an index. Each subject, whether it refers to a matter of practice or surgery, takes its place alphabetically in the book. The diagnosis and treatment of diseases is in every case the chief consideration, though a sufficiently extensive consideration is given to etiology, etc. This work is rich in valuable information and unexcelled as a ready reference book. "The Journal of Surgical Technology" is the title of a new periodical to be published monthly, beginning July 1, 1900. It will be devoted to the consideration of the technique of surgical procedures, at a subscription price of $1.00 a year. Valuable premiums are offered with the first subscriptions. Address the Technique Publishing Co., 404 East 14th St., New York City, N. Y., for sample copy. PERSONAL. ONE THING TO REMEMBER is that Dr. Givens' Sanitarium at Stamford, Conn., is a good place to send patients who have nervous or mild mental diseases, or who need special treatment for drug or alcoholic addictions. The location is on a hill overlooking Long Island Sound, and is one hour's ride from New York, with forty-two trains. each way daily. The sanitarium is arranged on the cottage plan, and is homelike, cheerful, and pleasant. The rest treatment, massage, baths, electricity, faradic, galvanic, and static, are utilized. This is a scientific, up-to-date institution. DR. HELEN L. F. WRIGHT, class of '81, Boston University School of Medicine, will resume practice on or about October 1, at No. 201 Clarendon Street, Boston. TO LET. A fully appointed office, including telephone. and attendance, in a prominent location on Boylston Street, near Copley Square, for morning hours. Address "V. Y. X.," care of Otis Clapp & Son, 10 Park Square, Boston. DR. LUCILLE A. JAMES, class of '97, Boston University School of Medicine, has removed her office from 222 West Newton Street, Boston, to 84 Dudley Street, Roxbury. MEDICAL GAZETTE No. 10. OCTOBER, 1900. Vol. XXXV. COMMUNICATIONS. REPORT OF TWO CASES. First, an Old Fracture of the Patella. Second, a BY WINFIELD SMITH, M.D. My reason for calling your attention to case one is twofold. First, I wish to demonstrate the proposition that operation and wiring of the patella is the best treatment in the ordinary case, and second that the complications of an old case must be many and unusual to prevent a good result from operation. It is astonishing to the surgeon who has wired patella as a routine practice to witness the wide diversity of opinion regarding the efficacy of the operation, and I would call your attention particularly to a paper by Dr. Charles A. Powers in the Annals of Surgery for July, 1898. Dr. Powers addressed letters to the members of the New York Surgical Society and of the Philadelphia Academy of Surgery asking as to the advisability of operating on recent simple fractures, the operation preferred, the number of cases operated with results, and the time at which, in average cases, a patient could resume daily life either with or without operation. Ninety answers were received from surgeons from all over the country, and the diversity of opinions and the differences in the methods of treatment is nothing less than confusing. The vast majority of the surgeons replying advised distinctly against operation, and the opinions expressed by two prominent surgeons of this city may be cited as showing what dangers are supposed to lurk in the operative treatment of this troublesome fracture. Dr. D. W. Cheever does not beVOL. XXXV. - No. 10. 473 lieve it wise to resort to operative interference in any case of recent simple fracture of the patella, and thinks the results of non-operative treatment in ordinary cases sufficiently good to warrant a continuance of this form of management. The non-operative cases resume daily life in about three months, patients wearing a guard splint. Dr. G. W. Gay would operate in young or middle-aged patients who are in good health and obliged to earn a living. Has operated on several cases with satisfactory results. Both non-operated cases and those submitted to operation resume daily life at the end of three or four months. "I give you my conclusions based upon a moderate experience and a larger observation. It is not proved to It is not proved to my satisfaction that the operative cases are ultimately any better off than are those not subjected to operation. There are good and bad results from both methods of treatment. It is a safe operation, and the immediate result is first class in the large majority of cases, even if there be some suppuration, though I have never had infection. I have seen the fragments pulled apart at the end of four months, and the fracture do well under a second wiring." Many other surgeons with wide experience in these cases, in fact the majority, it may be said, of those answering the questions, would use the posterior splint, adhesive strips, and even in many cases Malgaigne's hooks, the latter of which would seem