of from 0.5 to 0.8 of an inch. There was of course means of accurately measuring the transverse diameter; bat I estimated that the contraction in this diameter was about 0.5 of an inch.

The mechanism of the labor was quite characteristic of the justo-minor pelvis; that is, the head entered the pelvis in an oblique diameter and passed through the canal in a state of extreme flexion; whereas in the simple flat pelvis, or in any case where the conjugate is contracted and the transverse diameter of normal length, it is usual for the head to enter by the transverse diameter with more or less lateral obliquity of Naegele: in this latter class, too, instead of assuming a position of marked flexion, it is the rule for the head to extend and enter the pelvis, if at all, by the bi-temporal diameter, as illustrated in the two preceding cases.

From the existence of the lateral curvature of the spine, presumably of rachitic origin, and from the fact that the diminution in the distance between the iliac crests was somewhat greater than that between the spines, and again from the fact that the conjugate was perhaps a trifle more contracted than the transverse diameter, I was at first led to believe that this pelvis should be classed as of the generally, asymmetrically contracted, flat, rachitic variety. But the mechanism of the labor was not such as obtains in that class of pelvis; moreover I was unable to detect other evidences of rickets, and the pelvis seemed to me symmetrical. I therefore believe that if rickets existed in early life, it was recovered from before the pelvis was affected thereby to any appreciable extent; or rather that its influence was exerted in the disturbance of nutrition which caused a premature suspension of bonegrowth rather than a bony deformity.

PERIURETHRAL PHLEGMON.1

BY THOMAS WATERMAN, M. D., BOSTON.

THE following cases illustrate both mild and severe attacks of periurethritis, although the most severe and dangerous cases complicated with urinary fistula have not been met with by me.

I have retained the somewhat antiquated term phlegmon because the disease was first described under that title; it should be borne in mind, however, that it is to be interpreted in this paper as meaning simply an abscess, and that it has not a distinctly phlegmonous character, nor is there violent inflammation or gangrene of the cellular tissue. Some of the cases may appear trivial, but they are reported on account of their rarity, which consists in the fact that they occurred as a complication of simple gonorrhoea, and have nothing to do with the every-day abscesses of the penis and scrotum resulting from the urinary infiltration of tight strictures or accidental wounds of the urethra. These four cases are all I have met with in sixteen years.

CASE I. A. B. C., a police officer, thirty-five years of age, of steady good health and temperate habits, presented himself to me in 1879, with the following history, namely: three weeks previously, after impure sexual connection, he contracted urethritis of mild type, which readily yielded to the same treatment

1 Read before the Boston Society for Medical Observation, February 4, 1884.

which he had employed in a former case of the disease. Three days before I saw him he had noticed a swelling on the right side of the frenum. On examination I found a small globular tumor, somewhat less than a centimetre in diameter, slightly sensitive to the touch, and obviously containing liquid. I suggested incision, which was refused. Three days later he came again and showed me that it had opened spontaneously by a rather small orifice. He then stated that three years before he had had gonorrhoea, which was followed by a similar small abscess, and, he thought, in nearly the same situation. The discharge from the urethra had diminished and troubled him but little. He said that he could now take care of both clap and phlegmon himself, and I saw him no more.

CASE II. J. O. L., a mechanic, aged thirty. A short, slim, wiry man, but always in robust health. Never had any venereal disease before. On July 6, 1882, he had connection with a prostitute; two days later he detected a moisture at the meatus, and on that day or the next he felt a small lump on the right side of the frenum. Four days later it broke and discharged pus.

