in which the indications are not so plain, and it is just these in which the use of blood pressure as a gauge is valuable. A number of cases in which the blood pressure has been taken have been operated upon, and in all it has been a reliable guide when properly interpreted. This pressure can be learned by means of a very simple instrument known as the Riva-Rocci Sphygmomanometer. Attach a hollow rubber band to the arm and inflate it with air until the pulse disappears and, this being connected with a column of mercury, shows in a normal individual the blood pressure at one hundred and thirty-five or forty, while in those cases of injury requiring operative interference frequently the blood pressure runs to three hundred or more.

Upon the discovery of the X-ray it immediately took an exalted place as a permanent addition to surgical diagnosis, and it is still making new conquests in both diagnosis and treatment. It is getting to be of more and more assistance in all our work which involves bone and foreign bodies in the tissues which cast shadows, and in calculus of the genito-urinary tract, and it is going to be of much more value in relation to gall stones. It is my belief that in the near future the X-ray will locate gall stones with almost a certainty. We must come back occasionally, however, and think carefully about the radiograph, unless we leave the interpretation entirely to an expert, and remember that it is only a shadow after all, and may give all the distortions that are exhibited in our pantomime shows of childhood.

My first bad result from a Colles fracture was due to an overconfidence in the X-ray. Previous to that time I had watched each case carefully and kept the bone in good position, but in this instance left the arm in the dressing and relied upon the X-ray, which deceived me into thinking that the arm was absolutely straight. This may have been true in the particular direction in which the shadow was cast. As a matter of fact, there was considerable deformity. The shadow, if cast in the right direction, may obliterate a bad deformity of the bone, while on the other hand a very slight projection may be made to appear as an unjustifiable blunder. Thus a radiograph, while very valuable, becomes a very dangerous weapon in the hands of the ignorant, and often an unsafe method of diagnosis in the hands of those who are not experts. Recently a patient brought me a beautiful X-ray of a urethral stone in the pelvic region. It cast a rather faint, but distinct, shadow oval in shape, and apparently as large as the end of my thumb. A thoroughly reliable man took this radiograph, but when the patient brought it to me with the intention of having me operate she was asked to have second radiograph taken to be sure that it was a stone. In a previous case my radiograph of a urethral. calculus gave a much brighter shadow. She had another picture taken by another capable man, and he found the same thing in the same place and believed it to be a ureteral calculus. I operated, going in behind the peritoneum, and found the ureter and traced it through the pelvis, but found nothing in it. I felt through the peritoneum, however, what I believed to be the ovary in the exact location of this calculus, and then upon going into the peritoneal cavity a tubercular peritonitis was found with the ovary in this position and filled with a caseous semi-fluid material. This material had evidently cast the

shadow which caused the diagnosis of ureteral calculus. I do not mean to decry the X-ray, but simply urge the exercise of caution in our deductions from its use. While pointing out these danger signals, it is still my firm belief that it is decidedly advantageous to have a radiograph in every case of fracture, and from this in many instances. valuable aid will be secured, and in all cases in which there is a question as to bone injury the X-ray is almost invaluable in its assistance in diagnosis. It should also be used in all cases of suspected calculus in the genito-urinary tract, but at the present time too much reliability should not be placed on it, as I have removed a large calculus from the pelvis of the kidney which showed a negative radiograph.

In our various refinements in diagnosis, especially with the additional mechanical appliances, there is a tendency on the part of practitioners to become less expert with their own senses and less acute in their observations. Just as a blind man hears more distinctly, or the deaf one will see everything more plainly, so with our facilities-by the constant use of them we make them more valuable. The physician of old, without a thermometer, was well practised in his estimation of a patient's fever, and the physician who constantly feels the pulse to estimate blood pressure would be more acute than the one who depends solely upon a blood pressure instrument. This, however, is no argument against the use of the clinical thermometer or the sphygmomanometer. By using the latter instrument as a standard and continuing our observations on the pulse, we can develop a proficiency impossible to those acting independently of such accurate mechanical aid.

Two Cases of Locomotor Ataxia in
Man and Wife.

