In considering the anatomic diagnosis of this case I shall have to take into consideration mural, ovarian, tubo-ovarian, and tubo-abdominal pregnancy.

Can it be a mural or an interstitial pregnancy? The continuity of the sac, in the site of the placenta, with the upper surface of the fundus belongs to the signs of mural pregnancy.

The uterine portion of the Fallopian tube is 'of normal length and width, consequently the ovum cannot have lodged and developed here. However, a persisting "Gärtner's duct" might, perhaps, it is doubtful,—form a lateral branch of the tube and run in the wall of the uterus. Baudelocque ("the nephew") claims that a mural pregnancy can take place when the fecundated ovum lodges in this blind branch. Kleinwächter, in his article, “Tubal Pregnancy," in Eulenburg's Encyclopedia, remarks that this statement of Baudelocque's has yet to be proved. Aside from Gärtner's duct, there is another anatomic anomaly that might give rise to a mural pregnancy outside of the uterine portion of the Fallopian tube. Through the kindness of Professor Jaggard, of Chicago, my attention was called to this variety. The ovum may develop in a branch of a bifurcated Fallopian tube. Hennig* has an illustration showing a canal branching off from the Fallopian tube in the lateral wall of the uterus; the branch turns downward and inward in the uterine wall, and opens into the cavity of the uterus at the internal os. If the ovum is arrested in this branch, a mural pregnancy results. The sac will push the broad ligament and the appendices outward and upward, and we will expect, as in the ordinary mural pregnancy, to find Fallopian tube and ovary on the outside of the sac, and, further, we must expect that the round ligament should be dislodged outward some distance from the border of the uterus. Consequently, in our case, we cannot admit a bifurcated Fallopian tube as the seat of the pregnancy.

But supposing a mural pregnancy had taken place here, and consequently the uterine portion of the Fallopian tube could be found open outside of the sac: then we demand in this case certain conditions that cannot very well be dispensed with, and they are the following:

The abdominal end of the Fallopian tube, together with the ovary, must be found somewhere on the outer wall of the sac, and opening into the peritoneal cavity.

Supposing that the ovary, for some reason or other, was not found, and the abdominal end of the Fallopian tube was obliterated and buried in the wall of the sac, we might yet have had a mural pregnancy.

In this case, however, the Fallopian tube opens into the wall of the sac. If it has opened into the fetal cavity, it cannot be seen on this specimen. (However, it looks as if it had probably done so.)

The round ligament in mural pregnancy is expected to be pushed outward some distance from the side of the uterus. This might be different if the ovum could develop in the posterior wall of the uterus, but this possibility has never been proved. Gärtner's duct does not

*Lusk, The Science and Art of Midwifery.

run in the posterior wall, but from the parovarium first in the broad ligament (in the same fold as the Fallopian tube), then in the muscular substance of the lateral border of the uterus, and down on the side of the vagina, where it terminates blindly.

The sac can be dissected off from the posterior wall of the neck and fundus uteri, which looks as if the sac developed on the posterior surface and not in the posterior wall of the uterus.

Thus, although the positive proof against mural pregnancy, viz., the opening of the Fallopian tube into the cavity of the sac, is wanting, -the fault of the specimen, then, as all signs of mural pregnancy are absent except the apparent continuity of sac-wall and uterus, I shall declare against mural pregnancy.

The microscopic examination of Dr. Byford's Case No. 1 (our second case) does not give any points as to the solution of the question of mural or tubo-ovarian pregnancy; the sac here consists just exactly of the same elements as I have found in a case of abscess of the broad ligament, in a wall as thick as the sac in its thickest parts. The presence of organic muscle-fiber in the sac, and the continuity or connection between the muscle-fiber of sac and uterine wall, is of only secondary diagnostic significance, for the following reason: the organic muscle-fiber or cell belongs to the proletaires, so to say, among the tissues; it is of the connective-tissue class, and can be formed and found everywhere where connective tissue is formed and found. In fibromyomata or myofibromata it is often impossible to determine what is a muscle-cell and what is a spindle-shaped connective-tissue cell. Consequently, continuity between muscle-fiber in sac and muscle-fiber of the uterus does not mean that the former originated in the latter.

The next question then is this: Is it an ovarian, tubo-ovarian, or tubo-abdominal pregnancy?

In an ovarian pregnancy we must have (1) That the Fallopian tube does not participate in the formation of the sac (Kleinwächter); (2) ovarian tissue is found in the wall of the sac; (3) that there is a connection between the sac and the uterus through the ligamentum ovarii.

Of a tubo-ovarian pregnancy, we would require (1) That the peritoneal end of the Fallopian tube participates in the formation of, that is, opens into, the sac; (2) the ovary may be intact, but it may also have been used up in the formation of the sac, and have disappeared either entirely or only remnants may be found in the wall of the sac.

(It is easy to see how difficult it may be to find microscopic remnants of ovarian tissue in the wall of a sac 100 times or more the size of a normal ovary.)

As near as we, in my opinion, are able to come to an exact diagnosis in this case, I should pronounce it a tubo-ovarian pregnancy.

The exact location of the spot where the fecundated ovum has commenced development it is, of course, impossible to prove to satisfaction. Still there is one interesting feature in this case which, in my opinion, throws some light on this point. This is the pocket-the blind pocketon the upper wall of the sac behind the uterus (Fig. 43, 10, and 45, 8).

