with salicylic acid dressing, and of M. Guérin with carbolized raw cotton, and their personal experience with the several antiseptic methods, are disposed to attribute the good results mainly to the series of wholesome precautions above enumerated. So, likewise, in regard to the open treatment. Examples multiply of the favorable results attending this method when instituted with the rigorous adhesion and minute attention to the rational principles and salutary precautions on which all surgeons are agreed, and which have been so well taught us by Hunter, and John Bell, and Liston, and Syme, and Professor Spence in his sound address at the forty-third meeting of the British Medical Association.

PROCEEDINGS OF THE BOSTON SOCIETY FOR MEDICAL IMPROVEMENT.

E. G. CUTLER, M. D., SECRETARY.

66

JANUARY 14, 1878. Fractured Patella. DR. JACKSON showed the specimens, and reported the case. The patient was a practicing physician, fiftyeight years of age, and broke the right patella between fifteen and sixteen years before his death by a fall upon the ice and a direct blow upon the bone. The separation of the fragments was not far from an inch. His brother, who is also a physician, applied two strong bandages, one above and the other below the joint, tied them firmly together, and then placed the limb upon a straight splint with the thigh flexed upon the pelvis. The treatment was continued for some weeks, and with so good result that the patient felt perfectly sure that there was bony union; one of these days," he had often said to Dr. Jackson," you will see that it is so." The union was so very close and firm that after removal, with all the force that could be used, not the slightest motion between the fragments could be felt, and it would have been regarded as a bony union if it had not been either sawed or macerated. Three longitudinal sections, however, were made through the bone, and it was proved, so far as these would show, that at no one point were the fragments united by bone. The union was as close as possible, but by a very dense and fibrous tissue that practically would be quite as serviceable as bone. The patella was considerably elongated, and upon the under surface the cartilage seemed to be as directly continuous between the fragments to the extent of about two lines, as if the bone had never been broken.

A very remarkable peculiarity in the specimen was an extensive and pretty well defined depression of the anterior surface of the bone. It was so marked

1 Among pathologists who have written ably in favor of this view may be mentioned: Massini, Lister's Antiseptischer Verband, in Schweizer Correspondenz-Blatt, 1872, Nos. 15, 16; Schultze, Ueber Lister's Antiseptische Wundbehandlung, in Sammlung klinischer Vorträge, 1873, No. 52, Leipzig.

2 Esmarch (Fr.) (Verbandplatz und Feldlazareth, zweite vermehrte Auflage, Berlin, 1871, S. 55) argues in favor of the open-wound treatment, and denounces the "mechanical manner in which sticking-plaster bandages are employed by many surgeons." And Passavant (G.) (Bemerkungen aus dem Gebiete der Kriegschirurgie, in Berliner klin. Wochenschrift, 1871, No. 3) says that the excellent results of Bartscher's open-wound treatment induced him to imitate this simple method, and declares that he was highly astonished at his own sue

cess.

Dr. Goss (loc. cit., page 77) calls attention to the liability of danger of intermediary and secondary hæmorrhage in the open method from lack of sufficient support to the divided vessels of the wound. Aecidents had actually occurred to Mr. C. De Morgan in cases of amputation of the thigh and extirpation of the mamma in patients treated at the Middlesex Hospital by the open method. (Cases illustrating the Open Treatment of Wounds, in The Lancet, 1874, vol. i., page 570.)

as to attract attention at once, and it was an appearance that Dr. Jackson had never before seen in any specimen, recent or prepared. The fibrous substance over the bone and within the limits of the depressed surface seemed no thicker than elsewhere. As the fracture was the result of direct violence, Dr. Jackson suggested as an explanation of the depression that there may have been, besides the fracture, a crushing down of the cancellated structure, as is sometimes seen in the bodies of the vertebræ in the case of fracture, the injury being so far recovered from, after a period of fifteen years, that no trace is to be seen of it on section of the bone.

About six months before the patient's death he broke the left patella, and undoubtedly by muscular action, as he fell when going down-stairs in consequence of catching the heel of his boot. In this case the fragments are strongly united by fibrous substance, but with a separation of about one half of an inch. Dr. Jackson showed a patella from the society's museum, in which there was strong bony union after a partially transverse fracture. He also referred to a specimen that he had recently seen in the Army Medical Museum, in Washington, of complete transverse fracture, through about the middle of the bone, with firm bony union. In the museum of the College of Physicians, in Philadelphia, there are also two specimens, one in which the union is by solid bone, but not complete or continuous. The other appears to have had essentially a similar result, but requires a further examination. In the Army Museum there is also a very fine specimen of stellate fracture, with strong bony union. All of these last had been macerated.