He placed himself under my care August 7th; previous to this time he had been treated by an apothecary who had medical aspirations. I found that he had a pretty free urethral discharge and an induration at the point above indicated, surmounted by an ulcer, the remains of the unhealed phlegmon. There were no indurated glands in either groin. I prescribed an injection of zinc acetate and an ointment of iodoform and cosmoline. In spite of his distinctly phlegmonous history, I thought at this time that he had a chancre. Six days later, as his sore was unchanged in appearance, I discontinued the iodoform and prescribed a lotion of chlorinated soda. The ulcer soon after healed, but the cure of the urethritis was not complete until late in September. You will ask how do I know that he did not have a chancre. Because the history was plainly that of induration, inflammation, and suppuration; because the patient was desirous of wedlock, and dreaded to such an extent the possibility of infecting his future wife that his fears amounted almost to syphilophobia. He was hypochondriacal, frequently inspected himself with the most scrupulous care to detect the earliest secondary symptoms, and came at regular intervals to me for cross-examination. I had him under observation for months, and failed to detect the simplest lesion of secondary syphilis.

CASE III. B. R., a lawyer, aged thirty-seven, stout, fat, and flabby. Extremely addicted to over-indulgence in sexual intercourse both at home and abroad. He had connection with two different shop-girls on February 9th and February 14th, 1880. He came to consult me February 17th, having noticed a moisture at the meatus the day previous. Two days later he had chordee. Nothing unusual occurred until March 5th, when an induration was noticed on both sides of the frenum. Fluctuation was detected five days later, and an incision was made on both sides. At the time of the incision the abscess was globular in form and bilobed by reason of the constriction exerted by the frenum. A few days later a probe could be passed through from one wound to the other beneath the frenum. At about this time I incautiously (as it proved) one day told him that the wound was now fistulous, and that it would be extremely difficult if not impossible to heal it without dividing the frenum. It seems that he had

had a fistula in ano some years before and was not pleased at the prospect before him. Without inform ing me of his intention, he went immediately to the surgeon who had treated him for the anal fistula and showed him his penis. He was then rather bluntly and gruffly told that he had a chancre, and that he had secondary symptoms at that very moment. Back he came to me in terror and told me the story. I carefully examined him, and finding no indurated glands in the groins, and not a trace of secondary syphilis, I endeavored to reassure him. He had at this time a patch of ordinary herpes on the lower lip. I then went with him to Dr. F. B. Greenough, who, after hearing his story and examining the lesion, coincided with me in the diagnosis of periurethral abscess and dissenting from the "snap" diagnosis of the surgeon referred to above. A seton was suggested; it was introduced and retained for a considerable time. No benefit ensued from its use either before or after removal. May 29th the frenum was divided, producing a large, flat, ulcerated surface, and a variety of stimulating applications succeeded each other in a vain attempt to induce it to heal. Its centre was somewhat depressed, and this was frequently probed, but neither the finest probe nor colored urethral injections ever revealed any communication with the urethra.

September 5th the patient consented to an operation. He was accordingly etherized, and a Curtis's sound in troduced to distend the urethra to its fullest extent at the site of the ulcer. The granulating surface was carefully pared off as deeply as was consistent with preserving the integrity of the urethra, and the indurated margin refreshed. The edges of the wound were then brought together longitudinally and united with several fine sutures. All went well for a few days, the sutures had been removed, and silk floss moistened with collodion applied to support the wound. About five days after the operation an erection occurred and the edges of the wound were torn open. The upper and lower ends of the wound had healed, however, and the sore, diminished in size, granulated healthily and was soundly healed about a month later under the use of black wash and occasional touches of lunar caustic.

As this patient was a married man he was as anxious as Case II. to know positively whether or not he had contracted syphilis. He was, therefore, diligent in his personal examinations, and reported to me at regular intervals for a long time after the final cure. Four years have now elapsed, but no secondary lesions have ever appeared. His gonorrhoea ceased coincidently with the cure of the phlegmon.

