knowledge among us, and which is emphatically demonstrated in the case of the present writing. The brief period of time that tubal gestation has undergone systematic and scientific investigation has already borne bountiful rewards, resulting in improved diagnostic ability, timely and preventive surgery, saving many lives from permanent invalidism, if not from sudden death. This advancement we owe to the careful and systematic scrutiny of the early clinical manifestations, inducing prompt intra-abdominal exploration, and affording opportunities for early observation and study of the initial condition, thus extending our conception of its pathology and its rational therapy. Yet, with this advance and improvement in clinical methods, the progress in the study of its histo-pathology has not kept pace, so that there is still much to be learned from this. Bearing on this state of affairs, and our indefinite information of adnexal pathology in general, are statements from Kelly that "the majority of hematoceles are tubal pregnancy in origin, other causes rarely obtaining," and that "the etiology and pathology of hematoma of the ovary is not well understood, that it is probably the result of hemorrhage in a Graafian Follicle, or cyst"; from Clark, that "hematosalpinx can be diagnosed with certainty only when the most common cause, occlusion of the lower segments, is demonstrable." Wilmer Krusen, in an article published in 1902, remarks: "True hematosalpinx rarely occurs. It may occur when hemorrhage takes place into the tube previously closed by inflammation. Such an accident may result from trauma, or by torsion of the pedicle, of a tubal cyst, or when there is an obstruction to the egress of the menstrual flow. The writer has never seen a case of tubal hemorrhage, in which ectopic gestation could be excluded. Although positive evidence of impregnation may not be present, yet undoubtedly the vast majority of these cases are of such origin." Such expression of authoritative opinion has not been without its dangerous effect upon those optimistically inclined, and as a consequence encouraged them to proclaim that all tubal blood-cysts are gestation sacs, a firm belief in the authenticity of this fallacious assertion being, in fact, current among the credulous.

Much progress has indeed been made in the study of extra-uterine pregnancy, and a great deal has been accomplished since the publication of Krusen's article in 1902, though there are still far too many ectopic gestations that go unrecognized, and end in sudden collapse from a fatal hemorrhage, or more rarely, after a less formidable but inevitable interruption, to be wondrously tided over by Nature herself to ultimate recov

ery, eluding detection altogether, to be discovered by accident in the course of some later development, or completely disguised in the form of a complicating pelvic abscess.

Ectopic gestation is not so rare that we need not be on the constant watch for it, early diagnosis and prompt surgical relief being the sheet anchor. Typical signs and symptoms early in gestation are not invariable, and to wait for the development of the classical text-book symptoms is to invite possible disaster. Certain protean. clinical manifestations, formerly not identified with ectopic conception, have been acknowledged as very important desiderata in its early diagnosis, before it is made self-evident by the announcement of one of its accidental complications, too often, alas, a warning of the approaching end, rather than a premonition of beginning danger. The usual physiologic amenorrhea may be replaced by a metrorrhagia, frequently of dark color and accompanied by much mucus; especially when occurring in one who has been sterile, and who gives a history of a previous tubal inflammation, and following an unwonted delay in menstruation, no time should be wasted in confirming a suspected ectopic or ridding the case of suspicion. Of all the unrecognized ectopic cases, probably the majority are those presumably diagnosed as miscarriages. This error can be safely guarded against by adhering strictly to the rule never to pronounce with certainty a diagnosis of miscarriage based on the observation of the patient, or other technically unreliable informaation, but only on the direct evidence of an embryo or a fetus. A hasty curettage for a supposed hemorrhage post abortem, or for a metrorrhagia of a supposed simple endometritis is known to have resulted disastrously by precipitating the rupture of an ectopic gestation sac.

