the maternity ward of the Flower Hospital, December 21, 1902, at 10.30 a. m. Previous labors normal; previous childbeds normal. Last menstruation April 4, 1902, duration one day, amount scanty. Quickening latter part of June. Excessive nausea all through pregnancy. Latter part of July had a "fainting-spell," fell unconscious to the floor; was placed in bed and after a time recovered, but does not know the details of the attack further than as described. Patient rallied and has gone on to full term with more or less increasing pain and greatly increasing distension. Examination on admission—Inspection and palpation, nothing unusual. Position-Transverse. Presentation-Transverse; head to the right. Vaginal examination-Vagina, odmatous; cervix, not obtained; os externum, not obtained. Mensuration-Distance between spines 21cm; between crests 24cm.; R. O. 21cm.; L. O. 21cm. Conjugate diameter, 18cm.; conjugate diagonales, 11cm.; conjugate vera, 10cm. Date of expected confinement about January 9, 1903. The patient was brought to the hospital by her physician, Dr. J. Oscoe Chase of New York city, who, by the way, had already concluded that the case was one of extra-uterine pregnancy, and this diagnosis was confirmed by Dr. William Tod Helmuth. She was admitted to the maternity ward December 21, as labor was thought to be imminent on account of the pain. During the few days immediately following admission, the patient was examined by Professors Helmuth, Bishop, Hamlin and the writer, and members of the house staff. The physical condition was unique. Per vaginam the cervix could not be felt. The entire upper pelvic space was a solid mass, encroaching well into the pelvic cavity posteriorly. The examining finger could be passed up behind the pubic bone, into a cul-desac where it was supposed the cervix existed, but it could not be detected by any of the examiners. Just above the pubes, and resting upon the gestation sac, was a flat ovoid body, five or six inches in length and perhaps five broad at its widest part, immovable but possessing decided contractile properties. The patient suffered from dysuria, and the urine was laden with pus. The bladder was drawn up to the right, and the catheter passed two-thirds its length before the bladder was reached. The flattened ovoid body referred to was hardened and its shape. changes when irritated by the hand. Foetal heart sounds were not heard. Position of child was transverse, with head in the right flank. The abdominal wall was extremely thin. Upon making a quick tapping impulse against the head, it would re Half-tone from Photograph of Dr. Danforth's Case. cede from beneath the fingers against which it immediately rebounded. It was so superficial in its situation that it appeared impossible that there was little more than the skin of the abdominal wall interposed between the fingers and the child. The question of diagnosis was the first point to be determined. That pregnancy existed there could be no doubt, but whether the child was in the cavity of the uterus, or outside of it, was the question at issue. The words of the late Professor Thorburn of Manchester, England, written after an extensive experience of extra-uterine gestation and of diagnosis in doubt ful cases, came forcibly to my mind. He said: "Granted an absolutely certain pregnancy, with very strong suspicion of its being extra-uterine, the probabilities are nevertheless very greatly in favor of its turning out to be intra-uterine.” Excessive thinness of the abdominal wall is a condition which is met with in extra-uterine abdominal pregnancies, and is very strongly suggestive of this state, but it is very liable to mislead if relied upon implicitly, since both the abdominal and uterine walls may be extremely thin and the child be within the cavity of the uterus. Furthermore, the well-known fact that the great majority of cases of extra-uterine (tubal) pregnancies terminate in primary rupture with death of the foetus before the fourteenth week, and that full-term abdominal pregnancies are among the rarest anomalies of obstetrical experience, caused the writer to hesitate and weigh well all the evidence before pronouncing the case to be one of this variety. The possibility of a thin-walled retro-displaced sacculated pregnant uterus was thought of, and the presence of the cervix high up above the pubes was considered as possibly corroborative of this condition. And yet this seemed improbable in the light of the history and the physical signs, while the flat ovoid contractile body on the front of the gestation sac could only be accounted for on the supposition that it was the undeveloped, though enlarged, uterus lying in front of and upon the gestation sac. The symptoms strongly in favor of extra-uterine abdominal pregnancy were the following: Undoubted pregnancy as indicated by cessation of menstruation, breast signs and quickening. Symptoms of primary rupture about fourteenth week. The presence of a body which could not be interpreted as anything but the undeveloped