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corner of a marble slab, breaking the second, third and fourth ribs, about the middle. She had great difficulty in breathing, and almost incessant cough, and she was almost unable to sit down. Drs. Sims and Austin Flint attended her. only way in which she could be kept in a comfortable position. was by sitting upon the edge of a sofa between two assistants, and her arms reaching over their shoulders, her body being bent forward and her head resting upon a pillow upon a table. She had been in this position six days before Dr. Sayre was called to see her. Her medical attendants had tried all the ordinary methods for the treatment of fractured ribs, without giving relief. Watching the attitude of the old lady with her arms stretched tightly over the shoulders of her assistants, and learning that whenever a change of assistant was necessary to relieve those already on duty from fatigue, the pain was almost unendurable, and the only time she could get easy again was when she got in the position I have described, I discovered that it was simply by the extension of her arms, and the consequent distention of the pectoral muscles and other thoracic muscles that the ribs were held apart, as far as possible, and she was comparatively easy. After making traction on her hands and pulling her up as far as possible, spinal curvation with anchyloses rendering it impossible to straighten her, she was instructed to take a deep inspiration, and then she said that she felt more easy than she had at any time since the accident. Having made her undershirt fit as smoothly as possible, the plaster of Paris bandages were applied which Dr. Sayre uses for Pott's disease. The arms were held in the manner described until the plaster became hard, after which the old lady got into a chair in a comfortable position, and began a pleasant conversatio. During the seven or eight days previous to the application of the plaster jacket, it was almost impossible to get breath enough to articulate a few sentences, and her cough was almost incessant.

From the moment her arms were extended there was not a single cough. The patient died of exhaustion in nine or ten days. The comfort that this lady experienced after the application of the jacket, compared with the agony that existed

before its use, was a matter for consideration. It occurred to Dr. Sayre that it was the position in which she had instinctively placed herself that had given her comfort, and that the fixation of the trunk by the immovable apparatus was the plan of treatment. Dr. Sayre thought at the time that the method was original with him, but Dr. St. John, of New York, informed him that he had already applied plaster of Paris in the same way, when he was house-surgeon at Bellevue Hospital.

Dr. Sayre has applied the jacket in two other cases of fractured ribs by setting the patient in a chair or stool without a back to it, and having two assistants, one on either side, hold a broomstick over their heads, so that the patient can extend the arms over the broomstick, and at the same time take a deep inspiration. The ribs become thus accurately adjusted. The instant the parts are in accurate apposition, and are held by the muscles, the patient will let you know it, either by his face or his words; then apply the bandage and instruct the patient to maintain the position till the plaster soldifies.

Dr. I. N. Quimby, of New Jersey, then read a paper entitled

OPERATIONS ON PARALLEL BONES WITH LOSS OF SUBSTANCE, of which the following is a brief abstract: Having been called to attend a patient suffering from a compound comminuted fracture of the tibia and fibula, a little below the middle, he ascertained that there was a complete loss of 14 inches of the tibial shaft and corresponding destruction of the soft parts.

Dr. Quimby then proceeded to perform the following operation, the patient having been anæsthetized. An assistant seized the limb above and below the seat of injury, and bent the member at the wound, forming nearly a right angle, exposing to view as much as possible the ends of the fragments. Finding the remaining upper and lower fragments of the tibia sharp, jagged and irregular, the wound was enlarged, the soft parts dissected away from the broken ends of the tibia just sufficient to apply a small metacarpal saw, and these extremities removed. There was left a tibial deficiency one inch and threefourths in length.

The operator then carefully "worked his way" through the wound to the lower fragment of the fibula, dissecting the soft parts away from the end of the bone, and seized it when exposed with a pair of bone forceps, which were firmly held by an assistant while Dr. Quimby sawed off one and three-fourths of an inch of the fibula. The parts were then placed in accurate apposition, care being taken to avoid the interposition of the soft parts between the osseous extremities. The limb was then placed in an ordinary fracture-box, with lateral hinged doors and bran stuffing. To secure immobility, a large piece of adhesive plaster was made to cover the entire sole of the foot, and was then reversed over, and fastened to, the footboard, being afterward further secured with circular strips and a roller bandage. A compress was also fastened over the lower anterior part of the leg as near the wound as possible, which was held in place by a strip of plaster passing across the top of the box and secured through perforations in the latter. Thick, broad compresses were similarly applied above and below the knee, and also on each side of the limb.

