to ascribe their production partially, at least, to the injection of the lymph.

From the history of cases as given in this paper the profession will be enabled to form its own opinion of the value of Mr. Furley's cure for small-pox, but having carefully watched the cases while under treatment, and compared the result with that in others admitted during the same period, I feel myself justified in saying that in not a single instance did the treatment exercise any beneficial influence either over the progress of the disease or over the result, but rather the contrary. Consequently the opinion forced upon me is that the hypodermic injection of lymph in small-pox is worse than useless. July 13th, 1872.

DEATH FROM LIGHTNING.

BY ROBERT OKE CLARK, M.R.C.S., L.S.A.,

AND

JOHN KING BRIGHAM, M.D., M.CH.

ON May 8th, about 5 P.M., a man aged seventy-four was brought to our surgery, said to be suffering from lightning. stroke. The history was that during a very severe storm, which had passed along the valley about an hour previously, he had sought refuge from the pouring rain under a large fir-tree, which stood nearly alone on an eminence in a large field. The electric current seemed first to have passed down a high hop-pole on to which a woman was tying the young hops, glanced thence through a quickset hedge and stripped it of its leaves, and then, touching the fir-tree, passed through the old man (throwing him down on his face), and so to the earth. The woman herself was much affected by the lightning, which seemed to pass down her right arm, rendering it powerless, and completely drying up the milk in her breast on that side, the secretion of which has not returned.

We found on examination that the man was moaning a good deal, but was quite unconscious; the lower extremities paralysed, and the arms partially so. His high hat had been torn into pieces of a most fantastic shape; his jacket, waistcoat, and trousers were rent in various places; and one boot was completely ripped open. Blood was flowing freely from a serrated wound over the right temple, from several small wounds on the head and face, and also from the mouth, which was charred and lacerated. There was no ecchymosis or contusion in the neighbourhood of any of the wounds. His wounds were dressed, some stimulants prescribed, and he was removed to the union-house, which he had left in the morning to visit his brother. His state continued unchanged during the evening; the hemorrhage ceased, his pulse remaining fairly good.

May 9th.-Passed a restless night, being very violent at times, and moaning continuously, but dozing at intervals. Pulse 80, weak, irregular, and intermittent. Body moderately warm. Respiration deep and hurried. The facial paralysis had somewhat passed off, and he looked more conscious, but was not really so; he was quite unable to speak. There was manifest hyperesthesia of the skin, and great muscular irritability. The bladder was paralysed, and required the use of the catheter, two pints of urine being removed, which was perfectly healthy and natural. There was great difficulty in swallowing, owing to the abraded condition of his mouth. No fracture could be discovered in the wound, and nearly all hæmorrhage had ceased. Ordered to be kept perfectly quiet; to take farinaceous diet, milk, and beef-tea. An injection to be used if the bowels did not act.-8 P.M.: Condition very much changed. His face was flushed; skin hot and dry; pulse strong and bounding, 98, irregular and intermittent. He had been very violent, requiring slight restraint. The pupils were sluggish, with ptosis of right eyelid. The respiration was more quickened, deeper, and sometimes blowing. The wound over the right temple had closed. There was considerable ecchymosis round the right eye. The hair on the right side of the head, eyebrow, eyelashes, and whiskers in some parts were quite burnt off, in others scorched; as was also the hair on the trunk, over the pubes, and down the right leg-the cuticle in many places being completely

charred. Some blood was still oozing from the mouth and nose; the whole palate was charred and black; the mouth drawn a little to the left side; tongue dry and brown. He was again catheterised; and ordered a stimulating enema, with cold to the head.

10th.-Passed a restless night, though the febrile symptoms were much lessened in intensity. Pulse 89. The bowels had not acted, nor had the bladder been at all relieved; the urine when drawn off was found to be natural. Tongue still swollen and charred, and deglutition very difficult. He had answered, or seemed to answer, one or two questions in the night, but was now quite unconscious. There had been twitching of the left arm and leg during the night; and an epileptiform attack, with twitching of the left facial muscles, occurred during our visit. Ordered two drops of croton oil and some warm beef-tea.-2 PM.: Continues the same, but the twitchings are more frequent. -7P.M.: Pulse 98; temperature 102-8°. Patient evidently sinking. Convulsive attacks have increased. Croton oil has not acted. Deglutition quite impossible. Facial paralysis returned and increased.

He died next morning at 2 o'clock.

