a pair of these, and as these cells have the potentiality to give rise, by successive division, to all the orders of tissue, and all the tissues of the individual, so each when separated from its fellow can give origin to a complete (anterior or posterior) series of organs. Dependent upon the period in early embryonic life at which the separation occurs so may we have,—

1. Complete division, with formation of two separate embryos from the one ovum (monochorial twins). Dichorial, dissimilar, twins originate from two separate ova.)

2. Separation of the superior growing point cells at early or late period, leading to the various grades of anterior or superior deduplication from Dicephalus quadribrachius (earliest) down to deduplication only of the pituitary body (latest).

3. Separation of the inferior growing point cells causing inferior or posterior deduplication, with a corresponding series of forms, the slightest and latest being cases of deduplication of the external organs of generation.

4. Combinations of both superior and inferior dichotomy (Anakatadidymus).

5. Separation of the primordial cells given off from the superior and inferior growing points, the cells at the growing point not dividing, leading to Mesodidymus (very rare).

Besides these conditions of dichotomy, he discussed the series of cases of complete division of the embryo, and tendency to form two embryos upon one ovum, with subsequent fusion. This fusion he divided into:

1. Ventral.

2. Latero-ventral.

3. Superior-(a) apico-polar (early fusion, leading to Janiceps formation), and (b) dorsi-polar (late, craniopagus).

4. Inferior-(a) apico-polar, leading to the condition of pygopagus, and (b) dorsi-polar (late, leading to xiphopagus).

He further pointed out that the continuance of proliferation by the growing point cells, after the Anlagen of the axial organs have been developed, affords the simplest and most satisfactory explanation of the curious series of teratomas developing at the site of the anterior and posterior poles of the embryo, namely, conditions of epignathus and congenital sacral teratoma.

Lastly, he pointed out that premature exhaustion of the growing point cells affords adequate explanation for the conditions of cyclops formation at the superior pole, of sympus or symelia at the inferior pole.

TUBERCULOSIS OF BONES AND JOINTS-BIER TREATMENT.*

BY S. H. WESTMAN, M.B., TORONTO.

For the last fifteen years, Professor Bier, of Bonn, has been treating cases of acute infective diseases of joints, bones and soft parts, by arterial and venous congestion, maintaining the diseased foci in a condition of hyperæmia for a longer or shorter interval. For purposes of treatment, he has divided hyperæmia into two varieties, Arterial or Active, and Venous or Passive.

The best results have been obtained with passive hyperæmia, which he has applied, especially, to the treatment of tuberculous affections, and I wish, to-day, to describe to you Bier's method of treating tuberculous joints of the extremities, by means of venous hyperæmia. For the production of venous congestion a Martin's india-rubber bandage is applied to the limb, about two inches above the diseased joint, allowing the folds of the bandage to overlap slightly, and to cover the soft parts for an area of about three inches. The bandage is drawn so firmly as to produce a strong engorgement. The area below the bandage becomes bluish and swollen. The subcutaneous veins swell, and the joint is felt to be hotter than the corresponding joint of the opposite side. Tingling sensations are felt, but actual pain is rare, but if it does occur, and is not relieved after the bandage has been applied for a few minutes, the latter must be loosened. The patient should suffer no discomfort or pain from a properly applied “Engorgement Bandage," (Staungsbinde), and yet the joint has the appearances of moderately acute inflammation. In some cases slight oedema follows, but with such a short application of the bandage this is a rare occurrence. When it does occur, however, it can be reduced by the elevation of the limb for a short time after the bandage is removed.

The indications which point to too strong application of the bandage, are pain, severe œdema, absence of the peripheral pulse, decrease in temperature, and presence of vermilion spots in the parts on the distal side of the bandage.

This treatment is employed daily for one hour, and carried on for a period of nine months to one year. Care should be taken, in using the bandage, to apply it always above the diseased joint, and to bind a different part of the limb; otherwise, con

*Read befo e the Ontario Medical Association, June, 1907.

siderable atrophy will result, at the site of the bandage, after nine months' treatment.

age.

In applying the method of hyperæmia to the shoulder joint, it is necessary to use a piece of rubber tubing, somewhat resembling an Esmarks' tourniquet, instead of the broad Martin bandA piece of cotton is put loosely around the neck, forming a loop, The rubber tubing, covered with felt or wadding, is wound around above the joint, one end is slipped through the loop, the other over it, the right degree of constriction is produced and maintained, by clamping the two ends of the tubing together, on the upper aspect of the joint. Two straps are then passed under the ring of tubing, and fastened to it, one in front, the other behind the joint. The straps are then carried around the thorax and tied in the opposite axilla. The same degree of hyperæmia is produced and maintained as in the other joints.

During the course of the treatment, provided the diseased joint be in the upper extremity, the patient is allowed to go about, and to use his arm cautiously in gentle, active movements; passive movements are employed by the physician, or by the friends of the patient. Such manipulations must never be vigorous enough to cause pain.

