each case, except the second and ninth, the limb was straight after recovery. In the second case it was but a trifle flexed when dressed first, but, owing to the force necessary to keep it in this position, the hamstring muscles rebelled under the undue traction and caused increased flexion. The patient declined to submit to another operation, and left the hospital with the limb slightly flexed and well united. The bones of the ninth case were purposely joined with the leg slightly flexed, for the reason already explained. The degree of shortening of a limb after epiphyseal union is not a matter of scientific importance, because the amount of bone removed must depend entirely on the extent of the disease calling for the operation, and no act of the surgeon intended to preserve the length of the limb is justifiable in this operation when it exposes the patient to the danger of infection. The artisan can supply the difference quite as effectually, and with much greater safety to the patient, than can the surgeon by questionable methods. The digging out of isolated diseased products from the sound extremities of the bones, followed by immediate healing of these spaces, offers the only method known to me of preserving length of bone to the fullest extent.

The wires were not removed in any instance unless trouble was caused by them. In but two of the cases did it become necessary to remove the wires at any time, and in those they were removed after permanent union of the hard parts had taken place, and dependent in each instance upon external violence directed to the site of the wire. The removal was followed at once by rapid and complete recovery. It is possible, of course, that the patients did not all return for treatment of trouble caused by the wires, but sought relief elsewhere.

Operation.

Result.

Disease.

Remarks.

In addition to the measures
taken in the first case, an
abscess of the head of
the tibia was scraped out
and drained; antiseptic
throughout.
34 Transverse incision; patella
removed and fibrous tis-
sues of the joint dissected
away; antiseptic through-
out: bones wired.

SOME CURABLE FORMS OF RHEUMATIC GOUT.

BY EDWARD BLAKE, M.D.,

OF LONDON.

CASE I. Osteo-arthritis with sapræmia.-On August 21, 1890, I was consulted by the Rev., aged seventy years, residing in the south of Devon. He has consumed vast quantities of tea, but has been a strict abstainer from alcoholic beverages during the whole of his life. He has been, since reaching manhood, a very active worker in a poor agricultural district. A great walker during all weathers in a county where it always rains, he has been quite indifferent to such minor details as wet feet and saturated garments.

Until the November of 1889 he was in the habit of taking his cold bath in the open air, and this even when ice had to be broken to get at the water.

In spite of all this, with one trifling exception, this truly Spartan priest enjoyed an immunity from joint disease until he reached his sixtyeighth year.

Then redness, stiffness, and swelling of symmetrical type commenced in the middle fingers of both hands. Afterward the muscles of the upper arms began to suffer from pain and atrophy. Then the lower extremities were affected in a similar manner, until his excellent walking powers were gradually reduced to a miserable shuffle, so that his longest stride at present extends only to four inches. The knees and the ankles are ankylotic, and the circumjacent cellular tissue is very œdematous.

The synovial adhesions were soon broken down by forcible flexion and extension. The oedema was removed by means of slow, firm, upward electro-massage with a gentle, continued current. The affected joints were well compressed at night, and never allowed to rest during the day. After fourteen days this gentleman was sent home feeling greatly improved in health, and with all his joints in a serviceable condition.

Commentary: Why did this man, in spite of his reckless defiance of the ordinary rules of middle age, successfully evade the bane of later life, suddenly to fall a victim to rheumatism at the ripe age of sixtyeight?

If this remarkable immunity from what befalls so many was due alone to a scrupulously abstemious, active, and self-denying life, why did he abruptly fall a victim to rheumatism in his sixty-ninth year?

With one solitary exception no change, either in his habits or in his surroundings, occurred at the time. The only new element which could be ascertained to have been introduced into his existence, that would in any way explain this late succumbing to the foe, was that at this time he procured some artificial lower teeth. These were fitted in such a way that they could not be removed for needful cleansing. An offensive odor was detected in the mouth. With a great deal of difficulty I suc

ceeded in extracting the dental plate. The murder was out! The infra-lingual area was found to be in a most foul and filthy condition. Fungating masses of readily bleeding tissue lay bathed in a stinking fluid, swarming with microorganisms mingled with the débris of epithelial cells and of blood corpuscles, decomposing pus, mucus, salivary salts, and fragments of food.

This malodorous mixture was promptly cleared away, and the floor of the mouth was well swabbed out with decolorized iodine.

There seems to exist little ground for doubting that in this instance the septic elements were absorbed by the buccal venules or by the lymphatics, and were carried into the general circulation. They exerted their usual influence over the nervous system, acting as a sedative poison on certain trophic centres. These poisonous particles appear to possess an elective affinity for those nerve-centres which especially preside over the locomotor apparatus. In connection with this case of sapræmia, I will venture to deviate for a moment from my immediate subject. It will not be quite out of order to say that I have made a series of observations of considerable interest to the dermatologist. When putrid pus associated with schizomycetes, streptococci and similar organisms, and with decomposing organic matter from food, etc., is absorbed from the mouth, acne rosacea is occasionally seen on the cheeks and forehead. On the other hand, if pus products be absorbed from the genito-urinary tract, the chin is the favored locality for the acne. These are matters which well deserve careful notice and a scrupulous sifting.

To return to the question of the toxæmic origin of some forms of rheumatism, the problem naturally presents itself: Are the joints poisoned directly or indirectly?

That the septic material is not carried to the joints directly, but that these suffer via the nervous system, seems likely from the following considerations:

1. The frequent presence of symmetry, especially in first attacks. 2. The extreme rarity of joint abscess in connection with rheumatic gout.1

3. The researches of Raymond' make it probable

a. That the muscular atrophy is not due to mere disuse.

b. That the muscular changes, though at times associated with neuritis, are not themselves products of that neuritis.

c. That the changes in the intra-fibrillary muscular substance, in the neighborhood of an osteo-arthritic joint, are synchronous with the changes in that joint.

1 Morrant Baker: "Synovial Cysts," Bartholomew's Hospital Reports, 1874, p. 245; 1885, p. 189. Mansell Moullin: " Pyo-osteo-arthritis," Lancet, July 18,

2 Revue de Méd., No. 5, 1890.