Post mortem examinat on. The external appearances of the body were the same as described on the evening of the it and for some distance round blood had been copiously 9th. The scalp-wound had entirely healed; but underneath extravasated between the scalp and the skuil. Parallel to the scalp-wound, but slightly behind it, a very fine fracture was discovered, about an inch and a quarter long, in the squamous portion of the temporal bone, terminating in the and running backwards at right angles to it, was another temporo-parietal suture. About the centre of this fracture, fracture about half an inch long; the irregularly triangular piece of bone between these two fractures being black and charred. The sutures of the temporal bone were loosened, and the bone forced out beyond the level of the parietal and frontal bones. On removing the calvaria a large quantity of thickened but not coagulated blood was found beneath the dura mater in the vicinity of the fracture. The membranes were extensively torn, so that the blood was in contact with the surface of the brain at many points. The meninges were very much congested; and the greenish hue of suppuration was noticeable over the back part of the brain. All the sulci of the convolutions in the vicinity of the fracture were filled with black blood; the pia mater was broken down extensively, and reduced to a stringy condition-the very substance of the right hemisphere of the brain having become so soft as to resemble thickened pus, without losing the arrangement of its convolutions. The fluid in the ventricles was abundant and bloody. The upper ridge of the petrous portion of the temporal bone was charred in several places. A charred spot was seen on the orbital plate of the frontal bone, through which the electric fluid seemed to have passed out on to the face, the current apparently having passed down through the antrum into the mouth, lacerating and charring the mucous membrane and causing the hemorrhage from the nose and mouth. Rigor mortis came on very slowly. The charred skin was so tough that it could hardly be cut.

Great interest seems to attach to this case from the length of time that elapsed before death, and also from the blackened and charred condition of the bones and other tissues. Farnham, July 8th, 1872.

HAVING a considerable number of facts in connexion with

goitre, I have thought it worth while to record them-not that there is much of novelty in them, but I fancy few have such a field for observation. The statistics are taken from Nent Head, a lead-mining village situate on the mountain limestone, nearly fifteen hundred feet above sea level. Nearly all the water is hard, containing much lime. I tried to classify the villagers according to their water-supply, but found the results worthless, as many people were

goitrous who drank the same water as those who had never suffered at all.

There is a general feeling here, which I am convinced is true, that the water will not produce goitre unless the person inherit some tendency to it. I have found, as others have, that the poorer classes are the most subject to it; and in many cases I am sure that those who take beer or spirits are less liable: among the well-to-do there are some teetotallers, and I have seen goitre in several of these.

In obtaining my returns I left forms at the houses, and these supply my first table; but, not being quite satisfied, I examined all the children in the school myself, and append the result.

Goitre is so common that, unless the neck be very thick, it is not considered to be anything abnormal; hence my first table will only show most unmistakable goitres.

Many well-known facts will also be seen brought out strongly as the greater tendency in women, and the greater liability of the right side.

I obtained from the villagers their ideas as to causes, and subjoin these in the order of their belief:-Family; water; parturition; strains and coughing; overcrowding; cold, &c.

As to sources of relief, they mention-wearing of flannel; pressure of shirt-collar; heavy bead necklaces; change of residence, and climacteric change.

I have met with several dogs, setters and terriers, with enlarged necks; but do not know enough about a dog's thyroid. These tumours, on dissection, are found to rest on the trachea, and are firm fibroid masses which in life cause a difficulty of breathing.

Returns from 829 persons. Of these, 181 confess to goitre, of whom 58 are men and 123 are women. These occur81 most prominently or altogether on the right side;

20

left side;

80 are central, or indifferently on either side.

I examined carefully 234 school children, and of these 168 were goitrous. Returns as follows:

Right Left Geside. side. neral.

(two drachms and a half) of a yellowish liquid immediately escaped, together with a quantity of gas which I cannot exactly estimate. The tumour, which was as large as the fist, flattened immediately; and a very gentle pressure exerted for one minute near the neck of the sac caused complete reduction of the hernia. The patient felt immediate relief, and expressed his satisfaction.

During the few hours which followed-from 6 to 11, and more especially between 8 and 11 P.M.-there was a little vomiting, and more particularly nausea. The patient was somewhat feverish, and had slight rigor. I had administered, as I always do after reduction of hernia, whether by taxis or operation, pills of the gummy extract of opium (each containing one centigramme-one-sixth of a grain,to be taken one every two hours, so that ten or twelve centigrammes may be absorbed in twenty-four hours), with the object of bringing on paralysis of the intestines. At 11 P.M. the symptoms above alluded to all disappeared, and from that time the patient enjoyed the most complete comfort. June 22nd.-Pulse 60; countenance normal; scarcely any tenderness in the abdomen over the inguinal region. 23rd.—Three natural stools; no pain or fever; appetite excellent.

