tion seems to be the ideal one. I have tried other methods, but have come back to the Bassini, and practiced that entirely. The one difficulty I find in this operation is sometimes in separating the cord on the sac, sometimes considerable time is necessary for this. The rest of the operation is easy. In the use of suture material, each man has his own choice, and is very likely to stick to what gives him the best results. For myself, I use almost entirely silk. There are two reasons why I use silk. I know it can be made sterile-boiled before the operation. You cannot be sure of catgut, it seems to me, as it is difficult to prepare it so that it is always reliable. use medium size silk, and never have any trouble with it. I do not recall a case where I have had suppuration, or where I have had any trouble from this material. The other reason that I use silk for sutures, is that it is not absorbable, and it is a suture that will last, for we need something that will be a support for some time; sutures aid in holding the parts together. I have operated on a child as young as ten weeks, and on men as old as sixty years, with good results, but as a rule I think this is not wise. DR. WOLFE. In the matter of suture material, my experience is not very extensive. I have used silk in three or four cases. Perhaps the silk was improperly prepared, but my experience with it has not been very favorable. DR. FELL. I have had, this last month, two very interesting cases of hernia; one case where a man was sent to me for obstruction of the bowels. The bowels were obstructed for about three days. I determined to operate, and found the obstruction was due to hernia, reduced in mass. The sac was different from any others I have seen under like circumstances. If you could form a neck of the sac, this would be about the condition held by the intestines. First, I cut the sac from the abdominal side, and released it, then replaced the intestines, and the patient made a good recovery. There was a good deal of inflammation in this case, and adhesions were different from what we ordinarily find. The other was a woman who was sent to the hospital about three or four days after the hernia had appeared. Her physician advised her to be operated upon; he had used everything that he though advisable, but every method he used failed, and in operation he had the opposition of friends from outside who had seen the patient and advised her not to be operated upon. She was finally taken to the hospital one night, and the next morning we operated upon her. The sac and intestines were in an awful condition, portions of it were entirely rotten, but I think she has a fair chance of getting well. I have had three or four cases of obstruction of the bowels due to hernia, that reduced themselves in mass. I think it is wrong today to allow any person to die of obstruction of the bowels, without opening the abdomen and ascertaining the cause of the obstruction. DR. STEWART.-I think it is a mistake, as a rule, to operate on children much under four years. Of course I am not speaking of strangulated hernia-I operated on a child two or three weeks old for strangulated hernia. The majority of children are cured by wearing a truss, if the truss is kept on carefully. The same way with people over fifty years old; unless the form is strangulated hernia, they can be made comfortable. Now about suture material. I think catgut can be made as sterile as silk, if properly prepared. ARTHRITIS DEFORMANS. BY DR. S. P. MENGEL, PARSONS, PA. Arthritis deformans, rheumatoid arthritis, or as the older writers termed it, rheumatic gout, is a disease, the essential nature of which is still obscure. Authorities differ widely in their views regarding the etiology of this disease. In presenting this paper it is not our object to add any new view or champion any new theory concerning this malady, but merely an attempt to give you a review of the recent literature on this subject, more especially the etiology, diagnosis and treatment, and endeavor to differentiate it from the numerous allied rheumatic conditions. The theories advanced in explanation of arthritis deformans are, first, that it is a form of chronic rheumatism. Second, that it is a mixture of chronic rheumatism and gout. Third, that it is caused by a specific germ, and fourth, that it is of nervous origin. As regards the first and second theories there are but few authorities to-day who believe there is any relation between this disease and rheumatism or gout. German authors still maintain that there are some few cases dependent on a true rheumatic infection and result by a direct continuation of an acute rheumatic disease. Braumler names such cases chronic rheumatism of the joints, but admits them to be extremely rare. The fact remains that most writers admit they never observed any case of arthritis-deformans in which the affection was proven to result from an attack of acute articular rheumatism. Dr. Wm. Ewart, in a paper on the "Relation of Gout to Rheumatoid Arthritis," declares them to be distinct diseases, and states that attacks of the latter disease differ absolutely from an attack of gout. Instead of being sharp and of short duration they are apt to last almost indefinitely. Bacteriologists have long attempted to isolate the germ they believed to be the cause of arthritis deformans, and