telegraph of the failing condition of the patient and requested me to come prepared to operate. When I arrived at Honesdale, the next afternoon, I found the symptoms very markedly changed for the worse. The most pronounced of these were persistent and agonizing nausea and vomiting, with a small, feeble pulse of 110, which indicated further loss of blood; and this unfavorable change had been going on for about forty-eight hours. On examination, I discovered that, while there had been no perceptible increase in the mass of blood behind the uterus during my absence, the evidences of its extension in the right iliac and hypogastric regions were manifest. Here I was able to note with precision the increased size, and to map out through the abdominal walls a valuable diagnostic feature which I could not then explain. This was an apparently round body of about one third the size of the fist. It stood on a level with the fundus of the uterus and was quite immovable. Around it I could detect a peculiar condition somewhat similar to that of emphysematous pulmonic tissue when compressed between the fingers.

The only thing now to be done, in my opinion, was to open the abdomen and secure the bleeding vessels, and, accordingly, at three o'clock in the afternoon of August 21, 1884, the patient being under the influence of ether, the operation was begun with all the usual antiseptic precautions. There were present, Drs. Burns, Reed, Niles, and O'Connell, of Honesdale, and my assistant, Dr. R. B. Talbot, of New York. On making the usual incision between the umbilicus and pubes and opening the abdomen, there was a gush of a pint or more of bloody serum. After this was over and the peritoneal cavity exposed, clots of blood were to be seen among the intestines in every direction. There were no plastic exudations or other evidences of peritonitis. On examination, I now found the hard, rounded, immovable body, previously felt through the abdominal wall, to be the right Fallopian tube, greatly distended and looking like a large sausage doubled upon itself. The corresponding ovary, which could not then be felt, was fixed deeply in the pelvis, and to it the upper part of the fimbriated extremity of the tube seemed to be adherent, this accounting for its peculiar form. So tense and resisting was this distended portion of the tube, that no movement of it in any direction could be made during my search for bleeding vessels. Next, I passed my hand into

Douglas's pouch, expecting to find there the large biood-clot diagnosticated from the vagina; but in this I was mistaken, the clot here being felt in front through an intervening membrane. I then again turned my attention to the distended Fallopian tube, this time passing my index-finger below and under the concave side of it through what seemed to be an open space. Here, at a point near the middle of the tube, the finger entered a rent through which there was a direct communication with the peritoneal cavity and with the cul-de-sac below containing the blood-clot, but no fœtus was discovered.

From this point I now directed all of my fingers and then my whole hand into the cul-de-sac, where I found the blood-clot for which I had vainly searched in Douglas's pouch. I scooped out handful after handful of dark clotted blood, twenty ounces or more, until I finally reached the bottom of this abnormal sac. The boundaries of this were the detached peritonæum behind, and the uterus, with the upper part of the posterior wall of the vagina, in front, the usual situation of a pelvic hæmatocele.

Having thus finished this step of the procedure, I, for the third time, directed my attention to the enlarged Fallopian tube, with the intention of removing it, and in that way controlling the hæmorrhage which was the result of the rent. The tube was now found to be quite movable, and I succeeded without difficulty in applying a ligature around the broad ligament between the distended portion of the tube and the uterus, half an inch from the latter. This being done, the structures were divided on the distal side of the ligature. Another ligature was then thrown around the structures outside the distended portion of the tube as near as possible to its fimbriated extremity. Here the division of the parts was made on the proximal side of the ligature, including the ruptured portion of the tube. This completed the exsection of the injured and distended portion of the tube and afforded complete control of all the bleeding vessels.

The abdominal cavity and the emptied cul-de-sac described were thoroughly cleansed, and a drainage-tube was placed in the latter. The abdominal incision was closed in the usual way, and antiseptic dressings were used. The operation lasted one hour, and the patient received during the time one ounce of brandy hypodermically. She came from the influence of the ether fairly

well, considering the circumstances, and her general condition was thought to be hopeful for several hours; but her pulse and temperature soon began to go up, the former beating from 140. to 150 in the minute. In addition to this, her almost incessant nausea and vomiting, from which she had suffered so severely before the operation, returned, so that we had scarcely any hope of a favorable issue almost from the beginning of the after-treatment. Nevertheless, nutritive and stimulating enemata, with quinine and opium, were perseveringly used, and everything possible was done to quiet the stomach; but it was all to no purpose. Her condition gradually grew worse, and she died thirty-three hours after the operation.

I have in this jar the distended portion of the Fallopian tube, showing the original bed of the fœtus, and am indebted to Dr. H. C. Coe, Pathologist of the Woman's Hospital, for an examination of the specimen and the following report. He describes it as follows:

"Length of specimen, 9 ctm.; of which 6 ctm. belong to the tube, and 3 ctm. to the portion of the blood-clot, which projects beyond the torn end of the tube. Weight, 80 grammes.