to me little less than a form of barbarism. Dr. C. K. Briddon would operate only in cases in which the distension of the joint interferes with the reasonable approximation of the surfaces. Dr. O. H. Allis would operate in cases in which there is comminution with hemorrhage into the joint, also in single fractures with wide separation of the fragments. In rebuttal of this, I wish to go on record as advising the operation in fairly healthy patients in every case of recent simple fracture of the patella in patients under fifty years of age. I do not believe that any one can tell when there is not effusion or hemorrhage into the joint, and have found invariably that the joint is filled with clot and blood in every recent case in which I have performed the operation. There is no danger from sepsis at all commensurate with the discomfort and loss of general health which necessarily follows the longcontinued confinement in bed, which is incident to the old method of treatment. Patients get about in a month or shortly after, and it seems to me that the bones are stronger and less liable to fracture from the presence of the wire with which they are co-aptated. June 5, 1899. Case I. Mrs. G., aged twenty-five. On February 15, 1898, this patient slipped on the ice and fractured the right patella. There was a good deal of swelling and effusion, and the treatment consisted of strapping the fragments together as well as possible with adhesive plaster. In six days this dressing was removed and a plaster bandage applied, which, with the exception of three re-applications of the bandage, was kept on for thirteen weeks. After this confinement she began to get about on crutches until the second week in August, when she began to have more or less discomfort in the knee. The last day of September, 1898, she fell down stairs and fractured the band which held the fragments. Another plaster bandage was applied and similar treatment continued. It was then discovered that there was a wide separation of the fragments, and a thin band of fibrous tissue was the only connection between them. The latter part of October or first of November, the leg was useless, as extension of the lower leg was impossible. An upright iron bar, reaching from the right side of the waist to the sole of her boot, was then applied and secured about the waist by a padded belt, and the means of locomotion were crutches and the other leg. On June 5, the separation of the fragments was over two inches, and I advised operation. On July 20, 1899, the patient was operated on at the Massachusetts Homœopathic Hospital. The usual curved incision was made from one condyle of the femur to the other, the convexity of the curve being downward, and its lower margin about opposite the ligamentum patella. The flap was reflected and the fibrous tissue intervening between the fragments was entirely removed, thus opening the joint. The fractured ends of the bone were sawn through horizontally for better adaptation, but it was found that the fragments could not be approximated nearer than one inch. The flap was reflected still more and the quadriceps extensor tendon was cut transversely down to the bone about two inches and a half above the upper fragment. This allowed the fragments to come together, except for half an inch, and close approximation was not possible until the ligamentum patella was cut through in its central portion down to the tubercle of the tibia. A large silver wire was then passed transversely through the upper fragment, and back in a similar manner through the lower. This brought the fragments in apposition and held them firmly together. The recovery was uneventful, the patient leaving the hospital August 25, 1899, since which time, although using extreme care to prevent further injury to the patella, she has been able to walk with ease and comfort. Case 2. This case is reported for three reasons, first, on account of the unusual symptoms and site of the disease; second, on account of the difficulties surrounding the diagnosis from the pathologist's standpoint; and third, from the excellent results following the application of an appliance to take the place of the part removed. This patient, Mr. L., aged forty-five, had been suffering for a long time from a nervous disorder which was characterized by neurasthenia accompanied by marked aphasia. He came under Dr. Colby's care after having been under treatment by an eminent surgeon in Philadelphia. Dr. Colby sent him into the country for a few weeks, and after his return he came under my charge as a surgical case, on account of marked swelling in the right ramus of the lower jaw, and a sinus in the place of the right inferior wisdom tooth. This sinus was curetted at the hospital early in July, 1899, and this was followed later by cocainization and removal of a small bit of the mucous membrane and sub-mucous tis sue about the margin of the sinus. Several pathologists were |