There seemed to be some question as to the diagnosis, and the patient was permitted to come out of the anesthetic until signs of shock and hemorrhage appeared. When the abdomen was opened it was full of blood, and a large fetus immediately floated to the surface. It was a right tubal pregnancy, and ruptured while we made examination. The placenta was removed with much difficulty, on account of the adhesions and large quantity of blood clots in the abdominal cavity. I gave it a thorough irrigation with hot normal salt solution. Left drainage in for twentyfour hours. Recovery was rapid, patient leaving hospital in eighteen days. The age of the fetus, both from size and history, was about three months. TUBAL ABORTION, WITH SPECIMEN. Dr. CHARLES E. PADDOCK.-On December 15, 1904, I was called to see Mrs. S., aged 30, a widow for eight months. For the past month there had been a continuous discharge of blood from the uterus, more or less in amount, and occasional colics low down in the right side of the pelvis. She had menstruated regularly, except during the past eight months. In March, 1904, she missed one period, the amenorrhea lasting about eight weeks. During her nine years of married life she remained sterile. The uterus was found in retroversion and somewhat enlarged. Palpation of the right pelvis was unsatisfactory, owing to extreme rigidity and tenderness. The possibility of pregnancy was emphatically denied by the patient. An examination was made under nitrous oxide gas, followed by a curettement. At no time, however, was she completely relaxed, and examination of the right pelvis was not satisfactory. The cervix was soft and easily dilated. The uterine canal was about eight centimeters in length. The endometrium appeared normal, except in one place, where some scrapings were removed. These scrapings being considered of sufficient cause for the hemorrhage, no further examination was attempted. They showed large and small decidual cells. The hemorrhage continued and the colics became more and more severe. A week later, at another examination made by Dr. Besley and myself, a fluctuating mass was felt, this mass having occurred since the last examination. It seemed to fill up the right pelvis, pointing into the cul de sac. An abdominal section was made, and the pelvis found full of dark fluid and clotted blood. The tube was apparently free from adhesions and considerably enlarged. In the lumen of the fimbria was located an oval mass, three centimeters in length and one and one-half in thickness, which was considered to be the detached ovum, and upon which the hasty diagnosis of tubal abortion was made. This mass, upon section and microscopical examination, proved to be a blood clot. The tube was considerably enlarged, appar In the ently large enough to admit the passage of this mass. center of the tube the lumen was occluded by another mass, which contained a large number of decidual cells. Sections taken from different parts of the tube wall and from the mass in the center showed decidual cells in abundance. In this central mass were found villi. Until these villi were found, a positive diagnosis of pregnancy was not possible. Neither was it possible to make a diagnosis of pregnancy from the changes in the cells of the gland. Any stimulus of the uterine mucosa or tubal mucosa may produce decidual cells, and also give the cylindrical cells of the glands the characteristic flattened shape of pregnancy. The mass in the lumen of the fimbria, while not containing any fetal tissue, I believe to be a blood mole. Just how recent this conception occurred in this case it is impossible to say. The decidual cells incident to pregnancy may be found a year or two, or even more, after determination of the pregnancy. Dr. CHARLES S. BACON.-The diagnosis of extrauterine pregnancy early is such an important matter, and sometimes so difficult, that it is always an interesting subject, and I have never been able to agree with those who object to the investigation of the interior of the uterus in doubtful cases. I have two or three times myself, intentionally, carefully got a little of the mucous membrane of the uterus, and have made a diagnosis of extrauterine pregnancy from the presence of typical decidua and the absence of the villi, where the symptoms were not quite convincing, where the possibility of an extrauterine tumor previously existing was present, and where, of course, I hesitated to make a radical operation until the diagnosis was satisfactorily confirmed. I am aware that this procedure is condemned by a good many, but I do not believe that it should be always condemned, for there are cases where it is justifiable. Where one finds in the uterine scrapings typical decidual tissue, I think we can, with the complexus of other symptoms, decide positively on preg nancy. In regard to the specimen exhibited by Dr. Dodds, I should suppose that a diagnosis of that tumor was possible by finding the heart (fetal) tones. The fetus, as I measured it just now, is about seventeen centimeters long, corresponding to about seventeen weeks of gestation, and, according to recent observations, the fetal heart tones can be heard at the thirteenth, or even twelfth week. I have never heard the fetal heart tones under twenty weeks, but have no doubt it can be done, and it would be desirable in a case of this kind to make a very careful examination for the presence of the heart tones. Dr. J. CLARENCE WEBSTER.