DR. HODGES, in commenting on the specimens, said with regard to the first that, though the explanation given by Dr. Jackson might be correct, he was inclined to the belief that there had been a growth of new bone between the fragments. He founded his belief on the following facts: When the bone is fractured it cracks open, and there is a tilting up of the fragments. In the specimen referred to the anterior or superficial surface of the patella showed that the gap between the two fragments had been greater than on the posterior or deep surface towards the joint. The greater extent of the anterior surface demonstrated the existence of the usual tilting up of the fragments, while the length of the bone itself, which was much greater than a normal patella, indicated that there had been a very considerable filling in of new bone tissue between the fragments. In this case the increase in length of the bone was due apparently to an increase of bone outside the articular surface. He would confess, however, that on his own theory it was hard to explain why the union by bone had not been entire. The second specimen, where the treatment seems to have been the same, shows that chance is a great factor in the result.

DR. BIGELOW coincided with the view entertained by Dr. Hodges regarding the first specimen.

DR. DAMON considered that the stellate form of fracture gave rise to less deformity than the transverse; he mentioned a case in point, where fracture occurred, crepitus was found, and recovery without deformity resulted.

DR. JACKSON said that there was a patella in the cabinet of the society which presented the stellate form of fracture, and in which there was no deformity.

JANUARY 28, 1878. DR. WILLIAMS read a paper on Eserine and Pilocarpine in the Treatment of Eye Disease, which appeared in full in the JOURNAL of March 28, 1878. Morphia Habit. DR. LYMAN presented the following case as an oral communication. Mrs. W., aged forty-seven, married, had consulted him on January 4, 1878, and gave the following history: At eighteen years of age, under the advice of her physician, she began to take small doses of morphia for some obscure pains about the lumbar region and kidneys. She continued this unadvisedly, gradually increasing the quantity until she was twenty-four, and without intermission, except that at one time for a period of three months it was discontinued, but the craving became so incessant and tormenting that she felt compelled to resume it. Four years since she tried a specialist in Indiana, whose remedy she was assured contained no morphia, but suspecting from its effect that this statement was not true she submitted the remedy to Professor Wood, of the Harvard Medical School, for analysis, who fully confirmed the accuracy of her suspicions. With these exceptions she has since the age of twentyfour averaged daily the same amount that she takes at present. Her husband weighs out each morning four powders of four grains each, the whole sixteen grains being taken usually before midday. Occasionally she takes one half, that is, eight grains at a single dose in the morning, and the remaining eight sometimes separately and sometimes together during the day. These slight variations in the method and hours of taking are governed by her own feelings. Sometimes she has a morbid fear, an indefinable dread," of sleep, and passes several nights in succession without lying down. She complains only of restlessness and an inability for quiet occupation, some excitement being necessary to prevent drowsiness. Sometimes she drops asleep suddenly when in the horse-cars, or at the theatre, or at her own table, subjecting herself to much mortification. Otherwise she thinks that no one would suspect the habit. She is now in good flesh, though a small eater, and with indifferent appetite. General appearance decidedly anæmic; no disturbance of renal or cardiac functions; when asleep is tranquil, and without dreams; bowels regular with assistance of injection; and the catamenia were always regular until the menopause, a year ago.

Mrs. W. readily consented to a reduction of the dose to twelve grains daily, equivalent to a diminution of one fourth.

January 27th she reported that she had persevered with the reduced dose without any excessive inconvenience, and was to try a farther reduction of two grains daily. In view of the age of the patient, the long continuance of the habit (more than half her life), and the comparatively trifling effect upon her general physical and mental condition, Dr. Lyman thought it unwise, and indeed she would not consent, to make any attempt at sudden total abstinence, feeling confident that it would result in more injury than benefit.

Dr. Lyman also mentioned another case, in which a young woman, having received subcutaneous injections of morphia, acquired the habit of injecting herself. He brought about a discontinuance of the practice by advising the ordinary dose to be diluted one half with water, which was finally reduced to injections of water alone, which in turn was diminished in quantity, and finally stopped entirely.

DR. MINOT spoke of a case of the morphia habit in a woman. sent the patient to Dr. Day, who had stopped the morphia at once. lieved the patient never resumed the habit.

He had

It is be

DR. LYMAN mentioned a case he had previously reported to the society, in which a man had acquired the habit of drinking a wineglass of laudanum three or four times a day. In treating him he had never been able to get below a teaspoonful dose, which was still continued.

DR. WILLIAMS had seen a case of the opium habit consequent on an exhibition of the drug in repeated attacks of iritis. The habit was so confirmed that the patient had consulted him with the idea of having the eye removed, thinking that this might aid him in breaking off the habit. The operation was contra-advised from lack of evidence and other reasons, and the patient was cautioned to leave off the opium by the gradual method; this course was pursued, and he is now cured. The method of administration had been subcutaneous.

