opment of an ovum in any portion of the ovaro-uterine | To more fully explain this point, we will quote a few track results in the obliteration of the corresponding lines from the memoir before cited: "I am convinced, canal, and it remains so obliterated after all its attachments to the cyst have been severed." Another allusion to the subject is also made on page 44, of the same paper. The fourth condition was, that the tumor comprised a peritoneal coat, a sub-peritoneal coat, containing unstriated muscle whose fibres were disposed in longitudinal and transverse layers, and lastly a lining cyst. In respect to this cyst and the layer of muscle, this smaller tumor differed from the larger. The lining cyst was filled with a fibrillated, clotty substance, but no recognizable ovum was found, if we except some villous tissue which projected from a small opening through the peritoneal covering of the tumor, at the point indicated by B in the cut. This tissue we regarded, however, as the tufts from the surface of the chorion, the undoubted character of the cyst lining the tumor, and therefore definitely settled the question of the foetal character of this smaller tumor. The opening through which it projected was no doubt the point whence most of the fatal hæmorrhage occurred, though at the time the specimen was presented, the larger tumor was supposed to have been the seat of the final bleeding. This dissection explained the existence of a corpus luteum of pregnancy in the left ovary. The idea that one tumor indicated the locality of the ovum, and the other the placenta, was of course physiologically impossible. An instructive feature of this specimen, explanatory of the manner of formation of the larger tumor, is the presence of several apoplectic clots scattered about in the sub-peritoneal tissues over the fundus of the uterus, and both broad ligaments. A better name, perhaps, for these spots of effused blood would be ecchymoses. They show that a rupture of vessels supplying the foetal cyst took place, and that the blood found its way from that point along the course of the Fallopian tube and the broad ligament beneath the peritoneum, finally accumulating in that portion affording least resistance, viz., the areolar tissues connecting the folds of the broad ligament near the outer portion of the Fallopian tube, the position occupied by the larger tumor. It was in fact a very marked and illustrative case of circumscribed pelvic hæmatocele, resulting from rupture of vessels upon the sub-peritoneal coats of a tubal foetal cyst. Had the walls of the bloody tumor, or the peritoneal covering of the foetal cyst, resisted the pressure of effused blood long enough, there can be no doubt that the hæmatocele would have become general. It was stated at the time this specimen was presented, that the rupture whence the fatal bleeding took place into the peritoneal cavity, occurred on the surface of the larger tumor or hæmatocele, as has already been stated. The committee now regard this as very improbable, in view of the fact that a rupture of the coats of the foetal cyst was found, permitting the protrusion of the villi of the chorion through it. As this point of rupture is the general one in fatal hæmorrhage in these cases, there appears no reason for believing that it was not so in this case. We therefore conclude that the giving way of the peritoneal covering of the foetal cyst, prevented in this case the occurrence of a more or less general pelvic hæmatocele, and that by far the greater part of the fatal hæmorrhage occurred from this opening. Another fact which should not pass unnoticed, is the absence of decidua in the cavity of the uterus, a fact which cannot be accounted for, if we admit that there was extra-uterine pregnancy, without supposing that it had been thrown off at some period before death. The supposed return of her menses with unusual pain, two weeks before her death, affords us the means of accounting for the absence of the decidua. by the evidence afforded by a somewhat extended research, that an intra-uterine decidua is invariably formed in extra-uterine pregnancy, and that a careful history of the cases in which no such decidua appeared at the post-mortem examination of the uterus, would reveal the fact that a sanguineous discharge from the uterus occurred at some period before death. As such a discharge is pretty generally attended by the exfoliation and extrusion of the decidua, therefore, where a decidua is not found and such a discharge is known to have occurred, I should accept it as almost demonstrated, that the decidua had escaped at the time of the hæmorrhage. Conversely with this proposition, the absence of a uterine decidua in extra-uterine pregnancy, would to me be evidence that it had been discharged with the usual accompaniment of blood and pain. These bloody discharges are generally regarded by the patients as returns of their lost menstruation, or as some irregular manifestation of it. They are usually attended by hypogastric, colicky pains, and seem to result from either spontaneous efforts of the uterus to throw off an excrescence which the unemployed