-Dr. Dodds' report is one which should serve as a warning. We do not think, in our routine examination of cases, of the possibility of rupture of tubal pregnancy, and yet it may be possible for any one of us to produce such a rupture in ordinary office work. I reported at the last meeting a case that I had once in the clinic, where an interne produced a rupture previous to the operation. Dr. Paddock's specimen is an extremely interesting one, because it calls to mind the famous case in England, which was not one of ectopic pregnancy, but of uterine pregnancy, which ended so disastrously for a well-known obstetrician. The pregnancy occurred in a lady who had been separated from her husband for eighteen months, and the specimen of abortion which. resulted was considered by the physician as recent. In medical circles that case attracted a great deal of attention, because it brought up for the first time the question of the retention in the uterus of a pregnancy, and of the changes that occurred in the fetal structures. I had the privilege of examining some of these specimens, and since that case was published I have given a good deal of attention to this subject, and have come to this conclusion: That it is impossible to give with accuracy an opinion regarding the life and the age of retained fetal structures found either in ectopic or uterine pregnancy. Nothing has surprised me more than the variations which we find in the degenerative processes present. My recent case of ovarian pregnancy brought up some interesting points in this connection. You remember that Thompson of Portland, Maine, who reported the first case of ovarian pregnancy in this country, was not able to find any amnion. In the specimen which I described the amnion was well marked, yet Thompson's specimen was not as much injured by blood extravation as mine; it was in a better state of preservation, and one might have expected the amnion to be preserved. Yet it is the chorion to which chief attention must be given in such examinations. I have in my collection at present a specimen of a six months ovum which had been retained in the uterus about twelve months after death of the fetus, and was then expelled spontaneously the day of the examination, which was made under an anesthetic. The case was sent to me as one of fibroid tumor of the uterus. On microscopic examination some of the villi were found to be well formed, not differing greatly from normal fresh specimens, yet the majority were degenerated. There was hyaline change in the connective tissue; the Langhans cells had practically all disappeared, and there were great variations in the condition of the syncytium. But, comparing that specimen with a similar one, where the pregnancy was not retained more than three months, I have not been able to make out any differences as regards the chorion, except that in the latter a larger number of slightly degenerated villi were found. The older the specimen the more decolorized the blood and the denser the fibrin surrounding the villi. If, therefore, we find in a specimen, either uterine or extrauterine, widespread, advanced blood changes of this nature, we may, I think, safely say that the ovum was not very recently alive. I have seen one specimen of Dr. Paddock's case under the microscope which shows beautifully the attachment of villi to the mucosa of the tube, and the mucosa shows very well a marked decidual transformation, but the villi that I have seen certainly do not show very much degeneration. The characteristic mucoid structure of the connective tissue is well shown, as is also the epithelial covering. Before anything can be stated regarding the age of this specimen, a careful examination of the whole section of the abortion or mole should be made. In such a case as this one might at first make a statement which would reflect on the character of the patient concerned, and it would need a very thorough examination before anything definite could be stated, and even then I do not think we would be justified in making any positive statements as to the age of the ovum. Dr. PADDOCK.-I was in hope that someone would enlighten us a little in regard to the presence of decidual cells as bearing upon the diagnosis of pregnancy. Dr. Bacon has stated that he has in a number of cases made a diagnosis of extrauterine or uterine pregnancy from the presence of decidual cells. I think, if Dr. Bacon attempts to make a diagnosis of pregnancy, especially extrauterine, from the presence of decidual cells, he will find in some cases that he will be very much mistaken. I have no less an authority than a work published recently in Berlin by Dr. Abel (Gynecological Pathology), which states positively that a diagnosis of pregnancy cannot be made from the finding of decidual cells, and, furthermore, states that there can be a stimulus. to the uterus from other causes which will produce like changes in these cells, as well as in the cells lining the glands themselves. I had also hoped that someone would enlighten us with regard to the mass which was found in the fimbriated end, and whether a mole could be formed in so short a time and become organized as this was, and whether I had really a tubal abortion to deal with in this instance. HYPOSPADIAS AND CRYPTORCHIDISM. Dr. RUDOLPH W. HOLMES.-I wish to present a photograph of a so-called pseudo-hermaphrodite, which is in reality a case of hypospadias and cryptorchidism. The baby was born two months ago in the service of the Northwest Station of the Chicago Lying-In Hospital. The picture was taken when the infant was about two weeks old. With the thighs held closely together, the diminutive penis resembles an hypertrophied clitoris; the two halves of the scrotum, without their testes, look like the labia of the newly born girl, due to a failure of development of the median raphé; in fact, there is a depression in the median raphé, excreting a small amount of serous fluid, which simulates a rudimentary vagina. As the infant is a Jewish boy, the Mohel was at a loss in attempting to carry out the rites of the Hebraic religion. A DICEPHALIC MONSTER. The second specimen is particularly of historic interest, as it is a relic of the Chicago Fire. The mother of this monster was delivered by the late Dr. John King, Professor of Medicine in Trinity College, Toronto, about sixty years ago. The specimen fell into the possession of his son-in-law, Dr. William Winer, who was one of our well-known physicians in the sixties and seventies. As the fire approached Dr. Winer's home the jar of alcohol containing the baby was placed in the tub under the pump of St. Vincent's Orphan Asylum, then situated at the corner of State |