patient, I had a typical case of perforative localizing appendicitis, and taking in history and leaving out of consideration appendicitis, I had a typical case of ruptured extra uterine pregnancy. As soon as patient's strength admitted and operation could be had, which was on the seventh day after first taken, it was performed. On opening up abdomen a large tumor was found, stitched to the abdomen wall and incised, when a lot of foul, dark clotted blood, one-half liter probably, escaped. All clots were turned out with finger and the product of conception was found loosely attached to right tube. The right tube had burst and the peritoneum had walled off the contents from the general cavity. The wound was irrigated with normal salt solution and drainage employed. Temperature dropped to normal in forty-eight hours, pulse began to improve and patient made an uninterrupted recovery.

DISCUSSION.

DR. J. F. Y. PAINE, Galveston: I have listened with much interest to the reading of Dr. McCelvey's paper, and congratulate him upon the satisfactory outcome of the case he reported. There are some points in his paper which I wish to discuss briefly.

First, the changes which occur in the tissues of the tube in tubal pregnancy. The tube thickens under the stimulus of the presence of the fertil

ized ovum. This thickening is not due to hypertrophy of the muscular fibers, the connective tissue, the lymphatics and peritoneal covering, as occurs in the uterine walls in normal pregnancy, but to excessive vascularization, there being very slight increase in the tissue elements. With the progress of gestation the wall of the tube becomes stretched and thinned until it appears as a thin, almost transparent, membrane, composed of the attenuated muscle covered with its peritoneal investment. The fœtal membranes derived from the ovum are, with the exception of the placenta, the same as in intra-uterine pregnancy. Normally, the placenta is derived about equally from the decidua serotina of the uterus and the chorion frondosum of the ovum. In tubal pregnancy, the placenta is largely fœtal in its origin, being composed almost entirely of chorionic villi, the mucous membrane lining the tube being unfit to form a serotina.

The signs and symptoms of extra-uterine pregnancy are usually sufficiently well marked to lead to a diagnosis of that condition, if they are carefully investigated and faithfully interpreted. The history of an uncertain period of sterility, with the possible occurrence of pelvic inflammation during that time, the presence of the general and reflex phenomena of pregnancy, disordered menstruation, accompanied with gushes of blood, expulsion of the decidua, and coincident pelvic pain and tenderness, a pelvic tumor lateral to the uterus, progressively increasing in size, rarely fail to excite suspicion, and usually lead to a correct diagnosis after repeated examinations; yet there are typical cases in which the symptoms and signs are so slightly marked that the condition may be entirely overlooked until rupture of the gestation sac occurs.

The symptoms of rupture vary with individual cases. There is probably always overwhelming pain associated with the rupture, but the degree of anæmia varies with the situation of the placental attachment and the direction of the rupture. When situated at the floor of the tube, the rupture occurring into the abdominal cavity, the hemorrhage may be slight, while in cases of placental attachment at the upper border of the tube, rupture taking place in this region is usually followed by terrific loss of blood on account of the vascularity of the tissues. Again, rupture between the folds of the broad ligament is followed by modified anæmia, as the hemorrhage is limited by the lamina of the broad ligament. In a certain proportion of cases in which rupture occurs into the broad ligament, although the patient feels the sharp pain accompanying the rupture, and is compelled to keep her bed for a few days, may not be aware of what has happened, attributing the pain to some trifling matter associated with her pregnancy, a harmless hæmatocele having occurred, and the patient finally makes a perfect recovery.

With regard to the treatment of these cases, if the pregnancy is in the

early weeks, the operation for the removal of the tubal gestation sac should be conducted on the same lines, and ought not to be more dangerous than a salpingo-oophorectomy for pyosalpinx or hydrosalpinx. The dangers of operation increase necessarily as the pregnancy advances.

When rupture occurs into the broad ligament, and the embryo is known to have perished, operative treatment is sometimes unnecessary, the case pursuing the ordinary course of a hæmatocele.

The point of evacuation of an extra-uterine gestation sac should depend upon its location. If it is situated low in the pelvis, and is of easy access through the vagina, unquestionably the best method of procedure is to evacuate the contents of the sac into that canal, and establish free drainage. This method is especially adapted to cases in which rupture has occurred several weeks or more before the surgeon has seen the case, in which there are elevation of temperature and local tenderness, evidence of incipient suppuration of the sac. In these cases the vaginal route is far less hazardous, and entails none of the dangers, while obviating many of the risks of the abdominal method, and at the same time yields a satisfactory result.

DR. T. P. WEAVER, De Leon: I want to commend Dr. McCelvey for his good management of this particular case. With all due respect to the doctor who has just gone before me, if I understood him aright, that all such cases should be operated on immediately. Is that correct?

DR. J. F. Y. PAINE: Yes.

