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DR. H. A. BARR, Beaumont: I enjoyed listening to this paper very much, and wish to say that about six months ago I had two cases of compound fractures and did not get very successful results on account of infection and sloughing, and during that time I attended a meeting at Houston, and Dr. Crouse suggested his method to me. I wish to say that I have tried it on three cases and I am certainly well satisfied with the result, and I believe that this method, as soon as it becomes well known, will take the place of all other methods in these compound comminuted fracture cases. We often have a considerable amount of tissue which is torn and bruised to such an extent that it is devitalized apparently, and will die despite the greatest care on our part to prevent it.

DR. CHAS. WARDELL STILES, M. H. S., Washington, D. C.: I do not wish to discuss this paper from a surgical point of view, but I should like to enter a mild protest against a certain principle which Dr. Crouse has advanced. It is a recognized principle in science that the person who first describes an object or a method is its author. In the case at hand, Dr. Crouse, owing to his excessive modesty, now generously steps back and gives the credit for this method to another person. I do not think that the Texas State Medical Association should permit him to do this, for from the evidence he himself has given Dr. Crouse is the first person to make his method public; therefore, he is the first person to describe it, and hence he is the discoverer.

Dr. Crouse has said that he has met another man who, it seems, used this method on another operation before Dr. Crouse used it. But this other person did not make it public, hence he can not be admitted as the discoverer. The principle Dr. Crouse advances is one which has given rise to some of the most bitter discussions that have taken place in the medical profession.

There is only one principle that can justly be followed in such matters, and it is the principle of actual publication. The man who publishes his discovery first in print is the discoverer of the method; it does not matter if some other man has thought of this for eight or a thousand years; it is not public property until it is published, until it is printed and given to the entire world, and it makes absolutely no difference that another man has thought of or used the same thing; he has not given the world the benefit of it, therefore he is not the discoverer of it.

I well recognize the fact that these views are not held by all members of the medical profession. But it frequently happens that as soon as you have made an important discovery, you will find that some other man from another part of the world says: "Why, I made that discovery ten years ago." There is a proper principle upon which a fair test should be based, and that is, that every man should come forward and make his discovery

public and publish it. Therefore, I want to enter a mild protest against Dr. Crouse's exceeding modesty in this matter and to state that from the evidence which Dr. Crouse gives in connection with this method he discovered it independently, he is the first to make it public, and, in my opinion, he is the discoverer and should have the credit of priority.

DR. WM. KEILLER, Galveston: I think the method an excellent one, but I would take exception to one point, and that is that I would not shellac the whole splint; I would shellac all the plaster cast that has to come in contact with the discharges; as to the rest of it, I think one advantage of the plaster cast is that it admits of free evaporation and keeps the skin dry, and if you shellac the whole cast you lose this. I would rather use boric acid upon the skin in preference to vaseline, as it will materially interfere with the action of the skin, and boric acid does not so interfere with the perspiration and the cast could remain on for an indefinite time.

DR. F. P. MILLER, Midland: I do not understand how Dr. Crouse describes his packing. Was it put beneath the splint, and how did he avoid the pressure?

DR. H. W. CROUSE, said, in closing: I am decidedly obliged to Dr. Stiles for his statement when he remarks that he believes that I should have the credit because I have published the principle of this technique for the first time. As to that, it is immaterial. All that I wish to do is to bring this method to your attention, and to commend it to you, assuring you that my experience has proven it to be worthy of use in compound fractures, where windowing is desired. There was one thing that I had never thought of, and that was the point brought out by Dr. Keiller, as to shellacking of the whole cast. I readily see the point he makes relative to the escape of moisture through the ordinary plaster cast, and the prevention of such taking place where an impervious substance is used over the entire cast. I only shellacked to prevent the water, which always gets on your cast, from crumbling the plaster, and, of course, succeeded in doing so by means of this veneering; but, as Dr. Keiller says, it permits of no evaporation taking place, so, perhaps, it would be better that we simply cover a sufficient area in order to guard against the splashing of the water used in irrigating the wound. This method I have been using for three years, so it is backed with considerable experience. I have handled, as I have mentioned in my paper, several types of cases sucessfully.




In writing a paper on above subject, I have nothing new or startling to offer the profession, but only attempt to give a concise description of the most salient points one is liable to encounter most any day in practice. This condition is relatively rare and dangerous symptoms so liable to suddenly occur that if the attention of the practitioner is not occasionally called to it, the diagnosis and treatment might be temporarily overlooked.