CASE IV. E. W., a clerk, aged forty-eight, short, slim, cachectic, never possessed of robust health, contracted syphilis twelve or thirteen years ago and never entirely cured. Occasionally has plantar psoriasis. Eight years ago his first attack of gonorrhoea appeared, which was accompanied by a superficial abscess beneath the fossa navicularis at the left of the frenum. It opened spontaneously and healed readily. One year and a half later a second attack was followed by abscess on the right side of the frenum. This was incised and also quickly healed. Four or five years ago a third attack of gonorrhoea was contracted. An abscess then formed higher up the penis about half way between the glans and the peno-scrotal angle and in the median line. This was incised by an apothecary and was not completely healed for ten months or a year afterwards. An indurated lump, movable be

neath the skin, always persisted at the site of the abscess.

He came to me December 11, 1880, with this history, and stated that he had again caught the “ clap," and that ten days after the discharge showed itself the lump before mentioned began to enlarge. Ou examination I saw a large, shiny, tender, purplish tumor surrounded by boggy oedema, and not distinctly fluctuating. Seven days later it was as large as a walnut and evidently full of pus. There was little or no constitutional disturbance and no dysuria, although the pressure of the tumor upon the urethra had diminished the force and size of the stream of urine somewhat. The abscess was freely incised parallel with the length of the penis, and poulticed. About a week after the incision a sinus four centimetres in length was discovered extending upwards towards the bulb. The patient declined another incision at this time, and efforts were made to cause the sinus to heal by means of carbolized injections and packing with medicated lint. These methods were fruitless, and one month after the first incision the sinus was freely laid open with scissors, no opening into the urethra was found, and the resulting wound was induced to granulate from the bottom. Three weeks later the cure was complete, the discharge from the urethra having ceased previously. An examination some months later revealed no induration at the site of the cicatrix.

Periurethritis, periurethral phlegmon or abscess is rare, half a dozen cases probably being a large number for even a specialist to see in thrice as many years. It is said that folliculitis or follicular abscess of the penis is still more uncommon. The seat of attack is similar in the two affections, but they are anatomically distinct. The former is an inflammation of the cellu lar tissue which connects the skin of the penis with the corpus spongiosum, and always terminates in suppuration. The latter is an inflammation of the follicles of Morgagni, which open into the urethra and is cystic in character. Owing to the rarity of periurethral phlegmon its literature is meagre. C. Hardy, Ricord, Fournier, Bumstead, Otis, Van Buren, and Keyes all devote some space to it, the French writers more particularly.

Periurethral phlegmon is periurethritis ending in abscess. Chordee is a periurethritis, but it has no tendency to suppurate. It will be noticed that only one of the cases had chordee, and it was but slight. Suppurative periurethritis is probably never idiopathic, always resulting from acute urethral inflammation, leaving out of consideration those more common cases caused by infiltration in connection with stricture.

It appears from Cases I. and IV. that having once happened a recurrence is to be expected at each attack of gonorrhoea. Cases II. and III. had never suffered from venereal disease previously, and may be heard from again in the future. The phlegmon may be situated at any point of the urethral side of the penis from the glans to the bulb, but it is said that the points of election are the neighborhood of the frenum and the peno-scrotal angle. Those near the frenum may be limited to one side, as Cases I. and II., or both sides may be involved as in Case III. They are globular, not large, and superficial. The abscesses higher up on the penis, as Case IV., are larger, deeperseated, occasionally retard the flow of urine, and sometimes cause constitutional disturbance. The abscess usually opens externally, and this is the most favorable termination. It may, however, break into the urethra,

and subject the patient to the grave dangers of urinary infiltration and sloughing of the cellular tissue of the penis and, perhaps, of the scrotum also. In some cases the abscess breaks both internally and externally.

In regard to treatment it is self-evident that the phlegmon should be incised freely as early as possible after suppuration is definitely established. If possible any sinuses, which may exist, should be detected at the same time, and laid open to their extreme limit. The resulting wound should then be packed with lint, and allowed to granulate from the bottom. The cure in Case III. would doubtless have been less chronic if the bilobed abscess had been opened transversely, and the frenum divided in the first instance. Much troublesome induration, which prevented cicatrization, would thereby have been avoided. The sinus in Case IV. should have been laid open when the abscess was incised, and would have been if the patient had been etherized. If the abscess breaks into the urethra a counter-opening may be made externally at once, which is probably the most prudent course, or we may wait for the possible occurrence of infiltration, which Fournier says does not commonly happen. A urinary fistula may be the termination of a phlegmon, and is more liable to result near the bulb than towards the glans. Hardy says that "at the latter place it gives rise to an accidental hypospadias which is difficult to cure."