decidua has now become, or from sympathetic action with the disturbed and contractile foetal cyst. There does not appear to be any regularity in the matter of the date of the occurrence of this discharge with respect to the gestation, appearing sometimes before the sixth week, and again not occurring till some months have passed." Op. Cit., pp. 17, 18. The supposed menstruation in this case, which occurred two weeks before the fatal accident, we conclude was the usual discharge of the decidua, and so far from satisfying the physicians in attendance that the case was not one of extra-uterine pregnancy, as it did, it was the very symptom that they should have inquired for, and that should have confirmed their first impressions that such was the character of the case. We do not doubt that, had the exact character of the pains attending this supposed menstruation been ascertained, they would have been found the same as those usual to cases of extra-uterine pregnancy at the time of the extrusion of the decidua. As this woman had experienced the usual signs of pregnancy for several days at least, we do not doubt that she had, from the beginning to the end, the usual signs of extra-uterine pregnancy, viz.: First, those of pregnancy of the usual character; second, paroxysms of hypogastric, colicky pains, referred to the left iliac region, recurring at varying intervals, perhaps attended with nausea and a feeling of debility; third, a sanguinolent discharge from the uterus, which we know she had; fourth, the uterus appreciably enlarged, which we see was slight only in this case; and fifth, more or less tenderness over the region of the abdomen corresponding to the pain. Op. Cit., p. 35. We therefore regard it as a most unfortunate circumstance, that the medical gentlemen in attendance on this case were unacquainted with these symptoms and facts belonging to the natural history of extra-uterine pregnancy, for they were in consequence entirely unprepared to find that "during one of the accustomed attacks of colic, or perhaps without it, the patient suddenly experienced an acute pang in the right or left hypogastric region, followed by depression, sickness of the stomach, collapse and pallor; by sighing and syncope, and feeble or absent pulse; that the abdomen became more or less enlarged, attended by a sense of fluctuation and probable dulness on percussion over the more depending portions. Indeed, they were in consequence entirely unprepared to seek for these physical signs, and did not detect them. Had they been fully instructed in the subject, we cannot doubt that the presence of blood in the peritoneal cavity would have been early detected, for it must have been there in considerable quantity, to account for the symptoms of hæmorrhage said to have been present in this case. This failure naturally resulted in neglect to employ the only means offering any promise to save the life of this unfortunate woman, viz., gastrotomy for the purpose of ligating the bleeding tissues, pedicle or vessels, and the removal of the effused blood from the cavity of the belly. Op. Cit., p. 40. After a due consideration of the history of this case, the committee think that it presented most of the circumstances favorable to the success of this operation, and very much regret that so promising an opportunity to practise it was lost. We deem it of importance to comment upon the supposition entertained by the physicians in attendance upon this case, that a perforation of the intestine had taken place. This is a resort which physicians very unaccountably have too long practised, when placed under similar circumstances. We regard it as a pathological axiom that symptoms, such as this case presented, coming on suddenly in a woman whose health up to the moment of their appearance had been perfect, do not indicate perforation of the intestine and the escape of its contents into the peritoneal cavity; for such an accident must necessarily be preceded by other symptoms than those of perfect health. Op. Cit., p. 37. Should the bleeding be intra-peritoneal, it is obvious that the local signs compared in this table must be the same in both extra-uterine pregnancy and pelvic hæmatocele, the only difference being in the early rational signs of pregnancy. But it is to us equally obvious, that so far as the treatment goes, it is a matter of no importance whence or from what cause the bleeding comes, providing it be into the peritoneal cavity. The ligation of the bleeding vessels from the peritoneal cavity, and the cleaning out of that cavity, are unquestionably indicated in both cases.