ture and beneath the periosteum, with, as it were, two compartments, one on either side of the spine, communicating through the fracture. The left compartment, the larger of the two, had effected a perforation into the left pleural cavity. Besides this, disintegrations of bone, cartilage, and adjacent structures in general occupied the affected locality. The other patient was a middle-aged man, a music teacher, of German extraction. When under the temporary influence of liquor, he fell from an elevation of about five feet, and struck violently the internal circumference of his right knee joint. The intense pain that set in forthwith, soon sobered him, and impressed him strongly with the apprehension of grave injury to the articulation. A physician was immediately called but failed to discover any injury. I saw the patient the third day after the accident. There were no superficial traces left by the fall. The articulation was hot, swelled, flexed, and extremely tender to the touch. From time to time, spastic oscillations appeared, and terrified the patient, who was pale and dejected from want of food and rest. I placed him under chloroform, extended the extremity, and secured the position by appropriate appliances. The trouble yielded without any further treatment; and, for aught I know, the patient recovered from an attack that might have permanently affected the articulation.

The interval of time between cause and effect, is, after all, more apparent than real. Many cases, especially those of affections of the spine, commence in so insidious a manner, and the initiatory symptoms are so general and indefinite, as to be excusably misinterpreted not only by the parents, but even by the professional attendant. Among other cases of the kind, I remember one in particular, which had puzzled the physicians for a number of months, until a correct diagnosis was obtained.

The patient is a little boy of fine organization, of a most impressible and active nervous system. His agility and daring even to this day are extraordinary, notwithstanding the conspicuous posterior curvature which has gradually become established. He may have been five years old, or thereabouts, when he sustained a fall from a fence six feet high, causing at the time considerable alarm to him and his parents. But no perceptible disturbance of his health immediately following, all fears were dismissed and forgotten. A few weeks after the occurrence, the patient exhibited signs of general ailment, decrease of appetite, pallor, weakness, disturbed rest, irritable temper, and indisposition to join in the frolics of his playfellows, Occasionally the pulse became accelerated, with contemporaneous thirst and increase of temperature. He complained of a transient pain in the stomach. His alvine evacua

tions were sluggish, badly mixed, dry, of light colour, and offensive odour. The abdomen was often distended with gas. The urine was pale, and deposited a whitish sediment. These symptoms prevailed for months without material change. The diagnosis of an "affection of the liver" was not without plausibility, inasmuch as that organ had become enlarged in all its diameters. At the end of the eighth month, frequent and painful hiccough was observed, and tenderness of the back became manifest on motion of the spine. In fine, his gait became awkward, and the movements of his body restrained and stiff. He craved for rest and support, which he obtained by placing his elbows on suitable objects, and his head upon the palms of his hands. Ten months after the accident my services were called into requisition. At this juncture it was easy enough to recognize the true nature of the complaint. The marked prominence of several spinous processes at the thoracolum-bar region of the spine rendered the diagnosis both transparent and conclusive. To the experienced practitioner, it may seem surprising that the diagnosis was not sooner accomplished, and the disease of the spine arrested by appropriate means. The entire train of symptoms pointed at a local lesion of progressive tendency and a searching examination could scarcely have failed to reveal the locality of the affection. Nevertheless when we recollect the difficul ties in the premises, the aversion of children to manual examination, the disinclination of parents to see their offspring thoroughly handed by the surgeon, and last but not least the limited field of general practitioners for fully observing and becoming conversant with these insidious cases, we will be sparing in our censure even if it should be warranted. It cannot be denied that in the case submitted, there was an uninterrupted connection between the accident and the subsequent disease. I have made the same observation in many cases that have come under my charge and have no doubt that other observers have the same experience. Nevertheless I am far from denying that joint diseases may arise from constitutional disorder likewise. But according to my clinical researches their number is proportionately insignificant. In cases of this character we find originally more than one joint affected, though the disease may eventually fix itself upon one articulation. This appertains more particularly to rheumatism, gout, and especially to pyemia. When on the other hand but one joint suffers from the beginning to the end, and the constitutional symptoms supervening are in conformity with the inevitable reaction of the local process upon the general system, then it is rational to infer that the local affection is of strictly local causation.

Every candid practitioner will agree with the aphorism enunciated

under 6. It is certainly a simple fact that the anti-scrofulous treatment of joint diseases has disappointed both him and his patients. My own clinical training coincides with that period in which the old etiological views held unbounded sway. They consequently regulated my action at the bedside. I followed with full confidence and scrupulous exactitude the doctrines of my distinguished preceptors Rust and Von Graefe. I coveted cases of this class, which seemed to be tacitly slighted by the more experienced members of the profession. But all my efforts were in vain. I accomplished no material change that could have been claimed as the result of devoted services. My cases took the usual course to complete obliteration of the respective joints,-malposition of the affected extremities, suppuration, caries, exhaustion and death. Nay more, I had the mortification to perceive that I could but rarely control the intense pain usually attendant upon such cases. Similar admissions have been made by other experienced practitioners, and I am led to believe that the negative results of anti-scrofulous treatment of joint diseases is now generally conceded by that portion of the profession whose opinion has value.