Perhaps the most interesting practical point connected with this complication of gonorrhoea is its liability to be confounded with a primary syphilitic lesion, as illustrated by Cases II. and III. When it is a typical phlegmon, already containing pus, the diagnosis is easy. In the initial stage of induration, however, on one side of the frenum, before suppuration is established, the physician may well be pardoned for postponing a positive opinion until more light is thrown on the case by subsequent developments. Again, as in Case II., where a patient does not present himself until the phlegmon has opened, and it is seen for the first time in the condition of a small granulating ulcer with indurated base, expectant treatment should be practiced, and a long period of incubation allowed to occur before a final opinion concerning the nature of the lesion is given.

REPORT ON ORTHOPEDIC SURGERY.

BY E. H. BRADFORD, M. D. LENGTH OF LIMBS AFTER DISEASE OF THE JOINTS.

THAT limbs, after resection of the joints and after disease, sometimes cease to grow or grow less rapidly than the healthy limb is a well-known fact, and has been explained as an effect of the disuse of the limb, or as a result of the disturbance of the nutrition of the bone through injury of the line of the epiphysis. Wolff, after a number of measurements, has come to the conclusion that neither of these is sufficient to account satisfactorily for the result. A shortening takes place not only of the bones which were affected by the disease or the operation, but also those which apparently have been healthy. For example, ten or twelve years after disease or resection of the hip a shortening of the femur will be noticed, and a shortening of the tibia and fibula to a slight extent, while a much more marked arrest in the size of the 1 Vide Berl. klin. Wochenschr., 1883, Nos. 28-30.

foot and in that of the patella is almost constantly observed. And after affections of the knee and shoulder a lengthening of the humerus and femur is sometimes noticed. Diminution in the size of the patella is not observed in affections of the knee out of proportion to that of the limb, while a shortening of the foot is noticed.

The explanation of these facts offered by Wolff is that a primary joint affection is followed by a secoudary affection of the nervous system of the limb, which gives rise to an arrest of development of the bones of the limb. Analogous to this is what is seen in infantile paralysis and progressive muscular atrophy, and in the nervous muscular atrophy described by Valtat in inflammations of the joints.

TUBERCLE BACILLI IN JOINT AFFECTIONS.

Koch, Marchaud, Schuchardt, and Krause have all come to the conclusion that the bacillus plays an important part in the etiology of fungous osteitis and arthritis, but they agree as to the great difficulty in demonstrating the presence of these organisms as the number present is relatively small. Müller has, at the Göttingen Clinic, been able to examine for the presence of bacilli the bones from thirty cases removed by resection. In the majority of cases a few bacilli were to be found after examining a number of sections, but in a number of specimens of undoubted tuberculous ostitis the result was entirely negative. In one case, however, of coxitis, in the very earliest stages, appearing a short time before death from phthisis, and manifesting the symptoms of pain and contraction of the limb, and at autopsy a focus of tubercular granulations at the head of the femur, near the insertion of the ligamentum teres, perforation of the cartilage, pannus of the cartilage around the spot of cartilaginous perforation, and congestion of the synovial membrane, the tubercles in the granulations were numerous, but not caseous, but on examination a very large number of tubercle bacilli were found, and the writer suggests that, possibly, the bacilli may, in the earlier stages, be present in larger numbers than after the ostitis is more destructive, though the matter is one which will need further investigation. It would appear, however, that unlike those in tuberculosis of the lung the bacilli of chronic disease of the joints promise but little for diag nosis or prognosis.