The exact diagnosis of a chronic sactosalpinx is yet, unfortunately, largely a matter of inference. We have in the case-report one spurious hematosalpinx, the origin of which remains in doubt. That the history and clinical evidences are strongly suggestive of ectopic gestation cannot be denied. The points in favor of such a diagnosis in the early history are those of: (1) Sterility, (2) Long continued metrorrhagia, associated with peculiar colicky pains, inducing faintness and exhaustion, (3) Absence of rise in temperature, (4) Presence of enlarged uterus and tubal cyst, possibly the result of a succession of a number of small intramural hemorrhages from the tubal conception which the nature of the specimen at operation would indicate, (5) Prolonged uterine hemorrhage following the curettage. The finding of the blood cyst, at operation, giving no

As the vast majority of all patellar fractures occur between the ages of 30 and 50 and in people leading active lives, and, with few exceptions, in good health, it follows that but a small per cent. are unsuitable for operation.

The secreting synovial membrane of the knee joint is less able to resist infection than the peritoneal coat of the abdomen. And the more easily acquired infection of the knee joint is also more disastrous than a peritoneal infection. Consequently no operation for fracture of the patella should be undertaken by any one who is not a master of the practice of aseptic surgery.

We will not consider the management of nonoperative cases, nor operation by subcutaneous suture but will confine ourselves to the open method of operation.

Many points in the open method are yet unsettled.

The time of operation is a subject of debate. The tendency at the present time is to wait five to seven days after the injury before operating. This is to permit the joint to acquire a certain degree of immunity that follows a hemorrhage into the joint, and to permit swelling and immediate reaction to subside in a measure.

In an ordinary case, if seen early, I can see no good reason for delaying operation beyond a few hours. Indeed, delay is an acknowledgment of lack of confidence in our surgical technic. And delay protracts convalescence the number of days delayed.

The incision may be longitudinal, transverse, semilunar with convexity upward, downward, inward or outward.

The semilunar incision with convexity downward affords the best view of the field. Nerve and blood supply are best and it has the additional advantage of placing the cutaneous scar in the least objectionable location.

With the field of operation well exposed, it is possible and certainly best to cleanse the joint and broken surfaces with dry gauze rather than to irrigate.

Many surgeons wire the fragments together but there is a growing tendency to trust entirely to absorbable sutures properly placed in the torn edges of the fibro-periosteal capsule, for retaining the fragments in apposition sufficiently to insure bony union.

I confess that I have more confidence in the success of the operation if the bony fragments are properly wired together, and there is little objection to the persistence of a wire suture properly placed in the anterior shell of the patella.

Two wires should be passed through drilled holes in the anterior shell of the bone. It is not necessary that they penetrate deeply and they must not invade the joint. The torn shreds of fibro-periosteum should be carefully removed from the opposed surfaces to permit accurate coaptation of the fragments.

The repair of the capsule and accessory extensor aponeurosis should be done with an absorbable suture. It is of the utmost importance that this suturing be properly done.

The institution of passive motion at as early a date as possible, massage and careful use of the knee are of the greatest importance in the after

care.

The following is a report of a case that, so far as I have been able to ascertain, stands alone in the history of patellar fractures.

Mrs. M., 37 years of age. Mother of two children.

Personal history: unusually void of illness. Mother died of tubercular peritonitis.

Jan. 25, 1909, in descending a doorstep, her right ankle turned. She made a violent effort to avoid falling, felt a sudden pain in the right knee and fell to the ground. Within a few minutes I saw the patient and found a transverse fracture of the right patella.

Four hours after the injury, the open operation was done. A semilunar incision was made with convexity downward. The fracture was slightly below the middle line and horizontal, with one inch separation of the fragments. The blood clots were sponged out; torn, fringed edges of the fibro-periosteum lifted from the broken surfaces and the fragments drawn together with silver wire passed through drilled holes.

Chromatized catgut was used in repairing the capsule and aponeurosis, and subcutaneous catgut in closing the wound.

A plaster cast was put on from ankle to hip. Knee was flexed after five weeks and patient wore crutches which were discarded April 15.

Flexion was practically perfect and patient was soon able to walk with but little difficulty. July 6, 1909, while at a summer camp, I saw the patient slip on a wet board and sit down.

On examination I found that she had not only sustained a refracture of the right patella but also had fractured the left one.

Nine hours after the accident, both bones were operated on by the open method.

