broken bones and torn capsule fills the intervening space and distends the joint, if this is opened, with clotted blood. What becomes of this aseptic blood clot? On the same great proven principle of Schede's aseptic blood-clot in bone surgery, it becomes more or less organized into living, fibrous tissue, fixing the joint and surrounding tissues in a condition of more or less rigidity and ankylosis. Ob. viously, the thing to do is to remove both the blood-clot and the capsular fringe. The wonder is not that, by the old method, the joint is more or less impaired, but that it functionates at all. Yet, I repeat, that if one is not a trained aseptician, it is better to accept this result; at least it will not kill the patient from sepsis.

"The simplicity and ease of accomplishment which characterizes the result here presented to you is remarkable. A quarter of a 1 per cent. solution of cocaine was injected before making a transverse skin incision. As the patella lies subcutaneously and its fibrous periosteal capsule is already ruptured from the accident, this skin incision admits one directly to the field of operation. Nothing remains. to be done but to wash away the bloodclots, remove the interposed fringe of capsule, and suture, not the bone, but the capsular rent, as well as any rent extending into the lateral capsular expansion. In a great many cases, contrary to textbook teaching of the present day, the knee-joint is not opened by the accident nor invaded by the operation. This is due to the fact that the closed synovial sac of the joint is frequently reflected from the posterior surface of the patella at or near the median line. Consequently, any fracture below the level of this line of reflection does not enter the general articular cavity. This condition of extra-articular safety I have encountered several times.

"The skin incision being closed, if the work has been done aseptically, there is no swelling, no pain, no fever Beginning about the third week, carefully graduated passive motion, with daily massage, is inaugurated. At the end of the sixth week a perfect cure will result, as exemplified by this case presented to-night.

DR. W. R. TOWNSEND opened the discussion by saying that it is unusual to find a surgeon who never encounters sepsis as a result of his work. All surgeons should be clean, and practically speaking, all are

in a majority of cases, but surgeons have not reached the point of perfect asepsis. Especially in serious cases, such as opening the knee-joint, if an operator can avoid suppuration, so much the better, but there are so many possibilities of infection that he would hesitate before undertaking this operation. The growth of small hospitals throughout the country is very rapid, and he thought that the surgery of the future should be done in such places. He did not believe that a simple result can be counted on in every case of fractured patella by the method advocated by Dr. Bodine, and he said that he had seen some very good results by the old method, and in many instances in which it failed the fault was not due so much to the method as to the operator. Bony union is always better than fibrous union; yet he would hesitate very much in saying that every fractured patella should be treated by the open method.

DR. W. H. LUCKETT said that if every case that was operated on turned out as successfully as Dr. Bodine's case did, he would be inclined to advocate the open method in all instances; but, unfortunately, all surgeons are not aseptic. He did not agree with Dr. Bodine that blood in a synovial cavity goes through the same process or organization as blood in a bone cavity. Here the blood is in contact with a very rapidly absorbing surface, but more often blood exuded into an articular cavity will be absorbed rather than become organized. The most important treatment in connection with fracture of the patella is massage, applied particularly to the quadriceps muscle, and this should be forcible enough to allow relaxation of that muscle and juxtaposition of the fractured fragments of the patella. The bone must. be retained in place by straps and splints. The massage should be done properly by one who thoroughly understands the principles involved. This method was first introduced, he thought, by Dr. Howard

Lilienthal.

DR. W. C. GILDAY said that he had a patient who was treated by the old method, and the result was most unsatisfactory. He had been with Dr. Bodine when he operated on the patient presented this evening, and, having seen the result, he should hereafter treat all his cases in that

manner.

DR. BODINE closed the discussion. He

said, in reply to Dr. Luckett, that he did not mean to imply that every hemorrhage into the knee-joint becomes organized on the principle of Schede's moist blood-clot, but he was quite sure that this hemorrhage into the cavity of the knee and into the tissues surrounding the knee is a cause, in part at least, of the many cases of rigidity or partial ankylosis in fracture of the patella; and, furthermore, he was sure this rigidity is caused by a more or less complete organization of the blood-clot into the living tissue. He had never seen the statement emphasized that in fracture of the patella the general articular cavity is not opened. This statement was based on the fact that twice in his experience he had encountered a condition of an intact synovial membrane beneath the broken fragments. It is a well-known anatomical fsct that the reflection of the synovial membrane on the posterior surface of the patella as high as its middle posterior line frequently occurs, so that all fractures of this bone occurring below the level of this line of reflection would not involve the general synovial cavity of the joint. A knee-joint filled with a blood-clot, even though there is no external wound, may become infected through the medium of the circulation. He believes that the frequent occurrence of synovial osteomyelitis is sufficient proof of this statement. He

had known of occurrences of violent infection within the knee-joint following fracture of the patella when no operation had been attempted. If this infection were due to an external wound in the surface he was unable to find the point of entrance.