TREATMENT OF TUMOR ALBUS BY ARSENIC.

2

Landerer reports several cases where marked improvement followed the administration of arsenic interhally (0.004, 0.008, and 0.012 in pills daily for several weeks), and in one case the subcutaneous injection of an aqueous solution of acidi arsenicosi, 1 to 1000.

The writer does not regard arsenic a specific against tuberculosis, but, relying on experiments on guineapigs, he concludes that it increases the resisting power against tuberculous infection.

STATISTICS OF RESECTION OF THE KNEE.

Mensing has collected eighty cases of total and three of partial resection of the knee, operated upon at Kiel, and nine operations of removal of a wedge-shaped piece of bone for rectangular anchylosis. Forty-eight of these (52.01 per cent.) were discharged well. The average shortening was two and one half centimetres,

2 Centralblatt f. Chirurgie, November 24, 1883.
8 Centralblatt f. Chirurgie, No. 49, December 8, 1883.

tion.

In thirty-four patients the excision was not perfectly successful (that is, thirty-seven per cent.), fourteen undergoing a subsequent amputation, and twenty having an unhealed sinus at the time the patients left the hospital. Of these twenty the ultimate results of thirteen were obtained: in ten cicatrization took place; three died. Of the fourteen secondary amputations ten recovered, and two died.

Ten patients who underwent excision at the clinic died directly from the operation, five of pyæmia, one of Bright's disease, one of general tuberculosis, two of exhaustion, one of hæmophilia.

These operations were performed in the years from 1857 to 1883, and the time is divided by the writer into three epochs: First, before the introduction of Listerism and Esmarch's bloodless method; Second, after these were introduced; Third, after the introduction of Neuber's permanent dressing. The mortality in the first period in twenty-one cases was 33.03 per cent.; in the second period, twenty-three cases, was 8.7 per cent.; and in the third period, forty-eight cases, two per cent. The length of time required for healing in the first two periods averaged 129 days; in the third period eighty-nine days.

RESECTION OF THE KNEE.

Ollier' reports that before the introduction of antiseptic surgery his mortality in resection of the knee was eighty per cent.; since then his mortality has fallen to fourteen per cent.2 Formerly he used excision simply as a life-saving measure, but at present he feels justified in recommending it as a means of shortening the course of the disease. In children, however, he is disinclined to perform resection for fear of limiting growth. In operating Ollier is careful to spare as far as possible the periosteum and ligaments, though the capsule or ligaments should not be spared if diseased. A straight incision is only used for traumatic

cases.

In fungous disease an H-incision is to be used. The two lateral incisions should be as far forward as possible in order to spare the lateral ligaments. If the patella is affected it should be removed. The bones are wired together as well as the ends of the cut ligaments, and drainage tubes are to be inserted above and below if the posterior part of the capsule is diseased. In traumatic cases a single straight incision is advised dividing the patella. This method he has only tried on the cadaver, but is recommended because the ligaments are best spared in this way. Resection is to be performed in deformity at the knee if ostitis is present. If, however, perfect cicatrization has taken place with a rectangular position of the limb an osteoclast is to be used, but one devised that the rupture should take place directly at the desired point; but in some cases osteoclasis cannot be used on account of cicatricial contraction at the back of the knee. A wedge-shaped piece of bone is to be removed in these cases, and this is best done at the point of the obliterated joint.

1 Revue de Chir., 1883, Nos. 4 and 5.

2 Vide Revue de Chirurgie, February 10, 1884, page 157.

ACTUAL CAUTERY IN CHRONIC JOINT AFFECTIONS.

The routine French treatment for tumor albus is "boutons de feu" (that is, touching with the galvanocautery), immobilization, repeated blisters, tincture of iodine. The want of effect produced by ignipuncture has suggested more thorough treatment, namely, the pushing of the cautery directly into the bone and exciting a cicatrizing sclerosis. It is said that simple ignipuncture succeeds where it is not indicated, and fails where it is.