In the seventh aphorism, I broadly assert without fear of contradiction that in the treatment of joint diseases, local appliances scarcely ever fail of modifying or subduing the morbid process. For the last ten years I have held these views, and practically tested them at the bed side; and I can candidly and most emphatically assure you that the results thus attained have been most satisfactory in every particular. In but few cases have I ever had any need for constitutional remedies. Most of them yielded readily to local means; and with the local improvement the prevailing constitutional disturbances subsided. When thus rest and appetite were insured, the patients increased in weight, and rapidly improved in appearance and feeling. I need hardly state that my therapeutic views on this point were slighted for a number of years by those men to whom the profession look up for precept and example. But when Dr. Davis' portative extension apparatus became generally known the professional mind underwent a material change and then turned its attention to the subject. A few years ago the New York Academy of Medicine discussed the subject of hip disease at successive meetings. Most of those who participated in the discussion admitted in emphatic terms the therapeutic efficacy of that instrument, retaining at the same time the old tubercular theory of causation. Nobody seemed to notice the contradiction between theory and practice, and it was then and there that my views gained the ascendency. I simply stated on that occasion that but one could be right. "If hip disease were the consequence of

strumous invasion, a portative extension of but few pounds could have no effect whatever in relieving or curing that complaint; and if it actu• ally had the effect alleged, it would be the most undeniable proof against the constitutional character of the disease." The attempt to refute my logic was as feeble as it was unsuccessful, and from that date it may be said that the new theory was admitted to scientific citizenship. I shall not on this occasion enter more extensively upon the subject, inasmuch as I have to recur to it when speaking on the treatment of articular diseases.

Surgical Cases in the Practice of Louis Bauer, M.D., M.R.C.S. Eng. Reported by F. W. BIRD, M.D., Queen's College, Canada.

In the practice of every eminent surgeon, cases are constantly occurring illustrative of contested theories, and full of scientific interest to the speculative student of the healing art, as well as of great practical value to the earnest and studious practitioner. Most of these, however, are lost to the profession through want of time in the hurry of pressing business and the turmoil of passing events. But few surgeons combine the habit of plunging into one bold contest after another with the higher grades of disease, achieving grand results in quick succession, with the less brilliant qualities of the reporter and compiler. To the ant-like patience of the latter in accumulating and elaborating the materials upheaved by stronger hands, we are mostly indebted for the well adjusted magazines of knowledge which every good medical library contains. In preparing a few of the cases of Dr. Bauer for publication in your valuable journal, I hope to rescue from oblivion, facts and observations which afforded me much pleasure and profit, and I think cannot fail to interest your readers. The proper preservation of isolated cases like these can only be effected through the medium of medical journals, fitted as they are for specially recording events and suggestions that interlie the great periods of medico-surgical history, and are demanded for use before they can be associated with sufficient matter to be issued in book form. Your readers, being mostly medical men in practice, will, I trust, appreciate my motive in avoiding the tiresome minutia with which many clinical reports are lumbered, filling valuable space with commonplace descriptions and details to be found in ordinary text books, and thus depreciating in worth the journals which contain them.

CASE I.

Caries of the Spine-Abscess-Asthma Millari-Death-Autopsy. The little patient was placed under the care of Dr. Bauer on the 8th

ult. She was of a healthy family and of the tender age of three years and nine months. Four months ago she fell against a wall from a chair in such a manner as to force the head violently forward and downward upon the chest. From that time she suffered severe pain at the neck, became much attenuated, and experienced constitutional derangement. On examination the cervical portion of the spine was found to incline, and the head to be bent backward. At the cervico-thoracic portion of the spine there was a marked prominence of several spinous processes of which the first dorsal projected farthest. While the Doctor was carefully proceeding with the examination, the patient was suddenly attacked with so great an occlusion of the rima glottidis as to render her breathless, cyanotic, and slightly convulsed. This attack lasted at least fifteen seconds, and gave rise to serious apprehensions of instantaneous death. The examination was discontinued, but enough had been elicited to furnish a conclusive diagnosis, of which the following contains a summary. “In the peculiar fall of the child the body of the first dorsal vertebra had been either simply fractured or else crushed. The injury having been entirely disregarded for so long a time, it has given rise to inflammation and suppuration. There is most probably a cylindriform abscess in front of the affected spine, encroaching upon the esophagus and the recurrent. nerve or nerves. Hence the attacks of Millar's asthma. The prognosis is exceedingly unfavourable, and the child will not survive many of these paroxysms. The recumbent posture on the water bed is probably the only means of temporarily alleviating her sufferings." On the 12th ult. (four days after the reception of the case) the death of the child was re ported, having taken place in the exact manner foretold. Fortunately an autopsy was permitted, at which I assisted. We found an abscess in front of the spine, commencing at the fourth cervical and terminating at the fourth dorsal vertebra. The anterior wall of this rather narrow abscess was formed of the periosteum and the common ligament, and encroached materially upon the oesophagus. The diseased portion of the spine was removed. The specimen consists of the fragment of the seventh cervical, and of the fifth, second, and third thoracic vertebræ, the next superior and inferior bones being mainly healthy though slightly corroded. The bodies of the last cervical and first dorsal vertebræ are entirely destroyed up to the place where the bodies join their respective arches, Of the second dorsal a large portion of the body has disappeared, whereas the body of the third dorsal has been but slightly affected. Between the seventh cervical and first dorsal, there is an undue mobility. The first and second ribs on each side have lost their vertebral attachment. The spinal cord is deprived of its anterior bony protection