Caries of the Temporal Bone. DR. J. O. GREEN related the following case, and illustrated his remarks by a prepared specimen: A boy, aged eleven years, during an entire night last spring suffered from earache. The pain was followed by a slight discharge, which has continued ever since. When presented for examination the membrana tympani was healthy; just outside the tympanum and above there was a small mass of granulations, which were cauterized with good effect. The probe showed a small cavity at the seat of the former granulations, three millimetres long and one and a half wide, just outside the drum, and in it were some polypi, which were removed. The anatomy of the parts showed that but a very thin layer of bone existed between the bottom of the cavity and the brain. There had been no subjective noises and no trouble with the hearing; the caries had proceeded without symptoms with the exception of the slight discharge mentioned. The risk of such a case is evident.

New Apparatus for Fractures of the Leg.- DR. T. B. CURTIS showed the apparatus, a full description of which, accompanied by a plate, will appear in the JOURNAL shortly.

FEBRUARY 11, 1878. Aortic Aneurism. Case reported by DR. LYMAN, who also showed the specimen. E. A. S., a mariner, aged forty-eight, married, entered the City Hospital August 22, 1877. The patient then said he had been in good health until fifteen months before, when he was attacked with vomiting and irregular action of the bowels, diarrhoea and constipation alternating. He said that he had had a cough, with viscid sputa, for the same time, often so severe as to disturb his sleep, and occasionally resulting in vomiting. He had worked for some years in a grain elevator, where there was much dust; more recently he went to sea for two months, which relieved his cough. He complained at the time of his entrance to the hospital of frequent palpitation, with severe pain in the cardiac region, left shoulder, and arm. A year ago he first noticed a pulsating spot over the third rib below the middle of the left clavicle; this impulse is now very manifest over a space three inches by two. There is a loud, well-marked souffle, diminishing in intensity from the base to the apex

of the heart. No perceptible thrill. No difference in pulse of radials. The souffle is distinct in the scapular region, but less so than in front. He was put upon the iodide of potassium, twenty grains daily, and chloral hydrate pro re natâ.

The next day he reported that he had slept better the night before, though the pain in the left shoulder and arm at the time of the visit was more severe. Four days later he was much relieved. He had had but one attack of dyspnoea and palpitation in the past forty-eight hours. Had slept well, and had a good appetite.

September 2d (a week later), the iodide was increased to thirty grains. The cough had begun to be very troublesome and continuous, and for this reason tinctura opii was ordered as occasion required. For the next ten days cough, pain, and restless nights were the chief complaints.

On the 16th the record was as follows: A decided thrill is now perceptible in the tumor. The souffle in the tumor extends to the subclavian of the left side, and is still more extensive on the right side. The pulse in the right radial is now noticed to be sharp, quick, and firm, the pulse in the left being soft and full.

• Respiration normal in right front, obscure in left front, and the same in the back. Bronchophony in the neighborhood of the tumor. He was ordered digitalis and cannabis indica, but they disagreed with him, and he was obliged to resume morphia, as that only gave relief, and from this time it was given freely to relieve his distress.

November 25th, a violent fit of coughing was induced by an attempt to swallow a purgative pill. The patient complained of gastric irritation. For the past ten weeks he had been kept absolutely at rest, generally on his right side, and upon a low diet, with iodide of potassium and tincture of aconite, but the effect in slowing the pulse was never very marked. The 7th of October his pulse was 110, and for a few days it came down, occasionally below 90, but ranging generally from 90 to 100 until his death.

December 9th the gastric irritation had become so prominent that the iodide of potassium and aconite were omitted and not again resumed. He grew slowly but steadily worse, and died of exhaustion on the 12th of January, 1878.

Autopsy, twenty-four hours after death. Both lungs adherent posteriorly; nutmeg appearance of the liver; kidneys, spleen, and intestines normal. The heart was removed and placed in alcohol, and reported on by Dr. Bolles a fortnight later as follows: The tissues are partially shrunken and discolored. Heart as a whole not enlarged, but right ventricle considerably hypertrophied and dilated. Valves of right side normal; left side not hypertrophied, mitral valve normal, aortic valves somewhat stiffened. Immediately above the valves the aorta was dilated to the size of the closed fist, the dilatation extending so high as to include the origin of the innominate artery. The walls of the aneurism were generally thickened, except in one spot posteriorly. Over a large part of its circumference there was a deposition of fibrine in layers varying from one eighth to three quarters of an inch in thickness.

Aneurism of the Arch of the Aorta. DR. LYMAN reported the case at a