Necrosis of the Femur.

DR. W. R. TOWNSEND presented a very interesting specimen of necrosis of the femur, which was sent to him by Dr. Sledge, of Mobile, Alabama. It showed very clearly the dissection of the bone. Whether it was tubercular or specific it was impossible to determine.

A Case of Syphilis.

DR. D. A. SINCLAIR exhibited a man with syphilis. The initial lesion was on the glans penis. He presented large secondary squamous syphilides of the abdomen and back, large condylomata about the anus, and enlarged inguinal and epithrochlear glands. The patient had been seen about a month ago, and had been treated by in

tramuscular injections of salicylates of mercury suspended in liquid benzoinal, having received but three injections, one week apart.

The speaker desired especially to call attention to the method of treatment and the rapid results obtained. The salicylate of mercury is an insoluble preparation, and dose of which is one and a-half grains. On account of its insolubility, it requires five or six days for it to become absorbed, so that the patient receives a regular scientific dose each day. It is non-irritating and does not produce abscesses. The marvelous change seen in this patient's condition was nothing more than one might expect from this form of treatment. In the speaker's opinion the salicylate is superior to the soluble preparations of mercury, and also to the other insoluble mercurials, such as calomel. Hypodermatic medication is better than internal, as it enables the physscian to keep the patient more perfectly under control.

DR. A. R. ROBINSON said that he thought this method of intramuscular injection painful, and not so good as that of taking pills and other internal medicines. It kept the patient constantly running to the doctor.

DR. C. G. CHILD said that he wished to indorse Dr. Sinclair's statements with regard to the efficiency of the subcutaneous injections of salicylate of mercury in the treatment of syphilis, especially in those cases of the squamo-papillomatous variety. He began to use it three years ago in the venereal wards of the City Hospital, using it exclusively in both the male and female wards, and in more than one hundred cases in which there was a total of nearly one thousand injections, not one of the patients showed any bad after-effects either in the way of inflammation, induration or abscess formation. The injections were made in the deep tissues of the buttock and under the scapula. One, or at the most two, injections a week were all that were ever given. In the papular varieties a marked effect was seen in from one to two days after the first injection was given. He had experimented to some extent with the different solutions used as media for the salicylate, and found that the one which gave the most satisfactory results was liquid albolene.

DR. SINCLAIR, in answer to Dr. Robinson's remarks, said that the patient re

ceived an injection but once a week, and that it was not painful. It was less compromising than for a man to be carrying a little box of pills around in his pocket.

Malarial Blood.

DR. F. M. JEFFRIES presented specimens of malarial blood. He said that it might appear as though he owed the society an apology for presenting such an ordinary demonstration as tertian malaria, but there appeared to him a sufficient number of interesting features in connection with the present demonstration to make it more than worth while. Those who are familiar with malaria are aware that that of the tertian type rarely exhibits more than one stage of the cycle in the blood at any one examination. Occasionally, it is true, two stages are found. This occurs when the blood is taken during a paroxysm. In the blood taken at this time parasites at the fully developed stage are observed, together with the younger spore, because of the fact that segmentation does not take place in all of the parasites at the same moment, those which segment at first having sent their spores to invade a new set of red corpuscles. In order that one may be able to demonstrate the entire cycle of tertian parasite, he would be forced to take samples of blood every few hours for forty-eight hours required for its completion. In the specimen shown, which was blood taken at one time from a patient with a paroxysm, he was able to demonstrate practically the entire cycle; that is to say, with the six mounts there were six stages, beginning with the small spore just invading the red corpuscle and ending with the segmenting parasite. When he was taking this blood the patient informed him that he had chills daily. From this history one would be unable to determine as to whether it was of the estivo autumnal or double tertian type. It required the microscope to determine this. Since examining these preparations, he has been undecided as to whether it was a case of double tertian or of triple infection. He did not obtain the patient's history sufficiently to be able to state whether he merely had one paroxysm a day or had an extra third paroxysm.

As regards the staining of the specimens, he had used Goldhorn's method, the steps of which are as follows: Immerse for fifteen seconds in pure methylic alcohol;

wash with water; stain with Goldhorn's poly brown-methylene-blue sixty seconds; wash with water; stain with one-tenth of I per cent. aqueous solution of eosin very briefly; wash with water.

