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If recovery be possible under adverse conditions such as the report of this case reveals, no one need hereafter despair of recovery in any case.
Treatment. But little can be said upon the subject of the management of these cases. The surgeon wants less to know what to do than what not to do. Meddlesome surgery can not be advised. Rest of the joint is of the first importance. Whenever, therefore, a fracture is not made out but is suspected, the patient should be let alone as much as possible, and the limb left at rest in an easy position, with or without moderate extension, according as it is grateful or otherwise to the patient. In the case I have reported, it is quite probable the patient was deprived of her only chance of recovery by repeated examinations, two of which were entirely unnecessary, since they inflicted injury, without leading any nearer to a correct diagnosis.
NOTE.-At the conclusion of his paper, Dr. Gay exhibited two specimens; one of recent fracture, the case of Ella Smith, and the other a specimen of fracture with osscous union.
DR. DARWIN COLVIN, of Wayne County.-The paper read by Dr. Gay has of itself amply repaid me for having come to the meeting of the Association. I can now go home and make a diagnosis in the case of a man who fell from an apple-tree about two weeks ago and sustained an injury which confined him to bed. He was unable to raise the heel from the bed, and I expected, on examining the patient, who was an old man and had fallen upon the side, to find a fracture; but the examination proved not to be satisfactory. No crepitus was obtained. The patient is now going about on crutches. In another case, that of an old lady who had fallen upon the hip, I expected to find evidence of fracture of the neck of the femur, but found none, and the patient now is able to walk about with the aid of crutches. I feel that much light has been thrown upon these cases by the paper which has been read by Dr. Gay.
DR. JOHN CRONYN, of Erie County.-I desire to thank Dr. Gay for his paper, as it has thrown light upon a case now under my observation. The patient is a brick-manufacturer, who three weeks ago fell a distance of thirteen feet, striking upon the left hip. I saw him shortly after the accident, but could find no evidence of shortening or of eversion; the patient, however, was suffering greatly from pain. I placed him upon the back, enjoining perfect quiet. I had thought that the man would be about on crutches soon; but I feel satisfied that, if any marked injury have occurred, it must have been fracture of the base of the acetabulum. I shall follow Dr. Gay's advice not to try to do too much.
DR. BROWN, of Chemung County.-About a year ago, I was called to see a lady who had fallen a distance of several feet, striking upon a stone, and afterward complained of pain in the hip. I supposed, from the distance of the fall, that I should find fracture, but could obtain no evidence of shortening or of crepitus. Extension with a weight relieved pain, and it was only after four or five weeks that the patient was able to go about on crutches. She finally made a complete recovery, without any shortening. I have no doubt that it was a case of fracture of the acetabulum.
A CASE OF TUBAL PREGNANCY ADVANCED TO FULL TERM WITHOUT RUPTURE, THE FŒTUS REMAINING FOURTEEN YEARS IN SITU. REPORT OF THE AUTOPSY.
By J. G. ORTON, M. D., of Broome County.
MRS. W., aged forty-five years, gave birth, at the age of twenty-seven, to a living child, and again became pregnant at thirtyNo unusual circumstances occurred during the whole period of gestation, but when the full term was completed an abortive effort at parturition was made. The patient not being delivered and all pains simulating labor ceasing, it was concluded that there was an error in the diagnosis. The idea that she was pregnant was abandoned, and the tumor-theory took its place. However, she passed through a long period of sickness, and became emaciated, anæmic, and very feeble. After about a year and a half, her health improved, menstruation returned and became regular, and she regained her usual weight and healthy color.
I obtained these statements from the patient and her husband. They resided during this time in West Suffield, Conn., and were supposed to have been under the care of competent physicians.
I was first consulted by this patient, October 24, 1882, and found her suffering from considerable pain in the region of the rectum. She was passing a yellow, oily-looking substance from the bowels, which, upon careful examination, proved to be quite pure fatty matter, becoming hard on cooling, like tallow. The uterus was in situ and normal in size, as was determined by measurement with
the sound. Her bowels had long been habitually constipated, and I understood that the case had been recently diagnosticated "cancer of the rectum."
Upon making a digital examination, I found an opening through the walls of the rectum at a point about four inches above the anus, near Douglas's pouch, and about half an inch in diameter. Upon penetrating this opening with my index-finger, I distinctly felt a hard body, and, finding it movable, sent for a long bullet-forceps. On passing this along my finger to the opening, I seized the foreign body, and, on removing it, I found, to my surprise, that it was the right tibia of a full-grown fœtus. A considerable quantity of the yellow, oily fluid immediately flowed from the parts. The next day I repeated my explorations, and succeeded in removing several of the vertebræ. From this time, about every alternate day, I made efforts for the removal of the bones, and was generally successful in collecting quite a number at each operation. They were very clean, being entirely free from muscular or tendinous adhesions. The aperture in the rectum was gradually enlarged by dilatation until it was about two inches in diameter. The patient experienced considerable pain during these manipulations, and could only endure them for a short time on alternate days. A decided expulsive effort like uterine contractions was apparent whenever the parts were irritated. The immediate friends were opposed to the administration of any anæsthetic; however, I was succeeding very well in my operations, and my patient seemed to improve in strength and spirits after the first discharge of the accumulated liquid and the removal of some of the bones. I had taken away about one hundred of the fœtal bones, when the patient was attacked with a severe form of diarrhoea, which was prevailing quite extensively in Binghamton during the months of January and February of the year 1883. This disease, in connection with her previous feeble condition, was too much for her to endure, and, rapidly sinking, she died, February 3, 1883.
REPORT OF THE AUTOPSY (thirty-six hours after death).-My esteemed friend, Dr. C. P. Tucker, of New York city, who happened to be in Binghamton at this time and who had seen the case with me in consultation, kindly consented to make the
autopsy. He was aided by my assistant, Dr. W. F. Race. I recorded the following notes:
Rigor mortis was well marked. The abdominal cavity being laid open, the walls were found thin and pale, and the bladder, uterus, and intestines in situ and normal in character, with the exception of some recent inflammation in a limited portion of the large intestines. The agminated patches were enlarged, and some of the solitary glands were eroded. Circumscribed portions of the abdominal peritoneum were studded with evidences of recent inflammation.
The left Fallopian tube, ovary, and broad ligament were normal in size and character. The liver was fatty and somewhat broken down in structure, but not enlarged. The stomach, kidneys, and spleen were nearly normal.
Upon the right side of the median line, was found a sacculated tumor extending from the brim of the pelvis well down into Douglas's pouch. It was firmly adherent to the rectum, into which a free opening existed; and it was also attached to folds of the intestines by recent peritoneal inflammation. The tumor, with all its attachments, was removed from the body, and a careful dissection revealed extensive expansion of the Fallopian tube. The sac consisted of peritoneal, muscular, and mucous coats, in no wise compromising the uterus, or, on the other hand, involving the ovary, as that organ was found upon the outer surface of the sac, reduced to about one third of its normal size, and even the fimbria of the tube were distinctly traceable.
Upon laying open the tumor, the remaining bones of a fullgrown fœtus were exposed. They were comparatively clean, with the exception of a little cartilaginous attachment on some of the vertebræ.
I do not propose to theorize regarding this case, but have simply studied the facts and the conditions found; and, without attempting a rehearsal of the literature of tubal pregnancy, it will be sufficient to say that it is fully conceded, I believe, that its continuance to full term without rupture is exceedingly rare; so rare, indeed, that I have failed to find the record of any case occurring in this country. I shall only further remark that it