The right patella was broken at the junction of the middle and lower thirds, slightly below the former fracture, and somewhat obliquely, so that

established your motion, and at the best you can do all of your cases will not come out perfect. There is something still to be considered in the fracture of the patella, which sometime some man like Dr. Barcus will suggest to us.

SKETCHES OF THE MEDICAL HISTORY OF INDIANA

G. W. H. KEMPER, M.D.,

MUNCIE, IND.

(Continued from page 450.)

SOME OF THE EARLY PRACTITIONERS OF
GIBSON COUNTY

Dr. William W. Blair of Princeton, a personal friend of many years standing, has kindly furnished me the following notes. Dr. Blair began practice in Princeton in the year 1850 and has continued up to the present date, and has personally known nearly all of the practitioners of Gibson county:

Fifty or sixty years ago it would have been much easier to gather information in regard to the early history of Gibson county, than at the present day, for at that time there were quite a number of the first settlers of this county who could have given the names of all who had been practitioners in this vicinity from about the year 1805.

Among the pioneers there were two women who were perhaps as well known in the obstetric line as any two persons in the county. Mrs. John Severn, who with her husband settled on Patoka River, three miles northeast of Princeton when this country was inhabited mostly by Indians and wild animals, was the first practicing midwife. I have often talked with her daughter, Mrs. William Leathers-who was born, lived and died on the same spot of ground— about her mother's early experience.

There were neither bridges nor ferries on Patoka River and when "Old Granny Severn," as she was familiarly named, had a call to the other side of the river-should it be too deep to "ford" she would mount her horse and "swim" the river, no matter what the temperature or condition of the stream. She continued her work up to the time of her death, which occurred perhaps between the years 1835 and 1840.

The other midwife was Mrs. Rev. John Kell, who settled here in 1816. Just how soon she began her work in that line I am unable to say, but it was at a very early day, and she continued for a number of years after I came to Princeton;

indeed, till the feebleness of age laid her aside. She died in 1857 or 1858.

For a few years after white people began to settle in this locality, there is no record now accessible of any physician having located here, Vincennes, 27 miles north, being the nearest point where medical assistance could be obtained.

Drs. Casey, Charles Fullerton and Robert Stockwell were among the earliest practitioners to locate in this county. A few years later, Drs. Maddox and Kell were added to the number, but there is no available history as to the exact time of their location.

Dr. William Curl, a graduate of the University of Virginia, was the first medical graduate to practice in Gibson county, having settled in Princeton in 1832. He died in March, 1842, from pneumonia, at the age of 39 years.

Dr. I. I. Pennington (1805-1897) was practicing here in 1850, but how long before that time I am unable to say. Remained until about 1865.

Dr. George B. Graff, educated in Baltimore, settled here in 1843 and removed to Omaha, Neb., about 1862. He died about 1895.

Dr. James C. Patten graduated at Evansville and began practice in this county in 1849. He died in 1903. He served as assistant surgeon Fifty-Eighth Indiana Regiment during Sherman's march to the sea.

The names of a number of other deceased physicians of Gibson county have already been reported in the list heretofore published in your records, and need not be mentioned here.

SUPPLEMENTAL TO PHYSICIANS OF JACKSON COUNTY

Dr. A. G. Osterman of Seymour has furnished me some additional history of the early physicians of Jackson county (see p. 138).

Among the earlier physicians was Dr. John Tipton Shields, born in 1818. He located at North Vernon, where he practiced for a few years, then removed to Jackson county, where he practiced until the time of his death, Jan. 13, 1907. Dr. William Bracken practiced a short time at Reddington (1837). Drs. David and William Vanoose (Vanuise) practiced at Rockford in the early thirties. Among other physicians who located there were Drs. Crippen, Wiles, Batman, Lime, Woodward, Hagen, Brandt, Williamson, and Hillis. Dr. James H. Green was born in Jefferson county Dec. 19, 1824, and died March 17, 1901. Dr. Jasper R. Monroe was born in Kentucky in 1847. He practiced at Rockford and Seymour up to the time of his