Pregnancy may occur anywhere outside of uterine cavity, from the internal ostium of tube to the ovary, and probably, also, in the peritoneal cavity itself, though the latter is still a mooted question. The most frequent place of development, however, is in the tube and the most frequent part of the tube is the ampulla, hence I will discuss only tubal pregnancy, and that within the first four months. When pregnancy takes place in the tube, it undergoes the same development as when in the uterine cavity. The fecundated ovule implants itself on the M. M. of the tube and the M. M. begins to grow and envelop the ovum. There is formed a tubadecidua serotina, vera and reflexa. The chorion of the ovum begins to throw out the villi and later on with the villi of the serotina, the villi of the chorion form the placenta, provided rupture or abortion does not take place beforehand. The walls of the tube also thicken and the muscular tissue hypertrophies, but on account of the further development of ovum, the walls become stretched and thinned down and finally rupture. The rupture (and sometimes abortion into general cavity) occurs generally in the first four months, most frequently about the fifth and sixth week. It is very rare that the pregnancy is completed. The physician seldom gets to examine the case before disturbances arise unless by accident, as the woman holds herself far pregnant in the natural way. It is at the time of rupture the

physician is called upon for a diagnosis, and it is at this time he must diagnose accurately and act promptly.

The actual cause of this abnormal condition is not definitely known, but it occurs more often in nullipara, who have been married for several years without becoming pregnant, and multipara, who have not borne a child for a long period. It is also supposed that peritonitic processes have something to do with it by displacing, kinking or narrowing the humen of the tube. Inflammation of the M. M. of the tube and polipi may also be causes. At times, too, the fecundated ovule may wander from the uterine cavity, or may be in the tube and can not pass back through the narrowed tubal ostium into the uterine cavity.

The symptoms are the same as those of normal pregnancy until the time of rupture, such as nausea, vomiting, enlarged and discolored breasts, cessation of periods, enlarged uterus, blue discoloration of vaginal M. M. and pulsation of uterine arteries, but as the physician seldom has an occasion of making a diagnosis before then, I will discuss only the symptoms of rupture.

If the rupture occurs in the general peritoneal cavity, the patient is suddenly taken with excruciating, sharp, cutting pain in lower abdomen, attacks of syncope, great pallor, sighing, respiration, intense thirst, rapid running, feeble, small pulse, cold extremities and profuse perspiration. If the rupture occurs not into general peritoneal cavity, but between the folds of the broad ligaments, the shock is not so great and comes on more gradually. The menstruation, a day or two after the rupture, appears again and in about two-thirds of cases a decidua is discharged from uterus. Digital examination reveals uterus displaced in various ways, according to whether the outpouring of blood is in Douglas' cul-desac or anterior cul-de-sac or between the folds of broad ligaments. If the hemorrhage be large the blood may ascend up into the abdominal cavity, pushing the small intestines up, giving rise on percussion to tympanitic sound in upper part and dull sound in lower part of abdomen.

The prognosis depends upon many conditions. If the pregnancy

be discovered before rupture or abortion and the proper treatment instituted the outlook is favorable. If rupture has occurred and shock is not too great, the prognosis is also good.

The treatment is purely operative, whether in first months or in last months, whether before rupture or after rupture, provided shock is not too great. The method of operation, of course, depends upon the individual case. The entire sack with tube may be removed, or an incision through abdomen or vagina and turning out clot may be all that is necessary. If opened through abdomen, the walls of the sack should be stitched to the parietal pertoneum, if not already shut off by adhesions. When possible to open through vagina, that route is preferable.

The case I had some two months ago gave following history: Age thirty-two; white; married ten years; housewife; previous health good; mother of four children, the youngest being three years old; menstruated regularly until two months ago, since then cessation; for last month had been suffering with usual symptoms of pregnancy, nausea and vomiting being the most troublesome; patient considered herself about four or five weeks pregnant; while at breakfast table was suddenly siezed with excruciating pain in lower right abdomen, so severe that she could scarcely be gotten on bed. I was immediately summoned and on arriving about thirty minutes later I found patient in great pain with knees flexed upon thighs and thighs upon abdomen; incessant vomiting, almost no radial pulse, with a very feeble, rapid heart, cold extremities, appearance of great shock and temperature 97. A hurried digital examination was made and uterus was found enlarged up to pelvic brim and displaced towards the left, but no outpouring of fluid could be detected in pelvic or abdominal cavity. A diagnosis of ruptured tubal pregnancy or perforative appendicitis was made and the shock was considered due to pain and not to hemorrhage. A hypodermic of one-third grains morphia was given, hot applications to abdomen and extremities applied and six ounces normal salt solution as hot as could be borne was ordered by bowels. I left promising to return in two hours. Two hours later on my return,

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