* The only excusable mistake a physician could commit In conclusion, the committee would state that in their in diagnosticating a case presenting such a history and opinion, had the gastrotomy treatment been employed symptoms, would be in taking them to indicate pelvic in this case as early as it might have been, the chances hæmatocele. This pathological condition, and hæm that it would have saved the life of the woman were as orrhage from a ruptured foetal cyst, have been repeat-great, at least, as are the chances for recovery after an edly confounded by diagnosticians of acumen. The ordinary operation for extirpation of the diseased differential symptoms, however, we regard as sufficiently distinct, if carefully observed, to enable the physician to avoid such an error. We subjoin a tabular statement of the symptoms of the two, for the purpose of ready comparison: TABULAR STATEMENT OF SYMPTOMS. Extra-uterine Pregnancy. The usual rational signs of pregnancy are present. Paroxysmal, hypogastric, colicky pains are very com Pelvic Hæmatocele. Absent., Are not generally present, monly present from the end but when they are, they are of about the first month, and more diffused over the whole when present, are always re- pelvic and hypogastric referred more to one iliac region gion. than the other. CASES ILLUSTRATIVE OF THE ASSISTANCE AFFORDED IN DIAGNOSIS BY THERMOMETRIC OBSERVA- BY JOSEPH G. RICHARDSON, M.D., UNION SPRINGS, CAYUGA CO., N. Y. WHEN any new scientific instrument is introduced among the implements of our profession, it often happens that many practitioners, after a partial test of its capacities, become dissatisfied with its failure to aid them in solving all the problems which diseases, modi I would here state my reason for omitting in my memoir to discuss the differential diagnosis between pelvic hæmatocele and rupture of an extra-uterine foetal cyst. The latter pathological condition, It is extreme over the seat being one preceded and attended by symptoms of pregnancy so almost Tenderness over the seat of pain is generally not marked. of pain. Bloody discharge from the uterus apt to attend the colic pains, regardless of the menstrual period. More or less sickness at the stomach. After rupture of the cyst. Pallor, depression, and collapse. Enlargement of the abdomen with little tympanitis. Not present except at the usual menstrual period. Sickness at the stomach. invariably, it seemed to me an unnecessary addition to the paper already very greatly extended. In Dr. John Byrne's elaborate papers on pelvic hæmatoce'e, the following observation may be found in support of this decision, viz. : A sixth class of hæmatocele comprises those cases in which the blood has been derived from a ruptured ovisac, or a ruptured vessel in extrauterine pregnancy. These cases constitute, in my opinion, a nosological species of their own, and can be properly excluded in a treatise on hæmatocele of the non-pregnant female." The presence of the symptoms of pregnancy at the diagnosis can only indicate to which species any given case belongs; and as my paper was devoted to the accident of pregnancy, the accidents of the non-pregnant state were excluded The relation, however, of two interesting cases by Prof. Fordyce Barker, which had fallen under his observation, has convinced me that the discussion of this differential Pallor, depression, and col-diagnosis would have added to the value of my memoir. I shall certainly lapse. Enlargement of the abdomen mostly tympanitic. add it in my republication of the paper. One of Prof. Barker's cases fied by the infinitely diverse idiosyncrasies of patients, present; and, in the disappointment which they feel over its shortcomings, renounce even the benefits which it is able to confer-an injustice which the examples recorded below may help to avert from the clinical thermometer. headache, pain in the abdomen, and general feverishness were slightly increased; the temperature in the axilla was however still 99° only, and before the close of my visit I was informed by the matron of the establishment, that she had learned, from a rigid cross-examination, that the young lady was suffering from a difficulty about the bladder which had caused some retention of urine, a symptom which, with the natural modesty of a ly denied to me, and scrupulously concealed from all her attendants; under appropriate treatment she was soon relieved, and in less than a week entirely cured. DECAPITATION IN A CASE OF TRANS- DES MOINES, IOWA. A PARAGRAPH in a recent issue (No. 49) of the CASE I.--Eva E., a robust, healthy-looking little girl of five years old, was attacked on the 14th of September, 1867, with symptoms of fever, which, although some-school-girl thrown among entire strangers, she positivewhat relieved by domestic treatment the day after, again increased on the 17th, when, on the urgent solicitation of a relation, I was called to see her. I found my httle patient lying upon the bed, somewhat inclined to sleep, but quite willing to answer questions, and to interest herself in passing events. Her eyes, when thus aroused, were bright and intelligent, her sense of hearing unimpaired, her tongue lightly furred with a whitish coat, her skin dry and warm, but not hot, and her pulse beating 120 per minute. She complained of some pain in her bowels, which had been moved five or six times in the preceding three days; the abdomen was somewhat tympanitic, and there was a little tenderness, with occasional gurgling in the right iliac fossa, so that although there had been no epistaxis, my suspicions were strongly directed towards enteric (typhoid) fever, especially as I learned that her father and brother had