"The specimen has a regular sausage shape, both ends being smoothly rounded off. Two portions may be distinguished; one a blood-clot, being firm, non-elastic, and without any semblance of fibrous structure, and the other, evidently membranous in char

acter.

"The dilated tube contracts toward its proximal end, where there is a small portion of the original canal (about 14 ctm. long) which admits a fine probe for a short distance. On making a section through the entire mass (along what was doubtless its upper surface), the following appearances are presented:

1. "The tube itself expands suddenly 1 ctm. beyond its proximal end, the walls being greatly thinned, and the original character of its lining lost. It is filled with a blood-clot, which is continuous with the mass which protrudes from its torn distal end. The clot has contracted so that it is not every where in close contact with the sides of the tube.

2. "At the proximal end of the tube, there is a sort of parti

tion, apparently formed by a fold in the tube. This would have acted as a barrier to the passage of blood inward toward the uterus; hence the clot is abruptly rounded off at this spot."

I have said in the description of the operation that no fœtus was discovered. This is liable very often to happen on account of its escape into the peritoneal cavity or its becoming disintegrated and lost in the mass of clotted blood, which in this case amounted to more than a pint. Mr. Tait had the same experience in nearly all of his cases. The clot found in the distended tube, constituting a true hæmatosalpinx, came from the bleeding vessels of the ruptured point in the cyst after the escape of the foetus. The partition formed by the fold near the uterine end of the tube was the result, no doubt, of nature's provision for the bed and protection of the impregnated ovum.

The loop of silver wire on the under side of the specimen indicates the proximal angle of the rupture of the cyst.

CASE II. Abdominal Pregnancy; Death of the Fœtus at about the Sixth Month; Normal Pregnancy about Three Years and Two Months afterward; Death of the Child in the Eighth Month; Delivery with Forceps; Remains of the Foetus in the Abdomen, removed through an Opening in the Posterior Wall of the Vagina at the Same Time; Recovery of the Patient.-I was requested by Dr. John Burke, of this city, to see this case in consultation, September 18, 1884, and he permits me to report it as follows:

Mrs. K., aged thirty-eight, who had been delivered of six living children without difficulty or injury to herself, became the subject of abdominal pregnancy after a regular menstrual period which terminated January 24, 1881. She stated that the flow had always appeared three or four days in advance of the time, but that its duration was natural. On March 14th, seven weeks from the cessation of her last period, she was awakened out of a sound sleep about midnight by a violent pain across the lower part of the abdomen, soon followed by severe nausea and vomiting. She did not remember on which side the pain was greater. A physician in the neighborhood was called in, who administered a hypo

dermic injection of morphine, which gave prompt relief. For two or three days, there was tenderness of the abdomen, attended by a slight bloody discharge from the vagina. After this, the same physician made a vaginal examination and discovered, as he thought, retroversion of the uterus, for which he introduced a pessary. The instrument, however, was worn only a few days, so much pain and discomfort being produced by it that it became necessary to remove it. This was done March 28th by Dr. Burke, the family physician, who was now called in for the first time, and who was obliged to give a hypodermic injection of morphine for the relief of pain. This occurred about nine weeks after the date of the last menstruation in January. The bloody vaginal discharge still continued, and an examination revealed the existence of a large and rather elastic mass, painful under pressure and situated to the right of the uterus. There was also slight enlargement of the latter, and the organ was pressed to the left side. After a few days the abdominal pains in the right iliac region disappeared, together with the bloody discharge from the vagina. The patient had no knowledge of a discharge of anything like a decidual membrane, nor did she refer to symptoms indicating the probability of pregnancy. Dr. Burke's diagnosis was pelvic hæmatocele.

In the latter part of June, 1881, the patient went to the seaside, where she rapidly improved in health and strength. In August, about seven months after her last menstrual period, she noticed a slight "show," which she regarded as a re-establishment of the function. Her size at the time, she thought, was that of a woman at the fifth or sixth month of pregnancy.

In September she returned to the city. Dr. Burke then made an examination, and discovered, low down in the abdomen, a tumor, having, as felt through the vaginal wall, all the characteristics of a fœtal head. Its size was that of the head of a child of five or six months' growth, and it presented behind the uterus. The case was seen in consultation a few days later by an eminent gynæcologist of this city, who declared the existence of abdominal pregnancy.

Soon after this, October 6th, menstruation came on naturally, and the patient felt perfectly well, with the exception of an occasional attack of neuralgia in the right side of the face. Indeed,