enlargement at the uterine end, there was a flattened protuber. ance, from which placenta-tissue was seen to escape through a small rupture. On longitudinal incision, a clot was seen lying in the thin walled tubal sac, solidly attached at its uterine third. The interior contained a narrow elongated cavity, lined with amnion. The umbilical cord, which was inserted about the middle of the cavity, passed outward at the site of the rupture nearer to the uterus. The abdominal orifice gaped about 5 cm., leaving the ovum visible through it. The ablated segment of the left tube was a blind sac, 5.5 cm. long, 1.8 cm. thick, covered with adhesions and containing a solid blood clot. MICROSCOPICAL FINDINGS. Close to the point of ablation of the right tube, the lumen was already enlarged and full of folds, approximately corresponding to the middle of the isthmus; the thickened folds had crenated contours, often with adherent edges. The epithelium was cylindrical to cubic, the stroma mostly coarse, with small cellular infiltrations; distinct decidual changes were demonstrable only at some of the margins. The remaining tubal wall presented a moderate degree of diffuse infiltration, and there was a slight proliferation of the epithelium of the serosa, under the fibrino-sanguinolent deposits. The tube passed with well marked convolutions as far as the uterine pole of the ovum, then along the same in a forward and downward direction, where it became gradually distended so as to comprise the entire abdominal segment of the clot. The insertion of the placenta occupied principally the posterior wall, but extended beyond the middle line above and below. In the entire uterine segment of the ovum, the adhesions and adenomatous proliferations of the tubal folds assumed an enormous extent, rendering the passage of a fertilized ovum apparently very precarious. The folds were thickened, highly vascular, edematous toward the ovum, and much infiltrated. A formation of decidua was no longer present. Epithelium, low cylindrical to cubic. In the lumen, desquamated epithelia, detritus, leucocytes and a little blood. The same features characterized the tubal mucosa also at the inner surface of the fetal sac. The thickened tubal folds were flattened against the wall, lined with a low epithelium, and practically adherent throughout. Between the ovum and the tube, passing alongside of the same, there appeared a strand 2 mm. in thickness, consisting of the entire annular muscle and a few bundles of the longitudinal muscle tissue of the tube. The remaining longitudinal muscle could be distinctly seen radiating into the outer wall of the fetal sac. The ovum evidently had burrowed between the two muscular layers, fully 1 cm. along the as yet undistended segment of tube. From the end of this strand (which, of course, appeared as such only in the longitudinal section, but in a transverse section would represent the tubal wall itself), a short, narrow process, lined with epithelium, gradually passed under enormous infiltration of its terminal segment, into a strip of fibrin, which from here on bounded off the ovum against the tubal lumen. Both portions together represent the capsular membrane, still derived from different stages and directions of development on the part of the ovum. Also at other points of the placenta margin, the inner layer of the tubal wall could be made out as similarly undermined by the ovum. The degenerated ovum consisted of blood and masses of fibrin, which presented numerous necrotic but also many well preserved chorionic villi; these were seen to contain an abundance of vessels filled with anuclear and nucleated red blood corpuscles. The amnion and chorium were also well preserved; especially the parietal portions were still rich in well preserved villi, with a good double margin of epithelium. The syncitium as well as the cellular layer locally showed an active proliferation; from the sessile villi, wide strands of Langhans cells passed to the basal strip of fibrin directly over the muscular and connective tissue; followed by syncitium and forming broad layers upon the fibrin. Locally, the layer of fibrin was ruptured, and the cells were seen growing into the maternal tissue. In the outer wall, which was in places thinned down to a very few lamellae, the cells often formed enormous conglomerations, especially around the vessels, and were even visible in the vascular lumen, applied to the intima, in thin walled vessels. In those localities where the tubal wall had been most stretched, there appeared coarse connective tissue adhesions, with large vessels, under which were flattened cavities, lined with cubic peritoneal epithelium. No formation of decidua could be demonstrated. The left tube presented identical anatomical changes, aside from the fact that its lumen was filled with blood. The folds of the mucosa were equally thickened and adherent, but the epithelium was for the most part cubic, and in a more advanced stage of desquamation. The stroma again presented a well marked decidual reaction, almost more pronounced than in the right tube. The infiltration was not so marked. The next convolution, already somewhat dilated, passed under very gradual widening of the lumen directly into the segment of the tube which contained the degenerated ovum. The folds of the muscosa in the area of the ovum were flattened against the wall, with numerous adhesions; the cellular stroma, in individual localities, also still presented a decidual reaction. The elongated ovum was applied to the uterine end of the tubal wall, for a distance of about three-quarters of a centimeter. From the site of insertion, a wide strip of mucosa and muscle tissue passed to the ovum, taking along with it a number of adherent mucous folds, and demonstrable for a distance of about 1 cm. It naturally became thinner, the folds disappearing, until nothing was left but a smooth low epithelial