One is permitted a considerable degree of latitude in the use of this stain. He can stain for a short or a long period with the blue, with varying results, all of which are satisfactory, but there is great danger of overstaining with the eosin blue solution. Therefore, it is advisable to wash off the dye as quickly as it is possible to do it.

DR. ALBERT KOHN opened the discussion by saying that, taken in connection with Dr. Jeffries' specimens, the history of this patient was very interesting. He had had a chill each day. One day he had a chill immediately upon Dr. Kohn's arrival, and he sent at once for Dr. Jeffries. Dr. Kohn had left him about five minutes after the latter's departure, and the patient was in a comatose state. How long he remained thus he did not know.

DR. HENRY HEIMAN said that the specimens were of great interest, as they demonstrated the plasmodium in its different stages of development from one single blood examination. The flagella are probably intended to perform the same function as the tail of the spermatozoon-that is to say, they penetrate the cell walls of the red corpuscles and become changed in the further development of the malarial organism. It is very interesting to mention that north of the so-called Mason and Dixon's line, or of Chesapeake Bay, the pernicious or so-called estivo-autumnal type of malarial organisms are seldom found, but in the majority of cases only the tertian type. With regard to the treatment of malaria, he had followed a regular rule for several years. Believing that quinine acts only on the mature parasite, and knowing that the spores at times may remain normal for years in the human economy, it is advisable to administer the drug intermittently in small doses, about five grains three times a day, every four weeks for one year or more, until no further recurrences are noted.

Epithelioma of the Lower Lip; 'Extirpation by Brun's Method.

DR. W. H. LUCKETT exhibited photographs of a case of extensive epithelioma of the lower lip which had been extirpated

and a new lower lip made according to Brun's method. The epithelioma was first removed by means of the Paquelin cautery, thus removing all the infected tissue and leaving a clean surface, which is a prerequisite in a successful plastic operation. The operation itself consists of dissecting two tongue-shaped flaps from each side of the nose, turning them down and sewing them together in position, thus forming the lower lip. The edges of the spore from which they were removed were thus drawn together by sutures. Particular care should be taken to have the flaps large enough and long enough to accommodate themselves to the final contraction, due to cicatrization.

Three Cases of Tetanus.

DR. LUCKETT also reported three cases of tetanus. The first patient was admitted into the Harlem Hospital with a blankcartridge wound of the palm of the left hand. Within ten hours he had developed all the symptoms of a most pronounced case of tetanus. Treatment was by the usual method-potassium bromide, chloral hydrate, hot baths, etc.

The sec

ond case was that of a wound in the palm of the hand from a blank cartridge. Symptoms of tetanus developed on the eighth day-opisthotonos, lockjaw, and local tetanus of the left hand. Treated by injections of the New York Board of Health anti-tetanic serum in extraordinarily large quantities, between the third and fourth lumbar vertebræ into the subarachnoid cavity. After the cerebro spinal fluid had been withdrawn the patient received an injection daily for about ten days, getting from 8 to 10 cc. at each injection, from ten to forty-five minims of cerebro-spinal fluid being withdrawn previous to each injection. From the very start his symptoms improved. The patient was discharged from the hospital cured. The speaker believed this to be the first time that this method was used in this country.

The third case was a more pronounced type of tetanus than the preceding one. It occurred in a boy, nine years old, who jumped over a garden fence and cut his left wrist on the neck of a broken bottle. The wound was sutured at one of the hospitals. On the sixth day the boy developed stiffness of the muscles of the neck, of the abdomen, and of the jaw, in the

order given. He was admitted into the Harlem Hospital, the wound was opened, several particles of dirt were removed therefrom, and the wound was dressed. Very marked symptoms of tetanus were present. This boy, although in appearance much worse than the preceding one, recovered more rapidly under treatment, only five injections being necessary. This was attributed to the fact that preceding each injection, all of the cerebrospinal fluid possible was removed, as much as 560 minims in five days. The patient was discharged cured about two and onehalf weeks after admission. The reason for withdrawing this fluid is on account of its great toxicity, it being much more toxic than the blood of a tetanus patient. These patients, except the first one, received no internal medication whatever.

The paper of the evening was read by Dr. CHARLES GILMORE KERLEY, the subject being

Empyema.