Dr. E. Staehlin reports two cases, interesting on account of the indirect way in which the diagnosis was made and because they are both traceable to syphilis as the etiological factor (Medical Record, November 5). A man presented himself with the typi cal urine of an advanced cystitis, which caused few subjective symptoms, however, and the urine soon improved under treatment. His wife asked for treatment at this time, claiming to have kidney trouble, but examination of both heart and urine was negative. It was discovered by accident that she frequently stumbled, even on smooth pavements, and this led to an examination of the reflexes. The patellar reflex was absent, the

pupillary reaction to light was lost, and Romberg's symptom was present. Cross-examination of the husband revealed the fact that ten before he had infected his wife with syphilis, and it was found that he, too, presented the cardianal symptoms of tabes.

The really fascinating story of Russia's progress toward a constitutional government, with a clear and full account of the reforms brought about by Prince Svyatopolk-Mirski and of the development of the zemstvos as centers of representative government, is given in an article entitled "The Dawn of the New Era in Russia," in the American Monthly Review of Reviews for January, 1905. The article is written from St. Petersburg, by Dr. E. J. Dillon, the well-known English journalist.

OSTEOMYELITIS NECESSITATING HIP JOINT

AMPUTATION.

By E. B. MCDANIEL, M. D.

Baker City, Oregon.

Read before Eastern Oregon District Medical Society, July 7, 1904.

In selecting he subject for a short paper before this Society, I want to call your attention to a subject with which we are all familiar, namely, Osteomyelitis.

This condition was never accurately recognized until described by Chassaignac, in 1853, and he missed many of its most distinctive features. The disease is distinctly an infectious process, limited sometimes to the bone marrow and internal portions of the bone-sometime, apparently, involving every portion of the osseous structure. Its onset is sudden-its manifestations most acute and serious, and its ravages, when not promptly checked, are most destructive. The following, more or less distinct varieties, may be distinguished: staphylococcus, streptoccus, pneumococcus, tubercular and miscellaneous infections, including the colon bacillus and typhoid bacilus, etc., but be the organism what it may, the mode of infection and the lesions produced by it are essentially similar, and may all be described together. These consist in a rapid thombosis, coagulation necrosis, and suppuration, along with the local destruction incident thereto; and with the unlimited possibilities, in a way, of autointoxication, both from local lesion and from the disturbance of the general economy and interference with the excretion. For the average case three more or less distinct stages can usually be distinguished; first, a period of purulent infiltration; second, period of sequestration, or formation of sequestrum; and, third, period of repair. But in one case coming under my care, of extremely virulent bacteria, the intoxication was so overwhelming that death followed within forty-eight hours after the first symptom of Osteomyelitis developed. In a general way, the signs and symptoms of all acute infectious lesions in the bone are strikingly similar, and are most significant when properly construed. The patient usually complains, first of exhaustion, followed quickly by pain, which may speedily become agonizing. This is often accompanied by an introductory chill, with high fever, after which the general character of the disease assumes the typhoid aspect. The evening temperature may rise high, and be followed by some morning remission-the spleen is usually enlarged, and often have to do with the fetid diarrhoea. In the young the sensorium is early affected and children quickly become delirious. The pain, at first vague, quickly focuses in the particular bone or bones most involved, and as it increases in intensity, there is a more and more significant tenderness, which becomes exquisite. Ordinarily, there is also early and characteristic reddening and swelling of the affected parts. With all these

evidences goes, also, a characteristic muscle spasm, by which certain posture signs will be produced, varying with the bones involved. The pain is always intensified at the slightest degree of motion-in consequence the limbs, for they are the parts which are usually involved, are contracted, and every effort to overcome the contractures is followed by aggravated pain. The more acute the pain, the more vivid the external evidence of inflammation, and the odema of the parts, especially below and about the lesion-thus it may happen that within a few hours we have not merely swelling, but actual odema of the parts involved, which should always be regarded as pathognomonic. A little later we find fluctuation, if periosteal abscesses have formed, or, possibly, the evidence of epiphyseal loosening or complete separation. When the disease is primarily in epiphysis, the corresponding joint will early become involved, the joint symptoms will take on rapidly the type of an acute purulent synovitis, only with much more significant degree of pain. It is probable that under few, if any, circumstances is the pain complained of more serious or aggravated than in cases of acute Osteomyelitis of the fulminating type.