DR. WEAVER, Continuing: Right here is the point I want to make. It is all very well for the physician having the benefit of many years experience, but for the young doctors in particular, gentlemen, we should strive to be the guiding star of the community in which we live, with reference to caring for and preserving the life of those who may chance to fall in our hands. It is a mark of fine judgment to be able to individualize, for so often in our practice the life of the patient hinges on our judgment right at the particular time. No doubt, if you had said operate right now, notwithstanding the fact that older and perhaps more scientific men say do it now, your results would have fallen far short of what it was, in that you conserved the strength and tided her over the crisis or shock up to the point, that your operation was a success, in so much as you saved your patient. Judging from your statement, had you given that lady the very best possible operation at first call, why, undoubtedly, you would have had a funeral.

I want to commend the young gentleman for his exceedingly good management of his case. Not only in cases of tubal rupture, but in all cases of whatever kind, it behooves us to practice good common sense and judgment, as well as the fine-spun theory. I don't mean this for the old and experi

enced, but for the reason that it might help some young doctor when the older doctors say operate right now.

DR. JOHN T. MOORE, Galveston: I would like to say a few words relative to the differential diagnosis between appendicitis and hemorrhage from the rupture of an extra-uterine pregnancy. There has been done recently quite a good deal of work on the blood conditions found in these cases. Much information can be gotten that will aid in making a differential diagnosis.

I have in mind a case that our colleagues at Galveston made a mistake in the diagnosis; the case was diagnosed appendicitis, but upon opening the abdomen was found to be filled with blood from the rupture of an extrauterine pregnancy. In suppurative conditions there is, in most cases, a marked leucocytosis, with the iodine reaction positive. Cabot and Locke have shown the value of the iodine reaction in detecting a suppuration. It is found that in suppurative appendicitis there is marked leucocytosis, with the iodine reaction present; there is practically no alteration in the hæmoglobin or in the number of red cells in the blood. In cases of severe hemorrhages there is a marked fall in the number of red cells and in the hæmoglobin, while there is no leucocytosis, or, if any, only relative, and the iodine reaction is not present.

We need all the information we can get in the study of these cases in order to make a differential diagnosis. I feel that oftentimes the surgeon does not take advantage of some of the best means of diagnosis.

DR. J. M. FRAZIER, Belton: The question of diagnosis is the most important in that it concerns the general practitioner. Dr. McCelvey, in the case reported, was fortunately able to make at least an approximate diagnosis of either appendicitis or a rupture following a tubal pregnancy. In either case an operation was indicated, and the manaegment would be about the

same.

I had a case last year, which I reported at the last meeting of the Central Texas Medical Association, of tubal pregnancy with rupture into the broad ligament and up to the time of rupture there was almost an entire absence of symptoms of pregnancy. Patient passed two weeks over her regular menstrual period, then had a profuse menorrhagia with shreds of decidua, and suspecting an incomplete abortion I did a curettement. This was followed by a few days cessation of the flow, which then returned, and with consultation a second curettement was done. The patient went on without developing nausea or any of the ordinary clinical symptoms of pregnancy, but a gradually developing tumor on left side of uterus forced me to suspect tubal pregnancy, especially as it was accompanied by an indefinite train of nervous symptoms with unusual prostration, and finally, about the beginning of the third month, such marked evidence of shock that an abdominal incision was made and a large hæmatoma with extensive peri

toneal adhesions protruded. With irrigation and drainage, the patient made an uneventful recovery..

The point is, that in some of these cases a diagnosis without an exploratory operation is impossible. I am glad Dr. Moore has presented another possible way to make a diagnosis, and I hope it will prove of benefit, but I fear the general practitioner will not be able to avail himself of the suggestion.

DR. J. T. O'BARR, Ledbetter: Examination of the blood, as suggested by Dr. Moore, is all right if you have plenty of time. Many of these cases are not recognized until after rupture has taken place, and sometimes a very urgent and immediate operation is indicated, and in that case there is not time to wait and make a blood examination before operation.

DR. J. S. MCCELVEY, closed: In reference to the anatomical points as to the enlargement of tube, the doctor says you can not have enlargement of tube except that due to vascularity and not to hypertrophy. Now, gentlemen, I have never made a microscopical study of any specimen, but Runge, Obshausen and Fritch claim that there is a real hypertrophy of both the muscular tissue and mucous membrane, just as occurs in uterus in normal pregnancy. The muscular fibers of the tube increase and enlarge and the mucous membrane grows and envelops the ovum and the decidua serotina, vera and reflexa are formed. In regard to symptoms, if rupture occurs between the folds of the broad ligament, and there is but little outpouring of blood, the symptoms are very slight and patient recovers without any treatment whatever. But in this case of mine the rupture was into the general peritoneal cavity, and while there was not much hemorrhage, there was great pain, which pain caused severe shock. When the rupture occurs into the general peritoneal cavity there is nearly always shock, hemorrhage or no hemorrhage, and that shock is due to pain just as occurs in perforation or ulcer of the bowels. The patient may die from the latter in a few hours, though there be no hemorrhage and it is too early for sepsis.

Some one thought the patient should have been operated on immediately, which I think would have been a fatal mistake. The patient suffered from such marked shock for forty-eight hours that an operation was out of question altogether. As soon as reaction was brought about, which was several days, an operation was advised, but not consented to for several days

more.