As before stated, the upper side of the posterior wall of the pocket, viz., the ligamentum latum, or the Fallopian fold of this ligament, forms a circular figure, commencing at the left border of the fundus and terminating at about the same point; from the connection between the middle and outer third a branch goes off downward and to the right. The Fallopian tube is contained in the first two-thirds of the ridge and in the branch. The final third of the ridge, that does not contain the tube, but runs back toward the left corner of the uterus, would, in my opinion, correspond with the ligamentum ovarii (Fig. 43, 7). The formation of the pocket, clad with the peritoneum, and having as upper border the abovedescribed ridge, can, in my opinion, be explained if the ovum has been arrested and commenced development in the ligamentum “infundibuloovarianum" (Henle), between the fimbria that line the sulcus leading from the distal end of the ovary to the ostium abdominale of the tube. If the ovum is developed here, it can, with the vessels of the chorionfirst, reach the abdominal ostium of the tube, and thus permit the tube to open into the sac; second, it can reach down on the lower or posterior surface of the ovary, and thus, during its growth, lift up the ovary at the same time as it destroys it, but in lifting it up preserve and enlarge the peritoneal fold or pocket that normally exists between the posterior surface of the peritoneal fold containing the Fallopian tube, and the anterior surface of the peritoneal fold containing the ovary and the ligamentum ovarii.

In case the fecundated ovum from the ruptured Graafian follicle had dropped down below the ovary and had been arrested or taken hold on the peritoneal surface of Douglas' fossa or on the posterior surface of ovary, if a development in such a way and place is possible, the pocket could be formed, of course, but we could not expect to have the Fallopian tube open into the wall of the extra-uterine sac. If the pocket in question is formed in cases where the ovum has been arrested in the peripheral end of the tube I do not know, as my access to original literature on this subject has been extremely limited, and the common text- and hand-books, of course, do not contain anything like a detailed description of any of the cases in question.

In the proceedings of the meeting of the Gynecological Society of December 19, 1884, Professor W. H. Byford is recorded to have said* as follows: In the first case (our Case No. 2, where operation was performed) he thought that the fecundated ovum had passed through the tube, but found some diverticulum in the uterine cavity, had passed into the uterine wall and developed in this region, pushing the wall before it. The muscular element of the sac was directly continuous with the uterine muscle. Further (pp. 64, 65): "It is not necessary for the production of mural pregnancy that the tubes be involved."

A diverticulum in the uterine wall that would permit the ovum to develop down between the muscle in the wall is, as far as I know, not known or proved, but such a condition might be accepted in a proved mural pregnancy in which the Fallopian tubes were not involved.

Chicago Medical Journal and Examiner, 1885, vol. xxx, p. 64.

A Gärtner's duct, as place of development for the ovum, is not proved either; but, accepted as a possibility, let us see what would be the consequence: The ovum would be arrested either in the extra- or the intrauterine portion of the duct. (I do not know of any communication opening between Gärtner's duct and the Fallopian tube-does it exist?) If developed in the extra-uterine portion of the duct that runs in the Fallopian fold of the broad ligament, the formation of the pocket in this case (No. 1) would be impossible. The ovary might disappear and the tube might run in the wall, but ought to open into the abdominal cavity. If developed in the intra-uterine portion of Gärtner's duct, we would expect to have the Fallopian tube and the ovary intact on the outside of the sac, just the same as in mural pregnancy from the uterine portion of the Fallopian tube. How great value in diagnosis of mural pregnancy the fact has that the muscle of the uterus is continuous with the muscle of the sac I do not know; but in this case apparently only the layers of the surface of the uterus are continuous with those of the sac, and in mural pregnancy I would rather expect to have the deeper layers participate also.

In conclusion I shall proffer my thanks to the Society for the honorable task intrusted to me, and ask its pardon in that the material in question and the literature at my disposal have not enabled me to give a more satisfactory report of the matter.

ANTISEPSIS IN ABDOMINAL OPERATIONS; SYNOPSIS OF A SERIES OF BACTERIOLOGIC

STUDIES*

WITH BAYARD HOLMES, M.D.

Synopsis of a Series of Bacteriologic Studies. These investigations were undertaken to determine how far the necessary aseptic conditions had been secured and maintained in the abdominal sections performed by Dr. Christian Fenger. One case of another operator is brought in, to compare less thorough antiseptic precautions.

In order to estimate the results of these researches, you must know what preparations were made for the operation on the part of each concerned.

The Preparation of the Operating-room.-In the Emergency Hospital and in the County Hospital the walls and the floor and all the furniture were thoroughly washed with a 1 : 1000 sublimate solution on the day before the operation. The cracks about the windows and doors were. stuffed with cotton, and the room closed to every one except the nurse that made the preparations.

To test the condition of the atmosphere in this room in the Emergency Hospital four plates of gelatin were exposed for forty-eight hours on the operating table August 24 and 25, 1886. After six days' incubation in the moist chamber, from 8 to 12 colonies of all kinds appeared on each square inch of surface. Most of these were molds, which grew very rapidly; some were micrococci and some bacilli. As less than 12 colonies developed to the square inch, it is probable, if the plates were exposed only an hour instead of forty-eight hours, not more than one colony would be found on each 4 square inches, so that the danger of atmospheric infection from falling germs would be very slight under similar conditions. The danger would be, no doubt, increased by the movements of the assistants and the increased circulation of air through the difference in temperature of the external and internal atmosphere when the room was in use.

The Preparations of the Operator and Assistants. Each took a sublimate bath (1:2000) and put on sterilized cotton suits. The hands and arms were then washed five minutes with warm water and green soap, and scrubbed with a brush, and then washed half a minute in a 1:1000 sublimate solution. The patient received substantially the same treat

ment.

* Jour. Am. Med. Assoc., 1887, vol. ix, pp. 444 and 470.