Immobility was thus maintained for seven weeks, the wound being meantime covered with a lotion of carbolic acid. A profuse purulent discharge ensued, which gradually diminished, and at the end of eight or nine weeks union had occurred. The limb was then removed from the box, a plaster of Paris bandage applied with proper fenestrum, and retained for three weeks. In three months the patient was walking with a cane. (A photograph was exhibited, showing the patient supporting his weight upon the two limbs, the wound being cicatrized.) The patient has a slight limp in his gait, and the shortening corresponds to the length of the segment removed, 1 of an inch. The patient. had been seen by Drs. Post, Sayre, Crosby and others.

Dr. Quimby concluded:

1. That other limbs might be saved by such procedure.

2. That the attempt should be made in the case of parallel limbs similarly injured.

3. That the operation was original with the author.

4. That even without fracture of the fibula, a similar procedure would be advisable.

Dr. Bayard, of Quincy, stated that he had enunciated the principle in May, 1874, and in the New York Medical Journal of last year, having secured immobility by drilling holes through the extremities of bones and wiring them together.

Dr. Hodgen, of St. Louis, after inquiring whether every particle of bone and periosteum had been removed by the injury from the 14 inch of the tibia found wanting, and being then answered in the affirmative, remarked that there was a danger in reporting such cases lest they might lead to improper practice. The value of periosteum and fragments in such cases was great. In case of any doubt the patient should have the benefit

-of it.

The Chair remarked that, if there was any doubt respecting the filling up of the space left between the fragments of the tibia, it would, in his opinion, be wiser to fracture if the fibula and permit the broker ends to penetrate the flesh and remain overreaching. This would not diminish the chance of final consolidation, as it not unfrequently occurs from accident.

Dr. Truesdell, of Illinois, concurred in the views expressed by Dr. Hodgen. He reported a case in which he had finally to remove a piece of the tibia, one inch in length and fourfifths of the thickness of the bone. The entire space was filled by granulation, and the cure was complete without shortening or lameness. In some cases he had been able to scrape out the entire shaft of the bone with his finger, for two inches. Periosteum was not necessary to complete repair. The tissue forming the cancellated structure of the bones, is simply an extension of the periosteum, and those cancellated cells produce plastic material convertible into bone.

Dr. Sink, of Indianapolis, also believed in the restoration of bone under such circumstances, believing the source of it to be not the periosteum merely, but the medullary tissue, from which granulations arise even when exposed to the air, if that air be not irritating. Judging from his own experience, and alluding to the observations of Virchow, he believed that the bone in this instance would have formed to fill up the vacant space between the tibial extremities. In one instance he had removed five inches of the tibia, leaving but a little specimen

of bone, and reformation occurred, the man recovering with a sound limb.

Dr. Humphrey, of Missouri, concurred in the views already expressed, citing a case treated by himself where three inches and one half of the entire shaft of the tibia were removed, and the periosteum completely destroyed, the fibula being intact. The limb was kept extended upon Dr. Hodgen's splint, after the removal of the fragment, and the result was perfect.

Dr. Quimby referred to a case treated by Prof. Crosby, of Bellevue, where the entire shaft of the tibia was gone for 1 inches. The patient objected to removal, and only partial restoration occurred; the patient to-day is walking around with a steel splint. In his case, if spicula had been found, he would have attempted restoration. He had himself removed two, three and four inches of bone where the periosteum was partially left, and union had resulted. He believed that cancellated tissue also could reproduce bone.

Dr. Hughes, of Iowa, believed that many present, if called to a similar case, would have performed the operation described. In three instances, the speaker had removed portions of the bones of the fore-arm, and by shortening the limb had obtained excellent results. The operation is therefore not a new one. But where either medullary tissue or periosteum is left, removal, of course, is unjustifiable.

Dr. Hodgen remarked that he now understood one and three-fourths of the tibia was gone in its entire thickness. (Dr. Quimby "Yes.") In that case the anterior tibial nerve and artery must have been removed with the soft parts, and the danger of mortification being great, amputation should have been performed.

Dr. Clapp, of Iowa, could understand why bone might be removed in the fore-arm, but could not believe it necessary in the case of the fibula.

The Chair reiterated his former opinion, believing the danger of fracturing the fibula and thrusting the ends over each other, to be small. Dr. Quimby went through a very deep wound in his operation-through the inter-osseous space where important vessels lie. He (the Chair) could not sanction the operation.