both been ill with that disease a few weeks before, at their former home in northern Pennsylvania. The mother of the child insisted, however, that the attack was only one of "worm fever," and assured me that she had several times seen her little daughter exhibit just such symptoms, which would pass off in a few days without any trouble; and in opposition to this statement, it seemed difficult to feel positive of the nature of her malady, until having tested her temperature with the axilla thermometer, and found it 10240. I was able to assert that it was no ephemeral seizure, but a fever of severe type, probably typhoid in its character, an opinion which her condition the next day, when the thermometer marked 104°, rendered much less doubtful, and whose correctness the course of the disease during the following two weeks amply demonstrated. CASE II.-Miss E., æt. 18 years, a pupil at seminary, came under my care on the 2d day of March, 1868: she had been the subject of a slight attack of diphtheritic sore throat about one week before, and, as ap- Owing to the impacted condition of the child, it was pears to be often the case, even after mild seizures of with considerable difficulty that I succeeded in reaching that complaint, did not soon regain her strength or ap- the neck, and in passing my left forefinger around it in petite. On the 4th, I was called to see her again, and order to bring it as low as possible, as well as to protect a death from typhoid fever having occurred the week the parts of the mother from injury. Having succeeded previous, much anxiety was felt among the panic-in this I proceeded, with the per orator in my right hand, stricken students to know whether another case of that dreaded disease was about to develop in the person of their school-mate. I found the young lady with a flushed face, a hot and dry skin, a furred tongue, a pulse of 92 per minute, and a dull apathetic expression of countenance strongly suggestive of the hebetude so universal in fever patients. She complained of severe head ache, pain in her back and limbs, sleeplessness at night, sickness at her stomach, and griping pain in the bowels. The abdomen was a little distended, and quite resonant on percussion, but there was no special tenderness in the ilise fossa, nor had either diarrhoea or epistaxis occurred. With such a group of symptoms it becomes a matter of some difficulty to give a sufficiently definite opinion as to whether it was or was not typhoid fever, but finding that the thermometer in the axilla marked a temperature of 99° only, I discarded the febrile hypothesis, and informed her friends that I believed the attack was not one of the disease they so much feared. On the 5th of March I found her symptoms very much the same as on the day previous, except that the Upon examination, I found the patient well nigh ex-. hausted, the pulse at the wrist fluttering and barely perceptible, the surface bathed in a cold perspiration, and consciousness manifested only during the paroxysms of pain from uterine contractions, which were still strong and recurring at quite regular intervals of about ten minutes each. One hand of the child protruded from the vulva, the os uteri was well dilated and flaccid, and the right side of the head was resting against the left brim of the pelvis, the face looking toward the spine. The body of the uterus was so firmly contracted upon the body of the child as to defy all efforts to turn, and I determined to attempt delivery by decapitation. to cut against the neck of the child, with a rocking mo- The child was at full term and well developed. In this connection I will mention, further, that in 1865, I was called to visit a lady in labor-six months or more advanced in pregnancy. Upon arrival I was informed that the waters had escaped with a gush, while she was in a standing posture, some twenty-four hours previously, and that, too, without any premonition of the accident. The uterine contractions were quite hard and were recurring with considerable regularity. Upon vaginal examination I found one hand protruding from the vulva, the os uteri well dilated, and the foetus impacted in the superior strait of the pelvis. In consideration of the immaturity of the child, I ventured some traction upon the protruding limb, and in the course of an hour succeeded in delivering it doubled upon itself. The child had evidently been dead some hours, and the protruded limb was quite dark with incipient gangrene. The patient made a good recovery. Some years ago it was my fate to meet with two other instances of cross birth, in which it was impossible to turn, and both of which terminated fatally to both mother and child. As I kept no record of them at the time, I will not attempt their history from memory. But to return to the proper subject of this communication, I will say that I regard decapitation as the best means of delivering in very many cases of cross birth, where the child cannot be turned, and that in my opinion the head will be expelled in most instances without instrumental aid, on account of its freedom to engage its shortest diameter in the passage. A NEW