Note 12-inch rule in the bowl.

the series to the pestles and mortars in an upto-date pharmacy of the twentieth century.

The most ancient stones used for comminution do not distinguish between pestle and mortar, but the two pieces were interchangeable.

1. Plate II, Figure 3.

of medicine, consisting of incantations and mysticism, then the use of therapeutic agents. In time, this called for the preparation of medicines. The pestle and mortars used for culinary purposes, no doubt, alternately served in

2. Plate I, Figure 2.

With the advent of the white man, the Indian quickly gave up the use of flint knives and arrows, substituting them with steel and iron, obtained in trade and barter. The pestle and mortar were not so easily discarded. The white man had iron and brass mortars to offer, but the Indians looked on these more as a novelty than something to be accepted as an article of utility. Thus, the Indians continued to use stone pestles and mortars as long as they remained in this section of the country.

It is interesting to note that stone pestles and mortars of crude form are still in use among Caucasian people. I have a stone pestle and mortar which a medical friend obtained from a drug store in Monterey, Mexico. It was not a relic, but a utensil of every-day use.

Some of the mortars for domestic purposes were very large and not infrequently were the excavations made in large rocks occasionally so situated that they were protected by overhanging ledges. The mortars for pharmaceutical use were similar in size and probably shaped with greater care. They were made from any convenient kind of rock.

This collection of a half a dozen pharmaceutical mortars from Missouri will give some idea of the shapes and material. The study of pestles and mortars in general is a subject too broad for consideration on this occasion.

Some mortars were used for the manufacture and mixing of paints, so the cosmetic department of a modern drug store is a direct inheritance from the aborigines.

I suggest that the pharmacists of Missouri start a collection of pestles and mortars found in the state, presenting the same to the Missouri Pharmaceutical Association for exhibition with other historical matter in charge of the association historian. If each pharmacist in Missouri will let it be known through local papers that such a collection is in preparation and that due credit will be given to each contributor, I am confident that we can have a very interesting collection on display at our 1915 meeting. I urge those who take part in this work to see to it that a careful record is made of when, where and how each specimen was found, whether on an old village site, in an ordinary grave, in a mound, or in an open field. Such information is as valuable in archaeological work as is the date of a Pharmacopoeia in a reference library.

2342 Albion Place.

THE MO. PH. TRAVELERS' A. OFFICERS, 1914-15

J. J. Murphy, St. Louis, president; Percy R. Hoad, Kansas City, first vice-president; Schooling Chaplin, Kansas City, second vice-president; Frank Klein St. Louis, third vice-president; Bob Adelsperger, Kansas City, secretary; Charles Wagner, St. Louis, assistant secretary; Dan Liddy, Kansas City, treasurer; George Bennett, St. Louis, chairman of the Council.

3. Plate II, Figure 4. 4. Plate II, Figure 1

FRACTURE OF THE PATELLA AND ITS TREATMENT *

T. C. BOULWARE, M.D., BUTLER, MO.

The patella, as is well known to the profession at least, is a small, flat, triangular lensshaped bone, situated in the front of the knee in the tendon of the quadriceps extensor femoris muscle, consisting of dense cancellous tissue. This bone commences its development about the third year, previous to which it is of cartilaginous nature.

From external violence or muscular action this bone is occasionally fractured, the lines of which are either transverse, oblique or vertical. The transverse fracture is caused by a fall in while the body is thrown suddenly and forcibly which the leg is strongly flexed upon the thigh, backward, thereby causing powerful tension upon, and stretching of, the extensor muscles. The line of fracture in this case usually occurs above the middle of the bone. The other violence. A real fracture of the patella may be varieties of fracture are caused by external easily detected by the following symptoms.

SYMPTOMS

Pain in the knee and disability; partial or complete loss of power or inability in the extension of the leg. The patient may be unable to rise, or if he can stand, he will be unable to move, except backward, and then only by dragging the foot of the injured limb. A patient is frequently unable to raise the heel from the bed when lying upon his back. In transverse fracture the symptoms are usually well marked. The nature of the injury is at once detectable by the noticeable change in the contour of the knee, by inability to extend the limb and by the displacement of the upper fragment. Should the patient attempt to get up and walk, he will almost surely fall, from his inability to extend the leg and support the weight of the body upon. it.

The displacement is usually considerable, the superior fragment being drawn upward upon the fore part of the thigh by the extensor muscles, and the distance between the fragments is always increased by bending the leg. The front of the knee has a flattened appearance, and by passing the finger over it, its point will sink down abruptly, apparently into the joint. The lower fragment is stationary but the upper one is easily moved. If some time has elapsed since the occurrence of the fracture, there may be considerable swelling in the parts, due to the effusion of synovial fluid, and occasionally a considerable quantity of blood is

*Read in the General Session of the Missouri State Medical Association, at the Fifty-Seventh Annual Meeting held at Joplin, May 12-14, 1914.

poured into the joint; especially is this the case where the fracture has been caused by external violence.

