Professor of Gynecology in McGill University; Gynæcologist to the Montreal General Hospital; one of the Vice-Presidents of the British Gynecological Society.

The remarkable advances of obstetric medicine in the last decade have been evidenced as much perhaps, if not more, in everything connected with the subject of extra-uterine gestation than in any other direction. The transactions of every important meeting of obstetricians and gynecologists is enriched by one or more papers on the subject, generally with reports of cases; followed usually by a vigorous discussion which shows usually some divergence of opinion by able men as to the best course to pursue in the treatment.

The last annual meeting of the American Gynæcological Association, held in September, 1887, and the February (1888) meetings of the British Gynecological Society as well as the Section on Obstetrics of the American Medical Association at

its meeting last month, each discussed the subject. Dr. Herman, of London, has recently published in the Lancet for May 26th and June 2nd, 1888, an exceedingly able and thoughtful paper on the early treatment of extra-uterine pregnancy.

The fearfully tragic nature of the illness and too frequently of the death of women so affected when left to nature, and the brilliant success of the modern surgical treatment of this condition amply account for such wide-spread interest. Under these circumstances I venture to believe that the recital of a recent case in my own experience may *Read before the 8th Annual Meeting of the Ontario

Medical Association at Toronto, June 1888.

be of some interest and value as a contribution to the literature of the subject. The, to me, unexpected presence of my friend, Dr. Johnstone, of Danville, Kentucky, who has recently written very ably on the subject, will, I am sure, enrich the discussion of my paper.

Mrs. æt. 29, was married in July, 1887, and had a miscarriage at between two and three months the following October. In this she was attended by my friend, Dr. Arthur Browne, of Montreal, and she recovered easily enough. Her first following menstrual period was on the 2nd December, and was normal. She remained well during the rest of the month except that she presented some of the signs of pregnancy, slightly marked. Early in January a slight bloody discharge appeared and lasted two weeks; it was not like her ordinary menstruation. About the middle of January she was seized with intense pelvic pain. and a most alarming condition of collapse, lasting for two days. During a good part of this time Dr. Browne feared she would die. She, however, slowly rallied and partially recovered, when, a fortnight later, during the first days of February, there were alarming recurrences of the pain and other symptoms. Under these circumstances Dr. Browne came to ask me to see the case with him, and told me that he believed he had a case of

extra-uterine fœtation.

I found the woman suffering very severely from pelvic and abdominal pain, imperfectly controlled by full doses of morphia. There was marked distension and frequent vomiting, and the pulse was rapid and very weak. On vaginal examination, there was a tolerably free bloody vaginal discharge. The uterus was markedly softened, bulky, and fixed, and to the right of, and behind it, there lay a painful and firm mass of some kind or other.

The results of the history given are by Dr. Browne, and my examination of the patient was fully concurrent in the diagnosis of ruptured tubal fœtation previously made by him and Dr. George Ross, who had also be consulted. This being our diagnosis, what was to be done? We discussed the propriety of using electricity, or of performing abdominal section. Electricity, we considered, to be precluded by the evident hæmorrhage and peritonitis. At our second visit the patient was decidedly worse, and in great danger, and then we decided to open the abdomen. This was ac

cordingly done on the 8th February. On opening the cavity a quantity of blood clot, of varying age, and bloody serum was revealed. On the right of the uterus, in the region of the ovary and tube, lay a ragged, granular mass. On attempting to raise this to apply a ligature to it, it was torn away. I made no further attempt to tie the torn base, but proceeded to scoop out what I could of blood clot, of which there lay a large quantity in the Douglas pouch. The cavity was then well washed out with a large quantity of warm water. In this part of the operation, the signal advantage of Lawson Tait's large ovariotomy trocar became very apparent. This tube measures about of an inch in diameter, and at its free end is a blunt beak, with two lateral openings. The large rubber tube attached to it was immersed in a pitcher of warm water held aloft by assistants. The water was then sucked through till it flowed from the trocar tube, which was then carried to all the deep parts of the pelvis, the powerful stream bringing away masses of clot and fibrine, an operation which could in no other way have been so effectually managed. The blunt beak of the instrument precludes all possibility of any injury to intestines or other structure. A glass drainage tube was carried to the bottom of the pelvis, where it was retained for a week. It will be observed that I applied no ligature to anything, yet the torn vessels yielded no more than a moderate amount of blood and bloody serum, as shown by the fluid sucked from the tube. The wound was closed as usual and the patient put to bed in rather an alarming condition, her pulse was 140° and small. Nothing was given by mouth for three days. She was fed per rectum with beef-tea and brandy. Under soap-suds and turpentine enemata, flatus was passed within sixteen hours, and a fæcal motion obtained in twenty hours. The distension was thus rapidly reduced and the pain soon relieved. Not a particle of morphia or Not a particle of morphia or opium was given at this stage. She made a tedious but complete recovery. The tedious nature of the The tedious nature of the convalescence was entirely due to a severe attack of cystitis.

At the time of operation no semblance of a fœtus was seen, but on careful examination after wards of the mass removed, a blood stained fœtus about an inch in length, as well as characterstic chorionic villi were discovered by Dr. Johnston,

the Pathologist to the Montreal General Hospital. From the appearance of the fœtus and parts when removed, I have no doubt that the vitality of the fœtus ceased at the time of the first serious symptoms, but that it did not escape. Such a condition of course shows that electricity would have been useless at any time after this patient was first seen by her physician.

The diagnosis of extra-uterine pregnancy is on all hands confessedly difficult, and yet it is probably not so difficult as imagined by the inexperienced. The first thing to be sure of is the possibility of pregnancy. If then the patient present the signs of abortion-pelvic pain and vaginal discharge the pelvic pain being usually severe and attended with faintness or collapse, and the discharge containing fragments of, or a complete decidual cast of the endometrium; and if on examination we discover the characteristic softness, enlargement of the uterus and the violet discoloration of the genitals, but above all the rapidly growing tumour on one side and behind the uterus, the diagnosis is established with such a measure of certainty that we must act. The next question is, what shall we do? This part of the subject-the treatment-is by no means settled to the satisfaction of all parties, and some of the most recent discussions have indicated a wide difference of opinion on the part of high authorities as to what shall be done, or perhaps more correctly, what shall first be done. The treatment of extra-uterine fœtation may be spoken of under three heads: fœticide by electricity, abdominal section to remove the fœtation, and expectancy.

Electricity. The form of electricity which has the greatest number of adherents is the faradic current; it is the simplest and most easily applied, and there must be very few medical men who do not possess the necessary apparatus. Certain eminent abdominal surgeons strongly oppose it, and yet there is a mass of evidence in its favor which seems to me to make its position unassailable. I grant that the evidence in some of the cases will not bear close scrutiny, but this is not the case as regards the bulk of it. I have published a case in which I take it the evidence as certainly proved the condition as anything short of seeing the fœtus or chorionic villi.

Abdominal Section. Mr. Tait, Dr. Johnstone,