margin, upon a narrow layer of connective tissue. Finally, the epithelium disappeared and the connective tissue merged into fibrinoid tissue. The degenerated ovum itself contained, besides a number of necrotic villi, also groups of well preserved avascular villi, with proliferated epithelium. The basal strip of fibrin presented local conglomerations of cells. The historical picture of the degenerated ova pointed to the smaller ovum as the older of the two. With special reference to the occurrence of decidual cells, Kermauner calls attention to the very particular, and to him inexplicable fact of their presence, in the right tube, only at some distance from the ovum, towards the uterus, whereas they were absent in the immediate surroundings of the ovum. The perfectly uniform appearance of the chronic inflammatory changes of the tubal mucosa in the two tubes, is pointed out by Kermauner as a fact in support of the assumption that it was precisely this change which constituted the direct cause of the ectopic implanation of the two ova. In a large number of cases, the general findings indicate the presence of preexisting changes, independent of the tubal gestation, as shown by the extent of the salpingitis, with direct ascent of the catarrhal process from the uterus into the tubes; the bilaterality of the inflammation; and the frequent occurrence of salpingitic changes, in tubal pregnancy. Subsequent histological examination in these cases serves to show that the catarrhal processes are not acute and of recent onset, but that the inflammation evidently dated back a certain time, beyond the period during which the ovum has lodged in the tube. The first described case was characterized by the presence of suppurative inflammatory changes in both tubes, with degeneration of the ciliated epithelium. Findings such as the above indicate the necessity for care fully investigating the condition of the opposite adnexa at the time of operation. It is probably advisable to remove the opposite tube at the same time, when it is either imbedded in adhesions or when a large hematocele is found in the affected side; also, according to Puppel, when drainage of the true pelvis is required for some reason or other. The abdominal method yields better results in this respect than the vaginal route. Needless to say, the prophylactic removal of apparently normal adnexa on the opposite side is not in conformity with the modern principles of conservative surgery. Smith, R. E.— BIBLIOGRAPHY. Repeated ectopic pregnancy, with a report of four cases and a statistical review of the literature. Amer. Jri. of Obs., September, 1911, page 401. Rabinowitz, M.— Successive tubal pregnancies. Report of two cases, with a clinical analysis of the cases recorded in the literature and a consideration of its prevention. Amer. Jrl. of Obs., August, 1911, page 238. Prewitt, T. F. Extra-uterine pregnancy occurring twice in the same Fallopian tube. Coe, H. C. Internal migration of the ovum, with report of a case of repeated ectopic gestation, possibly supporting the theory. Amer. Jrl. of Obs., June, 1893, page 855. Haret Etude critique sur 35 nouveaux cas de grossesse ectopique recidivante. Varnier et Sens Sur la recidive de la grossesse ectopique. Etude critique de 96 observations. Annal. de Gyn. et d'obst. T. 55, 1901, p. 169. Puppel Wiederholte Tubengraviditat. Monatschrft, f. Geb. u. Gyn. 29, 1909, Kermauner Beitrage zur Anatomie der Tubenschwangerschaft. Monograph, Berlin, 1904. Orthmann Beitrag zur Kenntniss der Tubenschwangerschaft. Ztrlbltt f. Gyn. 1903, Vassmer Ueber viederholte Tubenschwangerschaft. 17, 1903, S. 881. Micholitsch Monatschrft f. Geb. u. Gyn. Zur Aetiologie der Tubenschwangerschaft. Zeitschrft, f. Geb. u. Gyn. 49, 1903, S. 43. Petersen Beitrage zur pathologischen Anatomie der graviden Tube. Monograph, Rosenfeld Ein Beitrag zur Anatomie der Tubenschwangerschaft und Bildung der Zedel Zur Anatomie der schwangeren Tube. Ztschrft f. Geb. u. Gyn. 26, 1893, Dobbert Beitrage zur Anatomie der ektopischen Schwangerschaften. Klein Virchow's Zur Anatomie der schwangeren Tube. Ztschrft f. Geb. u. Gyn. 20, 1890, Electro Therapeutics. *By J. A. ANDREWS, M. D., Holdrege, Neb. I'm not going to attempt to read you a paper giving minute details of the use and application of electricity in medicine; but for the purpose of awakening, if possible, an interest in its values and the necessity of a better understanding of the subject, I shall present a few thoughts. In the remotest periods of the world's history, when legend, myth and fact were inseparably connected the phenomena of electricity were regarded as symbolic of some special deity and formed the basis of a national faith. The philosophers of Greece would bow in veneration at the sound of the thunderbolt, and in Rome the oncoming of the storm would silence an orator in the forum. To describe the meanings attributed to the lightning's flash and the thunder's roar would take volumes written from the absorbing chapters of mythology. But in the midst of all this myth and superstition arose Thales of Miletus, whose profound knowledge of science had chanllenged the admiration of the famous Phoenician voyagers. These navigators werę accustomed to sailing the Straits of Hercules in order to reach the Baltic Sea and from its waters they would seize a substance fair in color and beautiful in transparency. To Thales this strange substance of nature had mysterious properties. He named the precious find electron or amber. He found by rubbing this electron it would attract to itself various light articles. Three hundred years later Theophrastus enlarged upon this teaching and conferred the name, animated gem, Pliny then followed with other more logical essays. Hundreds of years passed but the teachings of Thales were not forgotten. In the 'Read before the Republican Valley Medical Association at Holdrege. Nebraska, May 31, 1912 |