Curetting is a favorite method of Volkmann, Schede, Boeckel. It is a method, according to M. Vincent, either insufficient or excessive, excessive in simple granular fungous synovitis, and insufficient where excision is demauded, it being impossible to completely remove by a curette all the foci of disease. Ollier's method is described as follows: 3 Before the operation the patient is to be thoroughly washed, the site of incision being scrubbed with soap and brush, and any hair that may be present shaved. The operation consists of arthrotomy, the line of incision being parallel to the axis of the limb, either a knife being used cleansed by heat or a point of the Paquelin thermo-cautery. The incision should divide the skin and all lardaceous tissues, and if necessary the joint should be completely exposed by a cross incision. If the fungosities are tolerably superficial, the Paquelin cautery will be sufficient, but in extensive cases the old-fashioned" cautery irons" will be

needed to riddle the diseased bone.

In young subjects the cauterization should be pushed quite far, and is followed by excellent results. Irrigation by an antiseptic completes the operation. Iodoform is then dusted on the wound, and the limb wrapped in boracic acid compresses wet in carbolic, carbolic gauze and salicylicized cotton, mackintosh, and bandages. This dressing should reach up to the middle of the thigh in cases of affections of the knee, and the whole should be wrapped in a silicate bandage, strengtheued by card-board or light wood. A second dressing

is not applied for three weeks or a month.

DISEASE OF THE BONES OF THE PELVIS.

The initial site of the chronic disease of the joints is placed by the best authorities at the line of junction of the epiphysis with the diaphysis. "The point of election," to quote the words of Ollier, "is not the epiphysis but the region juxta' epiphysaire." Gouillaud and Ollier have pointed out that this is also the case in pelvic osteitis. Pelvic caries may be either intra-cotyloid, not distinguishable from hip disease, or pericotyloid, with difficulty separated from hip disease, or marginal, the site being partly dependent upon the age at which the inflammatory process is awakened, as before puberty the most active growth is at the junction of the three pieces of bone which form the ilium; after puberty the most active cellular process is on the margin at the epiphysis there. Acetabular hip disease is much more common than is supposed; it is regarded by the writers as at least as frequent as the femoral variety.

The most common age for marginal pelvic disease is twenty-three years, and the places most frequently attacked are the crests of the ilium, the posterior iliac spines, and the apophyses of the sacrum, anatomi

8 Vincent, Arthrotomie Ignée, Revue de Chirurgie, January 10, 1884.

cal points where the epiphyses are developed even in early adult life.

The early symptoms of this marginal pelvic caries are chiefly indications of visceral affections, that is, the intestine and bladder, and the appearance of abscesses either in the bladder or intestine.

In childhood frequent aspiration of abscesses and expectation are indicated, unless the hip is threatened. In case of pelvic hip disease excisiou naturally gives the best drainage, and perforation of the acetabulum so far from being a contra-indication to that operation imperatively demands it.

In the adult opening of the abscess is indicated, whatever its seat. If intra-pelvic, the pelvis can be trephined, an operation first done in 1778 by Boucher, and repeated with success by Verneuil.

SACRO-ILIAC DISEASE.

This affection is so rarely observed that the records of four cases are of value.1

One patient was a child six years of age, who recovered. A second was observed in a woman, who recovered after long suppuration. In the third case death took place after long suppuration, and an autopsy revealed extensive ostitis. The fourth patient died of phthisis, but underwent an operation of removal of carious bone by chiseling through the ilium. Riedel mentions having seen three cases, two in children of five and fourteen, one in a woman of thirty. The first was operated on by extraction of the sequestrum through an incision dividing the gluteus maximus, and in the second and third cases the iliac bones were trephined. Recovery took place in the first and third patients, the second dying of extensive caries.

