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tion occurred in 23 cases (85%). Faintness occurred in 10 out of 24 cases recorded or 41.6%. Nausea and vomiting in 6 out of 24 or 25%.

Condition on Admission.-The temperature ranged from a slight fever in 12 cases out of 34 (35%), to sub-normal in 9 cases (26.4%). There was normal temperature in 38%. Shock was present in 9 cases (26.4%). 5 cases were severe, the remainder of varying lesser degrees. There were signs of ectopic gestation in 19 out of 27 cases or 70%.

Time of Operation.-Six were operated on at once, two of whom were in profound shock. These two were the only deaths recorded in the 34 cases. All the others were in the hospital from one to ten days before operation.

Operation. Twenty-four patients were operated on by abdominal section; 3 cases by vaginal puncture and drainage. Of the 24 section cases recorded the right tube was involved in 10 cases, and the left in 14 cases. Tubal rupture occurred in 8 cases and abortion in 15. Intact tubal pregnancy in I case. The appendix was found involved in 4 cases and removed. The uterus was markedly retro displaced and suspended by Gilliam operation in 4 cases. Of the 3 cases recorded that had vaginal puncture and drainage, two developed rather high temperatures and had a stormy convalescence for a week and ten days respectively; both recovered, however. The other one, a broad ligament hematoma, drained out uneventfully.

I will now give a brief history, with treatment, of the five cases recorded that came to the hospital in condition of severe shock.

Case "A."-Mrs. I. O. Age 28. Admitted to hospital on stretcher 5:30 A. M. Patient complains of severe pain in abdomen and is in profound shock. Patient states she has had no menstrual period in two months but has had bloody vaginal discharge occasionally. About 8 P. M. yesterday she began to have severe cramp-like pains in lower abdomen, similar to labor pains. Pains continued all night and early this morning she began to get short of breath, was very weak and had great thirst with marked pressure symptoms in abdomen.

Physical examination.-Shows a large obese woman. Pale, lips blanched, rapid respiration, anxious expression on face, and very restless. Heart and lungs negative. Abdomen large, rigid, tender to touch, with dullness in both flanks on percussion. Pulse 160 and poor quality. On account of patient's history of growing worse, it was thought advisable to operate at once. Abdomen was opened, under ether anesthesia. A large quantity of blood and clots were removed. A ruptured right tubal pregnancy was found, and tube removed. Abdomen closed. Patient gradually grew worse in spite of treatment and died the next day.

Case "B.”—Mrs. R. F. Age 38. Admitted to hospital in condition of shock. Last menstrual period three months ago. One month ago had a little bloody discharge. One week ago had some pain in right lower

quadrant; this had returned at intervals. Last night pain became very severe and went into condition of shock. Her physician sent her to the hospital this evening. Temperature 96, P. 160, Resp. 58.

Physical Examination.-Patient in profound shock. Heart and lungs negative. Abdomen distended, tender and rigid. A diagnosis of ruptured ectopic gestation was made and on account of her history,—repeated hemorrhage was feared-so abdominal section was performed and a large amount of blood came out. A ruptured left tubal pregnancy was found, tube and mass with clots removed. Patient was given the customary treatment for shock but in spite of treatment she gradually became worse and died one day later.

Case "C."-Mrs. C. H. Age 28. Admitted to hospital in condition of shock. Has had no history of menstrual irregularity. This morning at breakfast table she was seized with severe cramp-like pains in abdomen, felt faint and vomited. A few hours later was brought to hospital.

Physical Examination, by one of the staff a short time later, found her pale and weak, but pulse of good quality so she was sent to operating room. When the anesthetist examined patient a few minutes after she was brought to operating room, she discovered her to be pulseless. The writer and another member of staff were called at. once and found that she was in profound shock and appeared to be in moribund condition. We decided not to operate but see if her condition would improve under treatment for shock. She did improve slowly and two days later was well enough to risk an abdominal section. The right tube was found ruptured I centimeter from the uterine end. A large amount of blood and clots was found free in the abdomen. Tube and blood removed. Patient made a slow recovery and went home in good condition 5 weeks after admission.

Case "D."-Mrs. H. C. Age 28. Admitted in extreme shock. Seven hours ago while lying in bed was taken with sudden severe general abdominal pains, fainted three times. Has been in state of collapse since and is growing worse.

Physical Examination.-Face pale and pinched. Mucous membranes blanched.

Chest.-Heart and lungs negative.

Abdomen.-Tender to touch and muscle spasm in lower part. Patient put to bed and treated for shock and after 18 hours condition is much improved. Operated on the second day. Abdominal section:-a large quantity of free blood and clots removed and the left tube was found to be ruptured one inch from uterine end. Tube and mass removed. Patient made an uneventful recovery.

Case "E."-Mrs. I. H. Admitted in extreme shock. Was taken one day before admission by sudden severe pain shooting through pelvis. Has not menstruated for six weeks. Has had a slight bloody vaginal discharge for several days.

