ness, pain in the breasts, and other mammary changes, cannot be relied upon in ectopic pregnancy in the early months. Of course if they are present they confirm the diagnosis; but they are very often absent, and indeed appear to be less constant in extra-uterine than in intra-uterine gestation. Irritation of the bladder is a common symptom, especially if there is a collection of blood, or hematocele, in Douglas' pouch pushing the uterus forward against the bladder.

Diagnosis before rupture: (1) the patient is within the child-bearing child-bearing age; statistics show that the largest number of extra-uterine pregnancies occur between the ages of 25 and 35 years; (b) the patient may have been childless, but more often she has had one or more children; (c) quite frequently a history pointing to some inflammatory condition of the uterus and its appendages may be obtain ed; (d) one or more menstrual periods have been missed; this, however, is not constant, depending on the age of the pregnancy; (e) bloody vaginal flow. usually moderate in amount and dark in color; but sometimes free or even profuse with bright red clots, this flow may contain shreds of tissue; (f) cramping pains more or less severe with an uneasy feeling in the pelvis; (g) a careful general and bimanual examination may further disclose changes in the breasts; purplish discoloration of the mucous membrane of the vagina and cervix uteri; enlargement of the uterus and a soft, tender and slightly movable tumor behind and to one side of the uterus.

There

Diagnosis at the time of rupture: I have already pointed out that usually these cases are not seen until after rupture occurs. At this time the diagnosis is more easily made, and we look for the following symptoms: Almost unbearable. sharp, tearing, cutting pain, unmistakably referred to a definite location, and accompanied by nausea. are present all the signs of internal hemorrhage. Prostration is shown by frequent and rapid respirations, rapid and thready pulse, and body covered with a cold, clammy perspiration. In addition to this the abdomen is distended and tender, and signs of fluid in the abdominal cavity may be found if the bleeding has been profuse. This is shown by tympany in front and dullness in the flanks. This dullness changes as the patient is turned from side to side.

In carrying out a bimanual examination the greatest care must be exercised, for a gravid sac very readily gives way when roughly handled. The sae varies greatly as regards size, position and consistency. Its size depends upon the age of the pregnancy, and also upon the amount of hemorrhage which has occurred. The consistency, too, is not constant.

Theoretically, it is soft and elastic, but, as a matter of fact, especially after an effusion of blood into the wall it may feel just as firm and hard as any solid tumor. In the early weeks the sac is usually situated on one side and somewhat behind the uterus, and as it increases it usually extends further and further backward; as it does so it pushes the uterus forward and upward; when the rupture occurs into the layers of the broad ligament the tumor may be distinctly lateral and the uterus strongly pushed over toward the opposite side.

Diagnosis in long standing cases: Undoubtedly in many cases a diagnosis is never made, because of the slight disturbance manifested. Tubal abortion with slight bleeding and subsequent absorption of ovum and blood may never be discovered. The encapsulated remains of a pregnancy, either in the tube or the free abdominal cavity, may never be suspected, and later be found when the abdomen is opened for the relief of some other condition.

TREATMENT.

Treatment immediately after rupture: A vast majority of the cases are not seen until after rupture. In such cases the all-important question for consideration is, when should one operate? Should we, no matter how great the degree of collapse, open the abdomen, remove the sac and arrest bleeding; or should we delay a few hours in order to combat the shock? If the symptoms of anemia have come on very rapidly and there is evidence of profuse bleeding, one should prepare for operation at once, in the meantime carrying out those measures to be employed to arrest internal hemorrhage. Personally I believe the safer procedure is immediate operation in all the immediate operation adds very little to cases. If the patient is extremely collapsed, the shock already present, for the operation can be performed quickly and with light anesthesia. When immediate operation is undertaken for sudden collapse, the abdominal route is the only one to be considered. Laparotomy may be done quickly, thoroughly and systematically at the patient's home as follows: The abdomen is made aseptic and the patient placed in the Trendelenberg position;

an incision is made in the middle line, the hand passed down into the pelvis, and the affected tube and ovary brought to view; the tubal sac is removed, the ovary being left the broad ligament are then ligated, and the behind if quite healthy; the two cut ends of raw edge covered with peritoneum; the pelvic and abdominal cavities are then irrigated with normal saline solution, or simply swabbed with dry sponges. The other tube and ovary should be examined if the condition of the patient will permit.