The treatment of transverse fracture is attended with serious difficulty, first on account of pressure from the accumulation of synovial fluid, and secondly, on account of the difficulty experienced in controlling the action of the extensor muscles, the constant tendency of which, especially during the first six or eight days, is to draw the superior fragment upwards, away from the lower. To counteract this tendency, therefore, is of great importance. For this purpose numerous contrivances have been used by the profession to keep the fragments together, in order to secure bony union. So So far, however, none have proved satisfactory in all cases.

Both practice and observation lead me to believe that the best results are obtained by the use of the subcutaneous silver wire suture through the tendon of the quadriceps and the ligamentum patellae, which method and operation may be described as follows:

After thorough antiseptic preparation of the limb and instruments, a 5 per cent. solution of cocain is injected in the skin at the four corners of the patella; then an incision or puncture is made deeply through the skin at each place where the cocain was injected. A strong silver wire suture is passed by means of a long halfcurved Hagedorn needle, from one lower incision to the other, through the ligamentum patellae, then in again at the point of exit and upward along the edge of the patella and under the skin to the upper puncture on the same side, and the wire is drawn until it disappears at the lower incision. Then the needle is introduced at the place of exit and passed transversely through the tendon of the quadriceps to the upper puncture on the opposite side; then the wire is drawn until it disappears at the upper puncture on opposite side; the needle is again introduced at place of exit at upper puncture and passed by side of patella under the skin to point of beginning. The fragments are drawn together with tenaculum inserted above and below the suture. The suture is now drawn tight and the ends of the wire twisted, cut off short and tucked back under the skin and pressed up smartly against the wire by side of the patella. Then apply antiseptic dressing and posterior splint.

After application of the suture the leg should be maintained steadily and faithfully in a complete state of extension, the thigh being flexed at the same time upon the pelvis, and the body kept in a semi-erect posture, as in this manner the extensor muscles are thoroughly and effectually relaxed. Perhaps the most efficient and successful arrangement for insuring this position of the limb is a strong, well-padded tin or wire case, long enough to reach from the middle

of the thigh to the corresponding point of the leg, a bandage having previously been applied from the toes upward and another from the groin downward. The dressing is now completed by the application of a long, thick and rather narrow compress, extending around the upper border of the patella and confined by the two bandages, passed around the joint in the form of the figure 8.

Managed and treated as above indicated, it is scarcely possible for the fracture to suffer the slightest displacement, or to conceive of anything that is better calculated to secure the end in view. At the expiration of four weeks the tin or wire case may be taken off and substituted by a leather splint and the patient may walk with crutches. The leg should in no case be used for the ordinary purpose of progression without the leather splint, for a period of from three to four months; and especial care must be observed not to flex the knee rudely or suddenly for a long time.

In the treatment of fracture of the patella, undoubtedly the greatest trouble lies in securing bony union, and this cannot be accomplished if the fragments are allowed to separate. If the fragments can be kept in apposition, ligamentous union is avoided. Many methods have been tried to keep the fragments securely together until union takes place, but the great majority of them have proved disappointing to the surgeon, as bony union was not the result. It is well known that if any bone is broken and the broken surfaces are put together properly and securely and firmly kept together for a certain length of time, a bony union is the result, and of course this holds good with the patella as with other fractured bones. The patella being a sesamoid bone, and situated in a tendon, has to contend with the contraction of the muscles. This is especially the case with the upper fragment. The contraction of the quadriceps muscle is so great that the appliances in most cases were unsuccessful in preventing the quadriceps muscle from drawing the upper fragment from the lower one, in which case the space between the two fragments becomes filled with ligament instead of bone. Bandages and splints alone, it is clearly shown, are inadequate to hold these fragments together in a manner to insure good bony union.

In some cases, incisions have been made and holes drilled in the fragments which have thus been wired together with fairly good results. But in this operation we expose the joint to inflammation and frequently have as a result ankylosis of the joint, in which case septic infection may set in and cause complications and trouble, which in some cases may lead even to the death of the patient. A fact which is admitted by all surgeons is that as a general rule it is not safe to make a compound fracture of a simple one.

DACRYOCYSTITIS, CAUSED BY A MEMBRANOUS CLOSURE OF THE NASAL DUCT *

MEYER WIENER, M.D.