DEVICE FOR THE TREATMENT OF FRACTURE OF THE PATELLA. By J. H. HOBART BURGE, M.D., ETC. THE number of methods already in use for securing the best possible union after fracture of the patella is so great, and so much ingenuity and experience have been brought to the subject, that one could hardly excuse himself for occupying afresh the attention of the surgical world, unless he felt sure that he had something of real value to contribute. limb by means of a bandage evenly applied. After a few hours it will be firm as a board. Then a small, strong cord, stitched across the lower end of the splint (2), is passed through a pulley at a lower level (3) on either side of the limb, and made to complete the circuit by traversing a pulley (4) beyond the foot. Another cord passes over the wheel (5) at the foot of the bed, connecting the flying pulley (4) with the weight (6). The lower fragment may be dressed in a similar manner, as shown in the engraving. Further description is unnecessary. The amount of extension and of padding, and the tightness of bandages, must, of course, be left to each surgeon's judgment. The smallest-sized metallic pulleys are cheaper, more appropriate, and just as efficient as the larger. Those at the side of the limb should not be attached to the long splint,-it is better to screw them into separate strips of pine board lying transversely under the long splint. Their distance from the limb, and their inclination from the perpendicular line, must vary in different cases; otherwise the cord will sometimes press unpleasantly upon the sides of the limb, or slip from the pulleys. While my efficient House Surgeon, Dr. A. E. Spohn, was dressing a case for me, he introduced what I have called the "flying pulley" (4), and I was glad to adopt it, equalizing as it does the pressure upon opposite sides of the limb. When the leather splint has become dry and firm, the bandage which secures it may be replaced by strips tied or buckled around, outside of both upper and lower splints, thus leaving the circulation free in the sides of the limb. If the fracture be simple and there be no considerable swelling of the limb, it will not be necessary to bandage from the foot. Should there be much local inflammation an evaporating lotion should be applied till its severity is abated. In other cases we may proceed at once to the permanent dressing. the Place the limb upon a straight splint of uniform width provided with a foot-piece and comfortably padded. The foot may be elevated, or not, as seems best in individual cases. A substantial piece of soleleather, of suitable length and width to cover anterior aspect of the thigh, should be nicely fitted by narrowing it towards the knee and making its lower end concave, to adapt it to the upper border of the patella. Immerse it in cold water till it is thoroughly pliable. (If hot water be used it will take too long to dry.) Pad it on one side with cotton-batting and cover with cotton-cloth, neatly sewed on. Confine it to the The straight splint upon which the limb rests, may be divided transversely and strongly hinged opposite the knee, to enable the surgeon to make slight passive motion without disturbing the dressings; in this case, however, it will be necessary to support it upon another board. The advantages promised by this apparatus are: surgeon's observation that he need have no anxiety in 1. It leaves the injured bone so exposed to the reference to tilting, side-slipping, or retracting of the fragments. 2. It grasps so firmly, and yet so tenderly, the quadriceps extensor, together with the upper fragment of the bone, that it enables us to approximate the broken surfaces more completely than I have ever been able to do without violence. 3. It is comfortable to the patient. 4. It is inexpensive, simple in all its parts,-easily extemporized and easily applied. I am not unmindful of the fact that some are now treating these fractures without apparatus of any kind, and I have no doubt that where the separation of the fragments is very slight, some of the best results will follow this plan of non-interference. This expectant method in surgical practice must, however, be the exception and not the rule. Surgeons using this apparatus are requested to report their cases, bad, good, and indifferent. BROOKLYN, 60 Court street. Original Lectures. We are now prepared to understand some of the pathological circumstances observed in this case. The cyst was unilocular. Its walls were quite thick, which accounts for the sensation of solidity which it gave to the finger. Its contents were chiefly a thin fluid stained with blood (sanguinolent). It contained also about two drachms of fibrinous material, composed of fine cords rolled into a mass, but separated entirely from the walls. These rolls of fibrinous tissue resembled so closely the small thread-like cords which I have so generally found in the patellar bursæ of old people, in the dissecting room, as to leave little doubt that they were the same. At first this fluid was deposited not in one cell, but in a number of cells, between which were interposed vascular walls. As the several cavities