(2). The woman suffers for some time from occasional faintings, pain and uneasiness over the abdomen, and a bloody discharge from the vagina: In this group immediate operation is always advisable, for one can never tell when all danger is past. The operaion in these cases is simple. Usually there are slight adhesions between the tube and the surrounding parts, but these are readily broken down and the sac,-be it an aborting tube or be it a ruptured tube,-is removed. Should the rupture have occurred into the broad ligament and a hematoma exist, the best plan is to split open the broad ligament, clear out all blood clot, and pack the cavity with gauze. The broad ligament is then stitched over, and the end of the gauze brought out through the vagina. It is undesirable, if it can be avoided to bring the gauze out through the abdominal wound, for drainage in that direction is unsatisfactory as it weakens the lower part of the wound. In recent years several operators have suggested a conservative treatment of the tubes in cases of tubal pregnancy. Some, for example, have dilated the abdominal end of the tube and pressed out the ovum; others have split open the tube and shelled out the ovum from its walls. In the latter case the wound in the tube wall is carefully sutured. How far such procedures are advisable I am not prepared to say, as there is not as yet a sufficient number of recorded cases to judge.

mend the expectant plan. This expectant treatment consists of absolute rest in bed, fomentations, something to allay pain, if needed, and later douching and the administration of the syrup of the iodide of iron, all with the object of favoring absorption. The treatment is a very prolonged one, and the recovery most protracted, two or three months sometimes passing before the blood is completely absorbed. In a number of cases it has proved quite successful, but in others adhesions between uterus, intestines, tubes and ovaries have followed and the ultimate health of the patient has been far from satisfactory. In a few cases the hematocele has been infected, and an abscess has formed with all its dangers. If it is decided to operate for the hematocele, either the vaginal or abdominal route may be chosen; there is much to be said for both. By the abdominal route all blood clots can be cleared away, and any other unsatisfactory state of the tubes, ovaries and uterus may be corrected. The disadvantages of this method is that the hematocele, shut off by adhesions between the intestines, is opened into, through the general abdominal cavity. By opening through the vaginal vault, blood clots may be removed without opening into the general peritoneal cavity. Whichever route is chosen, the cavity should be drained with gauze brought out through the vagina.

Personally, I prefer the abdominal route, unless suppuration has occurred in the sac, and I do so because I think it advisable in all cases to examine the tubes and ovaries, and if necessary to suspend the uterus to the abdominal wall, so as to prevent its becoming zxed in a position of retroflexion.

REFERENCES.

collapse is recovered from, the pulse improves. but the temperature which was subnormal rises first to normal and often slightly above. The febrile disturbance is the result of absorption of disintegrating blood. Should the pelvic hematocele he seen later, when a considerable portion of blood is absorbed, the tumor remaining may simulate any of the tumors connected with the uterus or its appendages.

Treatment: In dealing with a pelvic hematocele most gynecologists are in favor of operation, but there are still a few who recom

Playfair: System of Midwifery, 1889. Jewett: The Practice of Obstetrics, 1899. Peterson: The Practice of Obstetrics, 1907. Kerr: Operative Midwifery, 1908.

DISCUSSION.

Jno. W. Price: I have enjoyed Dr. Phillips' paper very much indeed. He has done well to

these cases.

In regard to treatment, I believe that, whenever the diagnosis is made, no matter what type of ectopic gestation it is, or whether the tube has ruptured or not, operation should be done, by the abdominal route, and the tube containing the gestation removed. In my opinion, it is unwise to irrigate the abdominal cavity before closing it, because irrigation tends to lessen the normal resisting power of the peritoneum. These cases should never be attacked by the vaginal route. I also believe that drainage after the operation is unnecessary; simply remove all the clots possible

and then close the abdomen without drainage. Sidney J. Meyers: I understood Dr. Phillips to say that these patients should be operated upon immediately, no matter what their condition may be. It has been my practice, in acute cases where the tube has ruptured and the patient is in shock, if she can be safely transported to the hospital, to endeavor to tide her over until the condition improves somewhat. I have never seen a case of ectopic gestation with severe shock, where I believed immediate operation to be absolutely necessary. I know that many men have compared acute ectopic gestation with ruptured tube with acute appendicitis, but to my mind they are not parallel conditions, because the first is a mechanical proposition while the latter is due to an infection. Therefore, I think some consideration for the patient's condition before operation is advisable.

F. T. Fort: I would like to hear Dr. McMurtry tell us something about the etiology of this condition. I received from Dr. A. Miles Taylor, of San Francisco, a few days ago, a reprint of an article on tuberculosis, in which he stated that tuberculous conditions arc etiological factors in the production of ectopic gestation. He reported 60 cases, forty-two of which showed conclusive evidence of tuberculosis, the other eighteen being rather obscure. From his report, it would appear that there is one ectopic gestation in every seven hundred cases of pregnancy. These figures, however, are not borne out by those of other authorities; for instance, Yandell, of Vienna, reports three cases of ectopic gestation in sixty thousand pregnancies, while another authority reports sixteen in one hundred and two thousand.

