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the bed quite freely without disturbing the relations of the bones. The fracture cannot be displaced so long as the extension force is not interrupted, and the extension force cannot be interrupted while the limb remains suspended and the patient remains in bed! Occasionally a patient, after the first two weeks, does venture to get out and sit in a chair near the bed with his limb swinging free; and, startled though the doctor may be to come in and find his patient up in a chair, the fracture, nevertheless, unites without deformity.

The longer the suspension cord-the higher the ceiling, in other words—the better. A long radius means a larger arc of liberty for the patient. In hospital wards with lofty ceilings the screw pulley may be permanently left in place over certain beds for fracture cases. In private houses it is sometimes possible to utilize the well of a staircase for the suspension cord, especially where the ceilings are very low.

Since there is not a great difference in the length of the limb in different persons, it is a good plan to have on hand three Hodgen frames ready to use. These may be made 27 inches, 32 inches, and 36 inches long.

It is hoped that this description will help to increase the popularity of the Hodgen method. There is every reason to believe that it would have become the method of choice long ago if the profession had really grasped the principle involved. John T. Hodgen was a genius in advance of his time. His teaching went over the heads of his contemporaries. His technic was rather too scientific for the minds of his colleagues.

Nowadays much attention is devoted in all lines of operative and therapeutic work to the effort to augment the patient's comfort, and hence his welfare. A more considerate technic is the rule in both medical and surgical progress. If we do not misjudge the trend of practice, Hodgen's suspension will be the method of choice in future for the treatment of fracture of the neck and shaft of the femur. Although fixed extension gives fair results in some hands, elastic suspension will give results at least equally satisfactory in the general run of cases, from the functional as well as the anatomical standpoint. At the same time, Hodgen's suspension vouchsafes an immeasurably greater degree of comfort for the patient than is possible when fixed extension is used.

CHORIONEPITHELIOMA ASSOCIATED WITH SEVERE

INTRAPERITONEAL HEMORRHAGE

BY

THEODORE A. ERCK, M.D.

Associate in Gynecology in the Philadelphia Polyclinic and College for Graduates in Medicine; Associate Surgeon to the Gynæcean Hospital,

AND

GEORGE W. OUTERBRIDGE, M.D.

Out-Patient Surgeon and Pathologist to the Gynæcean Hospital; Assistant Gynæcologist to the Methodist Hospital; Obstetrician to the Maternity Hospital, Philadelphia, Pa.

CHORIONEPITHELIOMA of the uterus is a type of tumor whose occurrence is so regularly accompanied by more or less severe and protracted external hemorrhage from the genitalia that in the absence of this symptom the mind of the physician will hardly be directed even to the possibility of the existence of such a condition. A case which has recently come under our observation, however, illustrates clearly the possibility of the occurrence in the uterine wall of a welldeveloped, malignant chorionepithelioma, without the slightest evidence of external hemorrhage, and since it is not only an example of an extremely unusual mode of development of this tumor, but presents also some features of marked interest from the standpoint of diagnosis and treatment, it seems well worth being placed on record.

In October, 1913, Mrs. P. S., aged 27 years, nullipara, had a miscarriage at about the second month, following which she was curetted at a hospital in this city. As we have subsequently learned, the surgeon at the time commented upon the large amount of material removed from the uterine cavity, and remarked that it was rather suggestive of hydatid mole. So far as we have been able to ascertain, however, none of this tissue was saved or subjected to microscopic examination.

Following the curettement, the patient had a slight amount of irregular bleeding until January, 1914, when the periods for a time became regular, occurring every three weeks. After a normal period

in March, however, irregular bleeding began again, and early in April she consulted a gynæcologist, who suggested a trial of the ordinary styptics, not knowing anything of the previous suspicious history. As only temporary relief was obtained, the following month one of us was consulted (T. A. E.). There were no symptoms present at this time other than the metrorrhagia. Examination showed the uterus slightly retrodisplaced and somewhat larger than normal, but freely movable; both ovaries were enlarged and cystic. Again, in the absence of all knowledge of the antecedent hydatid mole suspicion, ergot and nux vomica were prescribed, following which the patient left town, but reported by letter that her flow had stopped. Menstruation was normal in August, but she went somewhat over time in September, and then had only a slight show; she had morning nausea, and thought herself pregnant. In October she again missed her period, but a few days after the time that it was due she was suddenly seized, while at a hairdresser's, with such violent abdominal pain as to completely prostrate her. She fainted, but did not vomit. The hastilysummoned family physician found her exceedingly weak, with pain in the epigastrium, nausea, and a pulse of 100. Vaginal examination at this time showed the presence of a tender mass in the pelvis, with extreme tenderness and rigidity over the entire abdomen, particularly in the epigastric region. The woman presented every appearance of having had a sudden, severe internal hemorrhage, and, in view of the history and these findings, a diagnosis of ruptured ectopic pregnancy was made. The pulse was rapidly going up and the patient's general condition becoming alarming; she was therefore transferred at once to the Gynæcean Hospital for operation.

Operation (T. A. E.).—Upon opening the abdomen the peritoneal cavity was found filled with a large amount of free and clotted blood, which spurted out under considerable pressure when the peritoneum was first incised. Both ovaries were multicystic and moderately enlarged, the tubes were normal, and the uterus showed the area of perforation described below. A rapid supravaginal hysterectomy was performed, with removal of both tubes and ovaries, the condition of the patient not permitting of any more radical procedure. Under the influence of salt solution intravenously and active stimulation she gradually rallied, but on the following day still had a pulse ranging from 154 to 160, and a hæmoglobin count of 20 per cent. Her con

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FIG. I.-Anterior view of extirpated uterus and appendages. Projecting from the fundus can be seen a nodule of tumor tissue, which has eroded through the serosa, and from which the hemorrhage occurred. Beneath this is a smaller nodule, which has not quite reached the point of erosion.

FIG. 2. The uterus has been opened through the anterior wall. The tumor mass is seen in the fundal portion, but the area of erosion through the serosa is not shown in this view. The uterine cavity and endometrium are entirely uninvolved.

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