When the disease affects the lower extremity, the patient is confined to bed, to prevent the weight of the body from causing deformity of the already diseased and softened joints. After a month or two, however, he is allowed to get up, with the joint fixed in removable plaster of Paris splints or some form of mechanical apparatus. Active and passive movements of the diseased limb are carried out in the pauses of the hyperæmia. Many objections have been raised to this exercise of tuberculous joints, and some surgeons have gone so far as to accuse Von Bier of employing gymnastics as a remedy. His answer to this is a reference to the excellent results he has obtained by this combination of movement and venous congestion.

Bier therefore renounces, on the whole, the well recognized treatment of rest for these cases, because of the fact that immobility leads to stiffness and a bad functional result. His object is to obtain, wherever possible, a movable and good serviceable joint; for he considers that the annihilation of such an important and useful apparatus as a joint is a very poor result of any treatment.

During the progress of the disease, local complications are not infrequent, and are not, as some surgeons maintain, a result of

the hyperæmia, but are merely phases of the disease, which are just as liable to appear with other methods of treatment.

When the treatment was in its experimental stage, cold abscesses were frequent, and were predisposed to by the long application of the bandage, and by the extreme cedema which was caused thereby. These abscesses were allowed to grow larger, and were treated by aspiration and injection of glycerine-iodoform emulsion. The results were very discouraging. Now, however, with the daily application of the bandage, for only one hour at a time, abscesses have occurred less frequently, and when they do present, are opened as early as possible. If in doubt as to the presence of pus in a fluctuating or pseudo-fluctuating spot, it is better to incise it, even if no pus be found, than to make the mistake of allowing it to grow larger, for early evacuation of these abscesses gives an infinitely better result. In his treatment of these abscesses, Bier employs the aid of the cupping-glass, or, as the Germans call it, Schrópfkopf. The part is carefully sterilized, the abscess is opened, and the mouth of the cupping-glass is applied to the opening. A suction action of the glass is produced by a strong rubber bulb attached to it. The tissues inside the rim of the cupping glass immediately become swollen and hyperæmic, and pus, caseous matter and blood are drawn off into the cup. After a period of five minutes the cup is removed for an interval of three minutes, and at the end of three-quarters of an hour, including the pauses, the abscess is covered with an aseptic dressing, This cupping is employed daily, for the treatment of sinuses or fistulae, either the result of recent or old abscesses.

Under this treatment, the soft, pale, flabby, tuberculous granulations soon become hard and red. When this stage is reached the glass is applied every two days, and as further improvement takes place, every three days, until a cure results. With this method the sinuses are not scraped, neither are they probed, packed or drained.

Great precautions are taken to ensure complete asepsis, and for a long time Bier did not employ the cupping-glass, because he was afraid of secondary infection. After a few weeks of this combined treatment of cupping and bandaging, Klapp, a colleague of Bier, injected the drawn-off contents of these sinuses into the peritoneal cavity of a number of animals. None of them succumbed, showing clearly the absence of any secondary infection.

The very worst cases of tuberculosis are first treated in bed, but even in these cases movements of the limbs are allowed.

Joints of the upper extremity that are painfully sensitive, and in which some displacement has taken place, are immobilized, until the pain and deformity subside.

In the out-patient clinics of the University of Bonn and district, Bier employs his treatment, with excellent results.

Joint tuberculosis is very prevalent in some parts of Germany, and where there are so many cases, it is neither possible nor advisable to provide a bed for each case. Many of the cases are therefore treated in the out-patient department by their own physician, under the direction of the chief of the clinic, and the bandages are applied for the first few weeks under his supervision. The patient remains sitting for an hour, and during that time the bandage is inspected to see that it is acting properly. Later, the patient's physician, with his additional knowledge of the method, looks after his patient at home; and finally, the friends, if they can be relied upon, are permitted to continue the treatment. The patient himself soon learns to know the feeling of a properly applied bandage, and can thus aid its application. The physician sees the patient at his home from time to time, and should complications set in-for example, cold abscesses-the physician brings his case to the clinic, the abscesses are opened, and the pus evacuated by the cupping-glass. Where the friends are intelligent, they can be instructed in the use of the cuppingglass, and allowed to carry on the treatment at home.

Not all cases of tuberculous joints admit of the Bier treatment, and the following conditions are contra-indications to its use. Amyloid degeneration in the viscera, severe cases of pulmonary tuberculosis, cold abscesses filling the whole articular cavity. These last appear very seldom, and almost always in the knee joint. Then, again, in cases seen for the first time, where there is much deformity of the joint, and the latter is in a faulty position, Bier employs operation, removing the disease and the deformity at the same time, either by excision or by amputation.

A consideration of Professor Bier's statistics proves very interesting. The best results have been obtained in the elbow, wrist and ankle joints, and in the bones and joints. of the hands and feet; and the worst, in the knee joint. In this last joint more excisions have been done than in any other joint, because of the the occurrence of large abscesses and deformity, which necessitate excision. With reference to the hip joint, I may say that the artificial production of hyperæmia in this joint has been so difficult, and has proved so unsatisfactory, that Bier has discontinued it. Some