Lewis S. McMurtry: The essayist has presented this subject in a complete and interesting manner; his clinical classification and grouping of cases are most excellent.

One cannot but wonder that, with the knowledge acquired by clinical observation and from post-mortem investigation, this subject remained so long in obscurity and ignorance. Although the lesion was described and published by Bernutz and Goupil as observed post-mortem, it was not accepted by the profession until the epoch making work of Lawson Tait in 1883 elucidated the subject and established its successful treatment. Only a few years prior to this time a famous actress of world-wide renown died in the suburbs of Paris from this lesion, and after autopsy the most eminent surgeons there announced that death resulted from uterine apoplexy." Prior to Mr. Tait's elucidation it was known universally as haematocele. A remarkable feature of Mr. Tait's work is that it was so complete and thorough as to the diagnosis, pathology and treatment that no one has added anything of importance to the subject. As elucidated by this surgical genius ectopic gestation soon became

the most brilliant chapter in gynecological surgery. The diagnosis is easily made, and when treated promptly by operation recovery almost invariably follows. We rarely hear of a death following operation for ectopic gestation in the early months.

No adequate explanation has been made as to why the shock accompanying tubal rupture is so profound. We find on opening the abdomen a moderate quantity of blood, such as would not endanger a woman in normal labor, yet the patient is profoundly shocked. There is no clinical pieture more alarming than that of ruptured ectopic pregnancy in profound shock. The patient is blanched, the eyes incompletey closed, and the pulse may disappear at the wrist. The temperature is subnormal, and death seems imminent. Doubtless the traumatisma involving the sensitive peritoneum and the agonizing pain of rupture cause the shock to be out of proportion to the extent of the hemorrhage. Surgical anesthesia is essential for operations within the pelvic peritoneum. Transfusion of course is contra-indicated when hemorrhage from ruptured vessels is going on. Warm saline solution per rectum and heat applied over the heart will aid reaction. If seen early and the symptoms are progressive, immediate operation should be done. In no operation is expeditious work more essential than in the operation for ruptured tubal pregnancy.

The diagnosis is about the easiest of any surgical condition within the abdomen. The patient gives a history of normal pregnancy of recent or two menstrual beginning, has missed one periods: then comes bloody flow from the uterus which is usually present at the time of rupture. The breasts present the characteristic signs of pregnancy, the uterus is enlarged and the cervix soft. The patient believes herself pregnant and is often thought to be threatened with abortion when the rupture occurs. Many of these cases recover without any treatment whatever. Tubal abortion, and even tubal rupture with a moderate degree of hemorrhage, get well, the blood being absorbed and digested by the peritoneum.

As the essayist pointed out, some of these patients bleed a little and then stop, and then bleed a little more, and go on that way until the diag nosis is established and operation is done. I recall one case illustrating the ease with which diagnosis can be made. I operated upon this lady for a ruptured tubal pregnancy and she recovered. A year later she had a tubal pregnancy in the opposite tube, and before rupture occurred she made the diagnosis herself. I opened the abdomen and found a pregnancy in the tube. which had not progressed to the point of rupture.

As to the cause of ectopic gestation, it has not been definitely established. In a large proportion of cases, it is preceded by a period of sterility. It is found in women free from infection and of recent marriage. I have seen one patient with

rupture who had a child less than a year old. It occurs very frequently in prostitutes who have pursued their vocation for a long time in sterility, and is very often associated with gonorrheal conditions of the tubes. Mr. Tait's idea was that, in the vast majority of cases, there is an inflammatory condition of the tube and that the ciliated epithelium of the tube was destroyed, so that when the ovum got into the tube it was not carried on down the tube. This cannot be sustained in all cases, however, because Williams, of Baltimore, reported a rumber of cases of ruptured tubal pregnancy in which he found the cilia in the tube and functionating. Kinks and malformations of the tubes undoubtedly account for the condition in many cases.

Harry J. Phillips, (Closing): I wish to thank the gentlemen for their liberal discussion of the paper. I endeavored to present the subject in a simple, clear and concise manner, and to give you the result of my personal observations made at the bedside.

Experimental Polyneuritis.-When fed on an exclusive diet of white bread, whether with or without yeast Ohler noted that fowls develop a definite polyneuritis. When fed on an excessive diet of whole wheat bread fowls remain perfectly well. To say then, that any exclusive diet may cause symptoms of polyneuritis is not true to fact. Apparently, there is present in whole wheat bread not present in white bread some substance or substances essential to the health of the organism. In other words, it would seem that in the relation between whole wheat flour and highly milled white flour we are dealing with the same problem as in the relation between unpolished and polished rice. This problem arises, however, only when the diet is restricted and consists almost exclusively of white flour or polished rice, as the case may be.