uterus from its shape and contractility, resting on anterior wall of gestation sac. The extreme thinness of abdominal wall, through which the child could be felt and easily moved (external ballottement). The absence of the cervix or any opening into the uterus. The symptoms indicating the necessity for immediate operation were the bad condition of the patient; she was suffering pain, becoming septic, temperature ranging from 90° to 101°, and inability to retain anything upon the stomach. The child was dead and there was absolutely no possibility of its being delivered by the natural route in any case, whether intra or extra-uterine. In this opinion Drs. Helmuth and Bishop agreed, and there was general unanimity of opinion that the case was one of extra-uterine full term abdominal pregnancy— the child having expired at about the time the woman was admitted to the hospital. The patient was prepared in the usual manner, and the operation was performed on December 29, 1902, by the writer, assisted by Dr. Joseph H. Fobes, House Physician, Dr. Doremus, House Surgeon, and the house staff, many physicians and students being present. Details of Operation.-Abdomen opened by a long incision, one sweep of the knife being sufficient to expose the fœtal sac, which bulged into the opening freely on account of the thin abdominal wall and the great distension of the cavity. Enormous sinuses were visible coursing in the anterior wall of the sac. Extending across the sac was the left ovary and tube closely adherent and directly in the line of the incision. The right round ligament was adherent to anterior sac wall on the right side. Gauze packs were placed outside the sac all around to protect the peritoneal cavity. The left tube and ovary were ligated and removed. Severe hemorrhage occurred, and all attempts to check the flow were without effect, as the blood came from the large placental sinuses. An incision was at once made into the sac large enough to admit two fingers, the feet were seized and a full term male child was delivered, weighing 71⁄2 pounds. It had evidently been dead several days. The cavity of the gestation sac was packed with gauze and pressure exerted upon the placental edges to check the bleeding. After a few moments the pack was removed, the cavity washed out with normal salt solution and another pack inserted and allowed to remain. The gauze outside the sac was removed and the edges, including the placental tissue, were stitched to the abdominal wall with silk ligatures. This controlled the bleeding entirely and at the same time shut off the peritoneal cavity from the external wound. The removal of the gestation sac entire, including the placenta, was considered desirable, but it was found to be inexpedient to do this owing to the fact that the en tire right broad ligament was involved, and the cavity of the gestation sac extended to the bottom of the pelvis. Furthermore, the placenta extended over nearly the whole of the interior of the sac, and it was imposible to remove it. The umbilical cord was of average length and was attached to the left side of the gestation sac. The post-operative history, condensed from the bedside notes, is as follows: During the two days following the operation the temperature did not exceed 100.6°. The packing was removed in thirty-six hours and the sac irrigated with peroxide of hydrogen (50 per cent.) and Hg. Cl., 1-5000. The third day the wound was irrigated three times with peroxide of hydrogen (50 per cent.) and electrozone 1-6. The temperature ranged from 99.4° to 102.4°. Placental tissue removed at each dressing, at first only in small pieces-but later it came away in large pieces; odor very offensive. In all subsequent dressings formalin 1 1-1000, at first twice and then once a day until placenta was all removed, and the odor had ceased. In two weeks' time under this treatment the wound was clean, and granulating nicely. After each cleansing the sac was packed with plain gauze soaked in electrozone 1-6, or saline, or what gave the best results of all-formalin 1-2000. The patient sat up twenty-nine days after the operation and was discharged on March 18th practically well, having gained very much in general health and appearance. This excellent result was largely due to the devoted care given to the patient day and night during all those weeks by the house physician, Dr. Joseph H. Fobes. The special topic for discussion to which I would invite your attention is this, viz.: The management of the placenta in advanced extra-uterine abdominal pregnancy. This subject affords a problem which rises superior to all established rules of surgical procedure. Each case must of necessity be a law unto itself—no two cases can possibly be alike in all respects, although the same general procedures will apply in cases which are similar. That this must be so is evident from the variety of pathological processes witnessed by different observers as knowledge on this subject has accunmulated. As an example of the different varieties of |