Physical Examination.-Shows face pale and pinched. Pulse cannot be

counted and profound shock evident. Treatment.-Shock position, ice bags to abdomen, morph. gr. 1/6 for restlessness, Murphy drip or saline sub. q., no stimulant. Patient improved gradually and two days later her abdomen was opened, a moderate amount of free blood and clots were found and removed. The left tube was found ruptured and taken out. Right tube was absent. It was removed for ectopic gestation at a previous operation.

Conclusions as to Treatment.

I. All agree that if a diagnosis of an unruptured ectopic gestation is made it should be removed at once.

2. A ruptured ectopic gestation should not be attacked through the vagina,

I. Because you cannot examine for points of possible future hemorrhage,

2. The clots of blood are often hard to get out and when infected cause, to say the least, a very uncomfortable and stormy convalescence, as shown in two of the cases recorded. 3. On account of the well-known association of pelvic inflammatory conditions with ectopic pregnancy, our records of 33% previous miscarriages, of 15% pelvic inflammation, and of 4% previous ectopic pregnancy, we are justified in advising careful exploring of the opposite tube when the patient's condition is safe for the additional delay.

4. Although the two deaths recorded might have occurred if the operation had been deferred and patients treated for shock, I think the records of all the other cases, some of which were equally as bad as far as appearance at least, justify the conclusion that in the majority of cases where patients are first seen in condition of shock with a diagnosis of ruptured ectopic pregnancy, it can be more safely treated by deferring operation until the patient is given a chance to rally.

DISCUSSION.

DR. INGALLS (Hartford): Mr. Chairman and gentlemen: I want to say a word, to say that I thoroughly agree with the conclusions Dr. Elliott has arrived at. In the face of a great deal of opposition some years ago, I advised the policy of waiting in the case of ruptured ectopic where there has been hemorrhage, and not to operate in the case of shock.

I was very severely criticized at that time for delaying the work, but I think the results have justified the opinion at that time. Since then I have always stuck to those conclusions. Dr. Elliott's paper has conclusively shown that the cases in which he waited and in which the others waited, and in which the patients rallied from shock and had power enough to stand an operation did well. That would be obviously so. I will not say they may wait, but I will say in all cases of shock never operate, because I believe thoroughly that a patient brought in, in profound shock, that your operation is one hundred per cent sure to kill, and if you wait, you will get ninety-eight to ninety-nine per cent recovery. I believe it a cardinal rule not to operate in cases of severe shock and the end will justify the means.

I have never seen a case undergoing active hemorrhage while operating. I believe they are self-limited. The shock comes from the original hemorrhage and that is self-limited. You will find no active hemorrhage going on, and that is another argument in favor of waiting until the patient is over the shock.

We know a great many cases will get well if not operated on at all. We know a great many cases are not diagnosed and the results are found at future operations. I don't believe patients die from a ruptured ectopic. I believe they more often die from hasty surgery.

DR. ELLIOTT (Hartford): It is hard to add anything to Dr. Ingalls' discussion. I would like to add, however, that Robb in 1907 read a paper with an analysis of his cases and came to very similar conclusions. The majority of speakers at the next meeting of the American Gynecological Society did not agree with him. However, the conclusions drawn from my analysis substantially corroborates the conclusions drawn by Robb. The opinion held by many that the condition of shock is due to the amount of blood lost into the abdominal cavity, has never been proven. There is frequently more blood lost during a miscarriage or at many full term deliveries that are accompanied with little or no shock.

By our results, above recorded, we feel justified in concluding that the additional shock of abdominal section on a patient already in profound shock lessens her chance of recovery more than deferring operation until the patient rallies.

Recent Advances in Neurological Surgery and Especially in the Diagnosis and Treatment of

Brain Injuries..

WILLIAM SHArpe, M.D.

(Professor of Neurological Surgery, New York Polyclinic Hospital and Medical School, New York City.)

The field of neurological surgery has so developed within the last decade that I wish this afternoon merely to emphasize some points in the diagnosis and treatment of certain lesions of the brain, spinal cord and the peripheral nerves. This advance in neurological surgery has been due to three main factors:-earlier and more accurate diagnosis and localization, an improved operative technique, and, most important, better team-work-not merely between the operator and his assistants, which is most necessary for successful cranial operations, but of still greater importance that essential team-work between the surgeon and the neurologist at his side; formerly the neurologist knew little if any surgery and the operator knew little if any neurology; the result was frequently disastrous to the patient. The surgeon should have a practical knowledge of the principles of neurology-the more neurology the surgeon knows, so much the better will be his operative results; much permanent damage can very easily occur if general neurological principles are ignored.

If neurological surgery consisted chiefly in the removal of brain tumors it would be indeed a most discouraging field of endeavor. As you know, almost 80 per cent of tumors of the brain are malignant and even though a surgically successful removal of the tumor is possible, yet the end results are the same the pitiful condition of the patient is merely prolonged; the severe headaches, however, and the impairment of vision are thus temporarily relieved and even prevented by an early

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