Detachment of Retina.-A case of double detachment of the retina in a telegraph operator suffering also from nephritis is reported by L. W. Jones, Rochester, N. Y., (Journal A. M. A., Jan. 23, 1915). The patient had had albuminuric retinitis, which is not uncommon in nephritis, but detachment of the retina from this cause seems to be rare and Jones has not been able to find in conversation with local oculists of large experience, any history of a similar case. Roemer mentions its possibility, and Weeks reports a similar case.

Cultivation of Chick Tissue in Vitro. When combined the medium used by Smyth consists of egg albumen, 25; trypsinized peptone, 0.25; agar, 0.75; Ringer's solution, 74.

IN MEMORIAM

BENJAMIN W. SMOCK, M. D.

Whereas, Dr. Ben Wilson Smock who departed this life on December 16th, 1914, was for many years a member of this society, and it was ever his pleasure to promote the interest and welfare of the organization, and

Whereas, For a number of years the doctor was County Health Officer of Jefferson County, and through his earnest efforts the office was brought from obscurity to one of the most useful offices in the South, though he was seriously handicapped during the latter part of his career by illness and extreme suffering; his heart was ever in his work, and he gave his best efforts to furthering health measures; therefore, be it

Resolved. That the Jefferson County Medical Society has lost a good friend in his death, and extends its sincere sympathy to his famly, and be it further

Resolved, That these resolutions be spread upon the minutes of the society, and a copy be sent to the bereaved family.

(Signed) T. H. BAKER,

MILTON BOARD, E. T. GRASSER.

JAMES MORRISON BODINE, M. D.
(1831-1915.)

Born in Kentucky, educated in the public parochial and professional schools of his native state, he labored as a practitioner and educator within her confines throughout his life, save short intervals in his early career. The physical, mental and moral vigor drawn from her storehouse was given back without stint to his home people. Trusted by his patients, respected by his students, loved by his friends, honored by his confreres, he builded for himself in their memories an enduring epitaph. If a man's life be measured by years, he was old; if it be measured by service, then was he indeed a patriarch. Such men can be illy spared as citizens, and their going is an irreparable loss to their profession. Living, their influence is constructive; dead, their example becomes an inspiration. Thus, the Jefferson County Medical Society, in his death, has great cause to mourn, but in the heritage of his life and labor, exceeding reason to be both glad and proud that his lot fell alongside In sympathizing with his family we would congratulate them upon such ancestry. W. C. DUGAN,

ours.

C. II. HARRIS,
VIRGIL E. SIMPSON,
Committee.

COUNTY SOCIETY REPORTS

Clark-As it seems impossible to get any of our officials to tell you and the brethren throughout the State what we are doing in this garden spot of the universe I will take it in hand long enough to say that during 1914, we had the most successful meetings of the last decade seventy-five per cent of the membership came together twice (not once) a month to confab together and to do what we could to improve our selves and to better serve our clientele. Just think of it: for several years we could not get together enough members to make a quorum: and now we can scarcely get an ordinary room or office large enough to hold us. A good hustling secretary, we are told, is the one thing necessary to a successful society, and while that is all right and we have it, we have a hustling, get-up-and-get President to assist, and we believe that without his aid we would have been still beating the bushes away down in the slashes and still be a third or fourth rate society, instead of one of the leaders in this grand old Commonwealth. We believe in holding on to a good thing when we see it and that is the reason we reelected by acclamation W. A. Bush, President; Carl Grant, Vice President, and H. R. Henry, Secretary-Treasurer., at our meeting the 8th of the present month. We were honored by the presence of Dr. J. W. Kincaid, the disinguished President of the Kentucky State Medical Association at the meeting above mentioned, and while he was not at all well, his presence and address was very gratifying and did us much good. So. Mr. Secretary if you really want to know how to do things as they should be done, down in Warren or anywhere else in this good State, just watch the bulletin for our dates and make it convenient to call around and in addition to showing you how to "ride the goat" we will extend the glad hands of many, many Kentucky doctors. I. A. SHIRLEY.

Taylor The Taylor County Medical Society met at the New Merchants' Hotel in Campbellsville, on December 17, 1914, for the annual banquet and election of officers for the year 1915.

There were present, Drs. Buchanon, O. M. Kelsay, S. H. Kelsay, Reesor, Hiestand, Buckner, Gowdy and Atkinson.

O. M. Kelsay, the retiring president, made an address thanking the society for the honors that had been accorded him, disclaiming any merit on his part for such honors. In this address he reviewed briefly the honors that have come to Kentucky physicians, in many states, which honors came from work worthy of the highest praise.

This was a social meeting for getting better acquainted, and was a success from start to finish. However it is a difficult matter for doctors to get together without "talking shop" so the conver