hyperemic and covered with small blood clots. It was firmly adherent to the right tube and was removed with the latter. The right ovary, exhibiting a corpus luteum, was left behind. The stump of the mesosalpinx was carefully covered with peritoneum, the anterior side of the fundus of the uterus was stitched to the parietal peritoneum, and the incision closed in the usual manner. The short operation was well borne by the patient who had an uneventful recovery and is, to-day, in the best of health and perfectly relieved of her old symptoms.

The tube is 4 inches long. The uterine third, measuring 11 inch, is of normal caliber. It forms a very acute angle with the rest of the tube, which is transformed into an oval tumor. This tumor carries upon its outer pole the fimbriated ostium which is macroscopically normal. A portion of the omentum is seen in broad adhesion with the tumor, the connection extending from the sharp bend to a point immediately below the fimbriated end, thereby producing a sort of stricture. The surface of the tumor is intact, but covered with a great many adhesions. The inner half, toward the uterine end, is black on account of blood within; the outer half, toward the fimbriated end, is lighter in color and distinctly fluctuating; in this part the embryo may be expected to be found. The effect of the adherent omentum upon the tube is obvious. By kinking the tube about 11 inch from the uterus, it has barred the path to the ovum while the spermatozoa coming from the other direction could wind their way through the narrowed passage. The constriction below the fimbriated end was not narrow enough to prevent the ovum from entering the lumen of the tube, but it formed an unsurmountable barrier to its slipping back into the abdominal cavity so soon as the fertilized ovum increased in size. Consequently, the final outcome of this case of ectopic gestation would not have been tubal abortion, but was doomed to end in rupture which, as you see from the excessively thin walls of the distended tube, was but a question of the very near future. (Fig. 5.)

In connection with this case, I should like to remind you of the fact that extra-uterine pregnancy occurs more frequently in multigravidae than in primigravidae. This has an important bearing on the etiology of ectopic gestation. Usually these patients have remained sterile for several years, after the last confinement. There is apparently some obstacle to conception. This obstacle is to be found in some inflammatory condition either within or in the surroundings of the tube. The first would produce a swelling of the tubal mucosa with stenosis of the canal, while the perisalpingitis would, by means of adhesions, cause a tortuous course or even a kink in the tube. The minute spermatozoa may find their way through an almost complete stricture but when the ovum, after fertilization, moves toward the uterine cavity, it is arrested in its progress by its own size which does not permit of the passage through these greatly narrowed straits. This, of course, is not the only cause of extra-uterine pregnancy, but it is undoubtedly the most common. The same premises were fulfilled in my own case, although the patient was pregnant for the first time. Here, the appendicitis or the disturbance of healing had produced adhesions which almost completely cut off the free passage, thus blocking the way to the growing ovum. This consideration, together with the undeniable fact of pregnancy, facilitated the right diagnosis which was further supported by the finding of a tumor in the tube and the absence of signs of pregnancy within the uterus itself.

That the latter, i.e. intra-uterine pregnancy, cannot always be excluded with equal probability, may be illustrated by Case III. I speak of it the more readily as this diagnosis was a mistake and, consequently, is of greater benefit to me and the audience. This patient, 24 years old, had always had her menstruation delayed 2 weeks, her last period was August 1, 1905. She had been married 5 years, without conception. There was no history of previous pelvic inflammation. She was in fairly good health until 3 weeks prior to my first examination, when, at the last coition, she experienced

a sudden sharp pain in the left inguinal region. This region was still sore to the touch, and the patient has been feeling sick ever since. A few days ago, a slight flow of blood occurred from the vagina. She had no subjective symptoms of pregnancy. On September 23, 1905, i. e., seven weeks after the last menstruation, upon examination the uterus was found enlarged, soft, and in pronounced anteflexion. The place of the left adnexa was occupied by an oval-shaped, freely movable tumor, of about the size of a hen's egg, which was soft and sensitive to the touch. The right adnexa were normal. There were no other objective signs of pregnancy; in particular, no discoloration of the cervix or vagina.

Not being certain whether I had to deal with an intra-uterine or extra-uterine pregnancy, I kept the patient under observation for twelve days during which time I made repeated examinations. There seemed to be a slow increase in the size of the tumor while, on the other hand, the uterus apparently retained its original size. The sensitiveness in the left iliac region persisted, and there occurred also some cramp-like pains in this part of the abdomen.

Thus led to the diagnosis of ectopic pregnancy, I performed laparotomy October 4, 1905, and removed the tumor in question. This tumor, however, is, as you see, not a pregnant tube, but is a cyst of the ovary, oblong in shape, of the size of a hen's egg, and connected with the uterus by an unusually large and thick ovarian ligament. The tube on the other hand is very thin and soft.

As the mistake became evident at once, I tried not to irritate the pregnant uterus by any undue manipulations, yet, contractions set in already during the operation, and four days afterwards, patient miscarried. The convalescence was otherwise quite normal and the patient is, to-day, in the very best of health again.

Both the statements of the patient and the objective findings

were misleading in this case, but I feel that a prolonged observation would have cleared the situation.

I have reported these cases in order to urge the importance of an early diagnosis and to emphasize the grave responsibility of the examining physician. In the first two cases, the greatly thinned-out wall of the tube shows that rupture was imminent. If not detected in time, the chances for the patient sink rapidly, and human help may even come too late. None of us is exempt from mistake, yet, I contend, that, in view of the danger from extra-uterine pregnancy, one does better to diagnose it once too often than permit its course once to remain undisturbed. We may well bear in mind the famous dictum of Werth: "Ectopic gestation should be considered like a malignant new-growth and must be attacked whenever we encounter it."

ALUMNI ASSOCIATION.

Regular meeting held Monday, February 12th, 1906, in the Washington University Hospital, Jefferson and Lucas Avenues.

The meeting was called to order at 8:30 p. m., the president, Dr. J. C. Falk, in the chair. The minutes of the previous meeting were read and approved. The following communication was read and was referred to the executive committee for action:

Saint Louis, Feb. 12, 1906.

To the Members of Alumni Association,

Medical Department, Washington University.

GENTLEMEN: We, the undersigned, beg to submit the subjoined proposition for your serious and earnest consideration. We feel an effort should be made to enlist the interest of our alumni in the workings of the Medical Department. The near future promises very material aid on the part of the University for the Medical Department. It is believed by us that the interests of the school and its beneficial work can be very much enhanced by placing the students of the first two years in a building to be erected upon the University grounds at Skinker Road. In order to stimulate the University in its aid to the Medical Department we believe the Alumni should take an active hand. This, in our opinion, can be best done by the foundation of a building for the laboratories, lecture halls, etc., for Anatomy, Physiology, Chemistry and the allied subjects upon the University grounds. The sum of $80,000 to $100,000 would be needed for this purpose. The Alumni could show their loyalty by raising this money and putting it into such a building. A liberal endowment would surely follow such an independent move on our part. The plan for raising this money, in its crude outlines, would be to request the Alumni of the school, some three thousand in number, to