AND

Wм. E. SAUER, M.D.

ST. LOUIS

The importance of insisting on a thorough and careful examination of the nasal end of the

tear duct is emphasized by the cases here reported. I well know that the thought is ever uppermost with the majority of practising ophthalmologists of the existence of a close relationship between lachrymal obstructions and inflammation of the nasal mucous membrane, but I also believe as the appended cases will show, that sufficient care is not always taken in determining the exact cause of obstruction of the tear duct.

CASE 1.-Mrs. A. D., 70 years of age, native American, consulted me on Oct. 19, 1905, for a mucocele of the right sac, which she stated had been present for more than a year. Previous to that, however, she had been troubled with tearing for a period of several years. She had consulted several ophthalmologists, had been subjected to numerous probings and washings of the sac with little or no benefit. She insisted that she had no nasal catarrh, was not subject to colds and demonstrated that she could easily breathe through either nostril. I washed out the sac but was unable to

force any fluid through the nose, the solution regurgitating through the upper punctum. A No. 6 Bowman probe was easily passed through the duct to the nose.

It was with difficulty that she was persuaded to have an examination of the nose made; the report showed, however, no abnormality of the nasal cavity. At the instance of Dr. Sauer, another examination was made at his office with the probe introduced into the nose. A membranous obstruction prevented the probe point from entering the nasal cavity, although it could be distinctly felt and seen through this thin membranous obstruction. On October 26 the obstruction removed by Dr. Sauer, after which fluid readily passed through the nose and the mucocele permanently disappeared. This patient was last seen by me Jan. 30, 1911, and was at that time free from any apparent trouble with the lachrymal apparatus.

was

CASE 2.-Mrs. B. O., 50 years of age, native German, consulted me July 10, 1913, suffering with chronic dacryocystitis of the right sac. She had had many months of treatment by various ophthalmologists, but had given up in despair, and had had no treatment for

eighteen months previous to my examination. The last the passing of Bowman probes. The physician had sent her to a rhinologist, but the report came to him that the nose was in perfect condition. I also experienced some difficulty in having another examination made in this case, but succeeded in persuading the patient to be examined with the introduced probe, which examination was made Aug. 1, 1913. A No. 4 Bowman probe slipped easily down into the nose. Examination of the nose showed that here also the free exit of the probe was prevented by the presence of a thin membrane covering the opening of the duct; this obstruction was slit on August 14, after which time the pus from the sac drained through the nose. This

treatment had consisted of expressing the contents and

opening soon closed, however, necessitating an excision of the membrane about four weeks later. The patient has been free from accumulation of pus in the sac and also from excessive tearing for the last month.

I wish to lay particular stress upon the importance of the nasal examination being made with the probe being introduced. This can be done by the ophthalmologist himself, or by the nose specialist if he is practised in the art. And there are some who are quite proficient.

Schweinitz is the only authority that I have In a search through the literature, de

been able to find who described a similar condi

tion and emphasizes the necessity of exposing

the lower entrance of the nasal duct into the inferior meatus by means of the nasal speculum, after the probe had been introduced.

BY DR. SAUER

As stated by Dr. Wiener a pathological condition of the lachrymal canal may exist at its nasal orifice which cannot be detected by the ordinary methods of rhinoscopic examination. The opening of the duct is high up under the inferior turbinate and can be seen only with a Holmes' pharyngoscope, or when a part of the turbinate is removed. It is, therefore, necessary to pass a Bowman probe from above in order to locate the point of obstruction. In the cases reported by Dr. Wiener this was done. A part of the inferior turbinate was removed. The end of the probe was then located in a pouch of mucous membrane. The movements of the probe within the sac could be seen through the nose. The sac was then removed and the probe passed readily into the nose. A few probings were required to maintain this opening.

At various times attempts have been made to probe the nasal duct from its nasal orifice. La Forrest made the first attempt in 1730, but owing to the short distance between the opening of the duct and the floor of the nose, only a small portion of the canal could be reached. This method had been given up until Polyak resurrected it in 1902. He had a number of probes constructed with which he claimed to be able to dilate the lower portion of the canal, and reports three cases in which he succeeded in curing the epiphora. As far as I was able to learn, no one adopted his method. Caldwell made the first attempt to open the nasal duct through the nose in 1893.

In 1901 Passow described an operation in which after introducing a Bowman probe from the lower punctum as far as possible, he introduced a punch forceps in the nose and removed the anterior end of the turbinate as well as the nasal wall of the lachrymal duct, until he reached the probe. He reports a number of successful cases. Eight years ago, Hyman of Berlin advocated fracturing and turning up the inferior turbinate in those cases where the