So far only local symptoms have been described. To these must be added the list of those pertaining to thrombosis and metastatic infection, with their septic and disastrous consequence. The disease is frequently so acute and rapid, that even within the first day or two there is not only extensive thrombosis in and along the bond, with rapid purulent denegration and thrombi, but even more serious general conditions to which these lesions so early give rise, or unmistakable pyaemia. Moreover, other septic infections, as, for instance, septic pneumonia, metastatic meningitis, pericarditis or nephritis may occur in a more irregular or less classical manner. In fact, there are few, if any, infectious processes which can be followed by death from such a variety of causes, and which are so augmented by dangers if not promptly relieved as acute infectious Osteomyelitis.

The prognosis depends in a large measure upon the early recognition of the disease and the prompt affordance of surgical relief. I think there is no disease less amenable to purely medicinal treatment, and if bones are to be saved in their entirety, early and free incision is absolutely demanded. If the case is seen late it almost invariably entails necrosis, or possibly such a serious condition as to call for amputation of the limb, as was the condition of the three cases reported. However, if seen early enough, and operated upon promptly, almost every case can be saved with but slight loss of bone tissue.

The disease for which Osteomyelitis is most commonly mistaken is acute rheumatism. There may have been some excuse for this in the past, because of the lack of general knowledge of bone infections, but now this condition is changed. The majority of cases of extensive necrosis, following Osteomyelitis, which have come under my observation, were the result of mistaken diagnosis, at a time when surgical relief might have prevented any local disaster. The treatment of acute Osteomyelitis is essentially surgical. Anodynes may be necessary for the relief of pain, but no time should be lost when once the diagnosis is made in making incisions sufficiently long and deep to expose the bone involved, opening to its interior in order to relieve tension, and

to remove septic products. In almost every instance as we go deeper the tissue will be found more and more edematous or infiltrated, with every evidence of the proximity of pus. The periosteum will be thickened and infected, and between it and the bone we may find collections of pus, as well as outside of it. The periosteum should be incised completely down to the bone throughout the length of the incision, and then an ordinary bone drill may be used to perforate the bone for exploratory purposes. From the puncture in the bone will exude a purulent fluid, thus indicating the condition within. It is now necessary to cut a deep grove or channel, perhaps from one end of the bone to the other, completely opening the marrow cavity. The entire pus-containing cavity being freely opened, should be scraped and disinfected the bone cavity being packed with gauze and the wound left open. Even this may not always be enough, but, if there be epiphyseal separation, or, more unfortunate yet, if there appear evidence of joint infection, the neighboring joints must be explored, which, if pus is found within, they must then be freely opened, washed out and drained. These operations are often severe, but nothing in the way of operative treatment can be so severe, nor so serious, as the disease itself when left unoperated; and the rule is stringent and far reaching, that every infected tissue, and especially every infected. bone interior, must be thus exposed without mercy and thoroughly cleaned out.

REPORT OF CASE ONE.

Mr. McF., age 37; American by birth; occupation, farmer and miner; family history, good. Patient was brought to the hospital on March 1st, 1900, in a very impoverished condition. Three or four months before coming to the hospital, while chopping wood, the axe glanced and cut his leg about three inches below the knee; the cut being small, was simply tied up and nothing thought of it for a few days, when the leg began to be very painful. All the home remedies were tried, and then tried over again before a physician was consulted. By this time the leg was greatly swollen and very painful. All the local remedies were used, but no permanent relief followed. Upon examining the leg when he entered the hospital, I found the leg in very bad shape. It was badly swollen, of a dark red color, and had the typical contractures. At the site of the original wound made by the axe was a small sinus, through which the pus constantly escaped. Upon passing a probe through the sinuous an extensive area of dead bone could be felt, and by using a flexible probe it could be passed into the knee joint. At the time the pulse was 116, temperature 100 degrees. The cavity was washed out with peroxide of hydrogen, packed with iodoform gauze, and the limb done up in a bichloride. pack. This was continued until March 16th, during which time every means of stimulation was used with which to build up the general system. On the morning of March 16th he was operated upon. The tibia was opened up and found to be full of pus-also the knee joint. The destruction of the knee joint was very marked. The soft tissues about all gone and articular ends of the bones were exposed. The thigh was then amputated at the middle third. When the medullary canal was cut into with a saw a very free flow of pus occurred from