uterine body. If the mucous membrane be not too badly injured, the ovum may find a favorable lodging place within the tube where it may continue to develop. But if the mucous membrane be inflamed, this wave motion is lost so that it is impossible for the ovum to be carried on into the uterus or for the spermatozoid to pass through the Fallopian tube and reach the ovum. This being true we can readily understand why it is that women who have suffered from some infection at the time of delivery do not soon again become pregnant. As a matter of fact, a pregnancy subsequent to a salpingitis is proof that the inflammatory process in the tube has ceased, and that the mucous membrane has again become normal. If, however, the mucous membrane is only partially recovered we can readily understand how a fecundated ovum fails to be carried on into the uterus but finds a lodging place on the healthy mucous membrane of the tube, and there goes on to development and produces an ectopic gestation.

It will depend altogether upon the extent to which this tube has recovered from its former diseased condition as to how long this fecundated ovum will remain growing in this abnormal situation. The great majority of these cases are speedily destroyed for the lack of nutrition and never present any symptoms. Those, however, that find a lodging place in a fairly healthy tube get a sufficient amount of nutritive material from the mucous membrane so that development may take place.

The life history of such a fecundated ovum again depends, to a large extent, on the portion of the tube which has become healthy, because it will be in that recovered portion that the ectopic gestation will take place. If the ovum becomes fixed at the outer extremity of the tube it will end by aborting in the peritoneal cavity, whereas, if it is in the uterine end the abortion may take place into the uterine

cavity, while if the healthy portion of the tube to which this fecundated ovum attaches itself is in the center, the rupture will in all probability take place in one of two directions, either downwards into the broad ligament or upwards through the Fallopian tube into the peritoneal cavity. If the rupture is downward into the broad ligament the danger is very much less from a severe hemorrhage than if the rupture takes place into the free peritoneal cavity. These latter cases are the ones that sometmes prove rapidly fatal.

Treatment: Mauy lines of treatment have been advised and adopted for this serious condtion. It is probable that a great majority of the cases in which a slight hemorrhage occurs, this bleeding producing the death of the ovum, which then disintegrates and disappears without the condition having been recognized. In those in which the diagnosis has been made before the rupture, it has been advised to pass strong currents of electricity through the mass, or to inject the mass with alcohol, hot water or some other fluid in order to cause the death of the foetus, and bring about disintegration and absorption of the foetal products. But this blind method of treatment is usually attended by want of success and is always accompanied by more or less danger. If the diagnosis be made early, there is only one line of treatment and that line is without question. It is, to do an abdominal section and remove the tube with its contained foetal products. If, however, a rupture has occurred and we have reason to believe that disintegration and absorption of the foetal products may take place, it is possible to advance arguments in favor of non-interference with the condition. But since this diseased structure is hidden away inside the abdominal cavity, and so placed that it is impossible to know the exact condition and the attendant dangers of non-interference, the wise physician counsels an early operative procedure so that the life of his patient may be safe-guarded.

In this case that we have before us to-day, the diagnosis of extra-uterine pregnancy having been made, and being assured that a rupture of a greater or lesser extent has occurred, within a short time, as shown by the reduced hemaglobin per centage, the rapid pulse and the history of a recent pain, it is clearly indicated to open this abdomen and deal with the diseased condition that we find therein.

We shall make a long incision between the umbilicus and pubic bone, and just a little to the right of the mid line; thus passing through the rectus muscles, the fibers of which we shall separate. This incision when closed will leave a much stronger wall than if we make the incision directly through the center line. We have separated the structures down to the peritoneum, and we see that underlying this thin tissue is a dark substance which we know is blood in the peritoneal cavity. We have now opened the peritoneum and at once you see flowing from the opening free, bright blood, which demonstrates the fact that the hemorrhage is still going on from the open vessel which we will find no doubt in the Fallopian tube.

I am withdrawing the mass which was felt lying on the right side of the uterus. It comes up with some difficulty because of adhesions in the pelvic region. Now that it is withdrawn from the peritoneal cavity it is readily seen that the tube is greatly distended and already ruptured on its free peritoneal surface. We find that a small vessel is bleeding which accounts for the free blood in the cavity. We find here also a great many clots which more or less. fill the pelvis. The uterus is not much enlarged. The proximate end of the tube seems to be fairly healthy for at least one-half inch from its junction with the uterus. Consequently we will save this part of the tube by cutting through it in an olique direction, and then by suturing the peritoneal covering to its mucous lining. This procedure will insure the patency of the canal and enable an ovum to

pass on into the uterus at some future time. The tube and mass we will now cut away and then secure the bleeding vessels of the broad ligament. These are now tied off with catgut, and then all of the raw surfaces peritonized. The blood clots we will now remove from the cavity and proceed to close the wall in layers. Each layer being united separately with an iodized suture.

This is a procedure that I have been adopting for many years and I find no reason to make any change. The only dressing that we will apply is a layer of sterilized gauze saturated in alcohol. This dressing we shall not expect to remove until the patient is ready to get out of bed at the end of eighteen or twenty days. The recovery should be uneventful.

CASE II. A FRACTURED FOREARM.

This patient, upon whom we are about to operate, was brought to the hospital with the history of having fallen from a pony two weeks ago which resulted in the fracture of his forearm.

His family physician saw him immediately afterwards and succeeed in reducing the fracture so that the arm bones were quite straight and he applied splints to hold it in that position. The little fellow suffered practically none at all following the reduction of the fracture, and two days later the doctor, to be sure that the limb was in perfect condition, took off the splints and examined it again. He found it in good condition and so replaced the splints.

The little fellow was up and about and at the end of two weeks the splints having become displaced, the mother examined the arm and reported that it seemed to be crooked. This condition was verified by the physician and so he was brought to the hospital for further examination and for such treatment as might be necessary to correct the deformity.

Fig. 1. From X-Ray by Dr. Geo. C. Williamson, showing fracture two weeks after injury, ends of radial fragment attached to ulna by callus.

An X-ray examination demonstrated the fact that the boy had suffered a transverse fracture of the radius about its center and that there was a green stick fracture of the ulna at the same point. The plate which demonstrated this condition I am now exhibiting to you. The condition is very clear with this illumination, but not so clear by any means without the X-ray picture.

Now comes the question, "What are we to do for this child?"