in some instances have succeeded in the cultivation of bacteria from synovia taken from the affected joints. Their descriptions of the micro-organisms, however, do not agree. Definite organisms claimed to be the cause of this disease have been found by Dor, Bannatyne and Wohlmann, Schuller and Von Dengun and Schneider. Dor claims to have reproduced the disease by injecting cultures into the blood of rabbits, and considers the germ an attenuated culture of the staphylococcus pyogenes aureus. Bannatyne and Wohlmann cultivated a dumb bell shaped bacillus, resembling in many cases a diplococcus. They made their cultures from the synovia of the diseased joints. Blaxall found the same bacillus in small amount, in the blood of his patients. Schuller's description of a bacillus cultivated from the synovia of the diseased joint, its manner of development, etc., does not correspond with that of Bannatyne. Von Dengun and Schneider cultivated a bacillus from the liver as well as from the synovia. They injected the cultures into the knee joints of rabbits, and claimed it gave rise to a condition resembling arthritis deformans. Judging from these experiments it seems demonstrated that micro-organisms are constantly found in the synovia of the diseased joints but their true significance and mode of action are still left for future experience to demonstrate. Osler says the true nature of this disease is still obscure, but the neuro-trophic theory meets with many of the facts. He further states that it is difficult to separate some cases from ordinary chronic rheumatism, but the multiple form has, in all probability, a nervous origin as suggested by J. K. Mitchell. Mitchell's views are based upon such facts as, First, the association of the disease with shock, worry, grief, etc. Second, the symmetry of the joint affections. Third, the similarity of the joint affections to the arthropathies found in disease of the cord as in locomotor ataxia. Fourth, the trophic changes which lead to alterations of the skin, nails and occasionally to extensive muscular atrophy, and lastly the time of occurrence. Ord believes the disease analogous to progressive muscular atrophy and caused by a lesion of the cord or to changes due to peripheral irritation, traumatic, uterine, etc. Most cases set in between the ages of twenty and thirty years, although some claim it occurs most commonly at a later period of life, between forty and fifty years. It may occur in childhood. Women are more frequently affected than men. In Garrod's table of 500 cases, 411 occurred in females. Women affected with uterine or ovarian disorders, or who are sterile, are particularly liable to the affection. Heredity has been traced in some instances. All classes are affected. There is no evidence to prove cold or damp or traumatism to be efficient causes, although some claim the contrary. Charcot divides the cases into general progressive form (acute and chronic), mon-articular, and Heberden's nodosities. The acute form is difficult to distinguish from acute articular rheumatism. The presence of deforming changes and the extreme pain, out of proportion to the signs of local inflammation should exclude the latter. This form is extremely rare and is usually found in young women, often in connection with pregnancy, excessive lactation or the menopause. The chronic form is often equally difficult to distinguish from chronic rheumatism. The latter disease, however, is claimed by some eminent authorities to be far less frequent than was formerly supposed, and many cases diagnosed as chronic rheumatism are in reality cases of arthritis deformans. In chronic rheumatism usually only a few of the larger joints are involved, there is no marked fixation of the joints, and the peculiar deformity is absent. On the other hand arthritis deformans is a progressive disease and does not tend to cause any cardiac complications. Dr. James Steward, of the McGill University, claims there is no sharp dividing line between certain cases of rheumatism and the earlier stages of arthritis deformans. The editor of the Medical Annual, however, claims that if more attention were paid to the muscles than to the joints during an examination, the difference could be readily determined. He claims the loss of tonicity of the muscles, in arthritis precedes the joint affections, and is so decisive that by merely shaking hands with two patients, each supposed to have only slight rheumatism, it is possible to distinguish the arthritic case from the rheumatic. Later on in chronic rheumatism when wasting of the muscles occur, and so produces deformities which are supposed to be characteristic of arthritis deformans, mistakes are apt to occur. But in these cases the true arthritic patient should present a moist palm; when the skin is dry, chronic rheumatism or chronic gout may be suspected. The X ray may clear up a cloudy diagnosis providing it be possible to have a radiograph taken. In the successful practice of medicine, the most essential feature is the ability to make a correct diagnosis, especially does this apply to arthritis deformans. Dr. Ewart, whom we previously quoted, in speaking of the acute variety of this disease, says: "They are generally treated as attacks of acute or sub-acute rheumatism. But the more sedulously antirheumatic methods are applied, so much the worse may the |