The author began his paper with the statement that empyema is the result of infection of the pleura with pathogenic organisms. A large majority of the cases show that pneumococcus is in the pure culture; the streptococcus and the staphylococcus, alone or in combination with the pneumococcus, are seen less frequently. Tuberculosis is rarely a cause of empyema. The disease is rarely primary, being secondary to pneumonia in fully ninety-five per cent. of cases. The symptomatology varies, depending on the nature and severity of the primary disease. He cautioned against confusing empyema with malaria, typhoid fever, unresolved pneumonia monia and tuberculosis. The average case of empyema following pneumonia he described as follows:

A child has pneumonia; it runs the usual course of fever, respiration, pulse and prostration; after a time, from six to twelve days possibly, an improvement in the symptoms is noticed; the pulse and respiration become slower and the child brighter; the temperature range for twentyfour hours is lower; during the height of the fever it was perhaps from 104° to 105° F.; now it ranges from 100° to 102°, occasionally touching at 99°. Behaving in this way for a few days, it is soon noticed that it is lower in the morning than in the evening, although the evening tem

perature may not be high, perhaps not over 102°, occasionally reaching 1030. The pulse and respiration both remain accelerated and the child coughs. These symptoms may continue for weeks if the true nature of the case is not made out.

Forty-three cases comprise the number seen by the author, in patients from the various walks of life. Some developed under his own observation, and others were first seen after a long illness. In all of the cases there were three symptoms in common-cough, fever (higher in the evening), and accelerated respiration.

Under physical signs, inspection of the chest was referred to as being valuable in that there is a difference of mobility of the two sides; the diseased side rests, the sound side is active. An increase in the measurement of the diseased side is in itself of no diagnostic value. He cited cases in which the sound side was larger. This is apt to be the case when there is a small amount of fluid in the pleural cavity or when absorption has already begun.

Displacement of the apex beat of the heart upward and to the right is one of the most reliable signs of fluid in the left pleural cavity. Under auscultation it is claimed that fluid always produces a deviation from the normal respiratory sounds, but not always the same changes will be observed. There may be bronchial breathing and bronchial voice when the chest is full of fluid, or greatly diminished and weakened breathing and weakened voice sounds when the amount of fluid is small.

Percussion is considered one of the most valuable aids in diagnosing fluid in the pleural cavity. If there is a moderate. amount of fluid, there will be invariably dullness, and if the amount is considerable there will invariably be flatness.

Serum

and pus show the same physical signs. There is but one way to differentiate between serum and pus, and this is in the use of the exploring needle, which should always be used to prove the diagnosis. There is no danger in the use of a sterile needle and a properly prepared skin.

As regards treatment, in a recent case in a child under two years of age, incision under local anesthesia is all that is ordinarily required. In older children or in a prolonged case in a young child, the removal of a portion of a rib under gas anesthesia is best. Irrigation of the pleural cavity is not necessary. The dressing

should be changed once a day, and the tube shortened as the lung expands.

The author concludes as follows: "The disease in every one of the forty-three cases was secondary, and in forty it was secondary to pneumonia. Every child coughed, every one had fever, practically constant, higher in the evening, but rarely going above 103°; every child had accelerated respiration, the chest in each case showing flatness on percussion, and

marked changes from the normal in auscultation. Children in whom the disease had existed longer than a week showed marked emaciation."

DR. ADOLPH BARON opened the discussion by saying that he wanted to mention what Dr. Kerley, in preparing his paper, had probably overlooked, and that was the necessity for making numerous attempts at aspiration, as one frequently does not draw pus at the first attempt, and the reason for that is that the needles used are not of sufficiently large calibre.

DR. HENRY HEIMAN said that it is generally found by bacteriological examinations of the pus in empyema cases that the pneumococcus, streptococcus, staphylococcus, or tubercle bacillus, or any of the mixed forms, are responsible for the lesion. When no bacilli are found in the pus the empyema is generally of a tubercular nature. When this is found it is always well to inoculate several guineapigs for a positive diagnosis. It is at times important to decide what kind of an operasion is advisable in certain cases and for children of certain ages. The rule adopted by an institution with which he is connected is to incise all patients under one year of age and to resect all patients over one year. This, of course, is not a fixed rule, but may be varied according to indications. It is also of interest to speak of double empyema. Two such cases came under the speaker's observation within two weeks. One patient was resected on both sides, and the other, being rather marasmic, was incised, but two weeks later the child died of persistent broncho-pneumonia and exhaustion. In regard to the empyema necessitatus, one does not see these cases as frequently as formerly, which is almost undoubtedly due to the fact that great advances have been made in the physical diagnosis in children.