increased in size, the intermediate walls gave way, and a few drops of blood were poured out, staining the AFFECTIONS OF THE BURSA PATELLÆ. natural fluid of the sac. Or, if these intermediate TREATMENT BY EXCISION, ETC. REMARKS MADE AT THE MEETING OF THE N. Y. MEDICAL BY FRANK H. HAMILTON, M.D., PROFESSOR OF FRACTURES AND DISLOCATIONS, MILITARY SURGERY MR. PRESIDENT-As some question has arisen concern- walls had already degenerated into vascular cors, then, as the outer walls were separated by accumulation of fluid, one after another would break, pour out a little blood, and become rolled up by the motion of the limb. This will explain the sanguinolent character of the fluid in this case, and the fact, also, as stated by Velpeau, that the fluid often presents this character. Velpeau generally found it stained with blood. Sev I would call attention to the fact that enlarged patellar bursæ are not unfrequently multilocular; which is explained by a study of their anatomy. Again, I have constantly observed that multilocular cysts, occurring elsewhere in the areolar tissue, and not having their origin in nævi, or other vascular tissues, are very apt to have vascular walls, and sanguinolent contents. eral instances have come under my notice; and they have been among the most troublesome tumors with which I have had to deal. The explanation of their anatomy seems to be that these multilocular areolar cysts, or hygromata, are the results of serous effu-ion into several cells of the areolar tissue, just as in the case of multilocular patellar bursæ; the subsequent expansion of the cells leaves their intermediate vascular walls for a time unbroken; the vessels grow and enlarge as the cells expand, until at length the strain is suflicient to break some of them. Ellen Conklin, æt. 30, admitted to ward 18, Bellevue Hospital, Oct., 1867. The history of her case before admission is, briefly, that the enlargement over the patella began about three years before; and that it was caused by resting on her knees in scrubbing floors. At the date of the operation it was a little larger in circumference than the patella, circular, with quite abrupt margins, and about two inches in height. It felt so firm as to lead to the impression that it was solid, but an exploration proved it to contain fluid. Operation before the class, Oct. 26, 1867. A crucial incision was As to the treatment adopted in this case-viz., excision made across the summit of the tumor, and the sacit is only applicable to old cases with thickened walls, carefully exposed to its base, when accidentally the cavity was opened and the contents escaped. The dissection was continued, however, until all the sac was removed. Underneath the sac the tendinous attachments of the quadriceps to the front of the patella were exposed. The wound was closed by a compress laid over the flaps, and a roller, and the limb was placed apon a splint to render it immovable. The whole united by first intention; and in about one month the patient was discharged cured. These bursæ exist as natural cavities in most adults, but they are not often found in the dissecting room as complete, unilocular cavities. In general there is one cavity, or cell, covering the lower half of the front of the patella, or perhaps the middle; with several smaller cavities, or cells, occupying the upper half of the front of the patella, or the outer margins. If great care is not used, however, in making the dissection, the thin cell-walls will be destroyed, and the cavity will appear to be unilocular. In old persons there are found sometimes numerous small, round cords crossing the base and sides of the cavity, appearing like threads. Upon examination these are found to be vascular. Some of them are perhaps simply vessels stretched across; in other cases flattened bands, or plates, traverse the cavity, one above the other. or to cases in which the tumor is solid. Simple rest is often sufficient in recent cases. Pressure and blisters, or some other stimulating applications, such as tincture of iodine, are required in some cases. Others demand a free incision. Punctures, setons, and injections are more hazardous than excision, and cannot be recommended. This malady is not so much confined to housemaids as its name might imply. In the record of ten cases, six were women and four were men. The other cases were as follows: CASE 1.-In June, 1845. I was consulted by a German woman, aged 40. She was not accustomed to rest upon her knees; but she had a sudden enlargement of the bursa over the patella, supervening upon a severe illness. At the same time a small tumor appeared upon the upper evelid, which soon opened, discharged, and got well. The bursa was cured in a short time, without suppuration, by the application of tincture of iodine. CASE II.-One of the "Sisters" at the hospital of the Sisters of Charity, in Buffalo, had, in 1854, an enlarged patellar bursa, caused, probably, by kneeling. It was never tender, and 'disappeared in a few weeks under the application of tincture of iodine. CASE III-Ellen Allen, æt. 22, presented herself in one of my wards at Bellevue Hospital, April 30, |