REPRODUCTION OF BONE AFTER RESECTION.2 Experiments have been made on young dogs to determine this matter. The lower end of the femur, the patella, and the semilunar cartilages were removed subperiosteally, the saw being always applied in the line between the epiphysis and diaphysis. A complete regeneration took place, the bone consisting of the ordinary spongy bone tissue, and covered to a greater or less extent at the end with cartilage. The bone began to be developed partly from the periosteum of the diaphysis, partly from the marrow, and partly, but to a less degree, from subperiosteal tissue which had surrounded the excised portion, the formative activity of the periosteum being greater at a later stage. The surface of the tibia suffered little alteration except where the differences in pressure or mobility affected the growth of

the bone.

THE FEVER OF GROWTH.3

Bouilly has described and named "la fièvre de croissance," the symptoms sometimes seen in growing children, which are probably analogous to those grouped in popular language under the head of "growing pains." Bouilly is inclined to classify it as a light form of osteo-myelitis which runs its course without suppuration, and is most prevalent at the time of the most rapid growth. A comparison may also be suggested with the view of the nature of rickets which has been advanced, that the disease is characterized by a faulty

appears in

ment. Bouilly's "fièvre de la croissance three forms: (1) acute, which is the lightest and most frequent; (2) an acute form with severer symptoms; (3) a chronic incipient form. All these varieties have fever and pain in the bones, chiefly in the juxta-epiphyseal zone, most frequently near the lower epiphysis of the femur. The short and flat bones are seldom affected. The joints are almost never affected, but exceptionally effusions into the joint are seen. In the lightest form the symptoms pass in thirty-six hours, in severer cases the fever may last several days and even be attended by some typhoidal symptoms, followed by a sudden fall of the fever and recovery. The chronic subacute form may last for months, and relapses may occur; the prognosis is, however, favorable. Quinine and tonics are recommended. The disease may appear from the fifth to the twenty-first year, and the symptoms may be brought on by long walks, strains, or fatigue.

ETIOLOGY OF LATERAL CURVATURE."

Sklifosowski found, on examining twenty-one cases of scoliosis, in seventeen shortening of one limb, in four the shortening was so slight as to escape observation. In eleven the right thigh was longer than the left; and in twelve the right leg was lengthened. In nineteen young persons not suffering from lateral curvature, in five a difference in length of the lower extremities was observed, and the writer concludes that a difference in the length of the lower extremities alone could not account for the existence of lateral curvature, and in all probability some disturbance in the development and growth of the bones of the spine is influential in bringing about the distortion. Confirmatory of this he found other abnormalities in the development of the skeleton (genu valgum, pes planus, valgo planus) in two thirds of the cases suffering from lateral curvature.

THE NATURE AND TREATMENT OF RICKETS.5

Kassowitz is of the opinion that rachitis results from an abnormally increased vascularization of the bonemaking tissues. Wegner reports as a result of a series of experiments upon animals the opinion that phosphorus given in small doses for a length of time gives rise to a diminution in the amount of the medullary tissue and arrests the normal transformation of osseous tissue into medullary cells, while large doses cause the reverse condition, namely, an increase in the medullary transformation, that is, an artificial osteo-malacia. Kassowitz, therefore, has in a number of five hundred and sixty patients administered phosphorus with beneficial results, namely, a diminution of the nervous symptoms, spasm of the glottis, restlessness, sleeplessness, and an improvement in the ability to walk, an improvement in the general condition of the patient, as manifested by an increase in weight and appetite. The phospho

rus is administered with cod-liver oil in from half a teaspoonful to two teaspoonful doses daily, of a mixture of 0.01 of phosphorus to 100.0 of cod-liver oil, or in older children the medicine can be given in pills commencing with a dose of half a milligramme.

OSTEOTOMY IN OBSTINATE CLUB-foot.

4 Centralblatt f. Chirurgie, 1884, No. 3.

5 Zeitschr. f. klin. Med., 1883. Bd. vii., p. 36.

6 Bull. de la Soc. de Chir. de Paris, t. viii., p. 766.