Eight days afterwards the cure, which had been evident even on the third day, had become quite permanent. The patient's health is now excellent. Paris, July, 1872.

1

...

...

27

STRANGULATED INGUINAL HERNIA OF THE RIGHT SIDE.

ASPIRATING PUNCTURE; ISSUE OF FLUID AND GAS ; IMMEDIATE REDUCTION; CURE.

BY DR. LÉON LABBÉ. SURGEON TO THE HÔPITAL LA PITIÉ, VICE-PROFESSOR AT THE PARIS SCHOOL OF MEDICINE, ETC.

THE extreme importance which the process of reducing hernia after an aspirating puncture must rapidly assume in surgical practice, the limited number of facts which have been known until now, and the interest there is in encouraging medical men to follow this direction, induce me to communicate the following case which I have just had an opportunity of observing.

In the night of June 20th Mr. D, aged seventy, an exceptionally strong and robust individual, after a violent fit of coughing felt an intense pain in the right inguinal region. This was followed in a few minutes by nausea and vomiting; whilst a somewhat large tumour showed itself in the right inguinal region.

On the 21st, at 6 P.M., I first saw the patient, together with his ordinary medical attendant, who had employed taxis with great care, but to no effect. I then tried taxis myself, but was equally unsuccessful. The nausea and vomiting still continued; pulse 75. Taking into account the circumstance that strangulation dated only about eighteen hours, and that probably the anatomical lesions would be very slightly advanced, I without hesitation proposed puncture with the aspirator, and without further delay I introduced the No. 2 needle. About ten grammes

FISTULA. TRACHEOTOMY.

(Under the care of Messrs. CALLENDER and MORRANT BAKER.) THE notes of the following interesting cases have been communicated to us by Mr. G. B. Ferguson, house-surgeon. CASE 1. Hysteria; a number of needles and pins removed from the arms and legs.-M. D a fresh-coloured, artlesslooking girl, spare but not badly nourished, was admitted into the hospital with the following history:-About four years ago she was subject to fainting fits, but has never appeared very excitable. According to her own account she had a fall last July whilst in service, by which her left knee was injured, and was for some time exceedingly painful. In this condition she was sent home, and the knee was then poulticed. After a day or two a needle was seen protruding over the patella; this her mother removed. As the knee was now better, she returned to her situation; but in about a fortnight, the same knee again commencing to distress her, she was again sent home, and before long five needles were removed, from the same situation. After a short time the arms and legs became similarly affected. Things proceeding after this fashion, 101 needles and pins, many of large size, curiously twisted and deeply imbedded, were removed by her usual medical attendant, Mr. Wicksteed, of Walthamstow. Although some years ago she had a habit of swallowing strange things-pieces of paper and the like, she is sure she never swallowed any pins or needles, and cannot, she says, give any explanation of their appearance. During her stay in the hospital in February last, ten needles and pins were removed by Mr. Baker and Mr. Ferguson.

The facts that the right hand and arm presented two marks only where needles bad been withdrawn, whereas the left hand and arm showed thirty-seven marks, that the girl was right-handed, that the pins were all destitute of heads, together with other circumstances, led to the conclusion that the case was one of hysterical deception.

slept the greater part of the night; temperature 101.1°; pulse 106.

11th.-Is very sick; passed a restless night; a good deal of fæcal matter has passed through the lumbar aperture; sickness recommenced this morning (it having begun yesterday but did not last long), and has been more or less constant ever since; has severe headache; expression anxious; knees drawn up; temperature 99-4°. 12th.-Sickness continues; ordered one drop of creasote in a pill every two hours; temperature 994°; pulse 112. The wound looks quiet. To take half an ounce of champagne every half hour.-9 P.M.: Sickness somewhat relieved; she has had an injection of morphia every six hours; temperature 98°; pulse 120.

13th.-Passed a restless night, vomiting at invervals; is quieter this morning, but is evidently sinking; pulse is very feeble. She died this afternoon.

Post mortem appearances. — Diffuse suppuration between the external and oblique muscles extending upwards on lower ribs and over the front of belly to groin, downwards along psoas and iliacus; here subperitoneal. From this inflammation seemed to have spread to the peritoneum, the surface of which was generally slightly dull, its polish dimmed; general redness and a little flaky serum in peritoneal cavity. Colon greatly thickened. An opening into peritoneal sac from the external wound, which would admit the finger-tip, just at median border of colon.

DISLOCATION OF THUMB; EXCISION OF HEAD OF
METACARPAL BONE.

(Under the care of Mr. ANDREW CLARK.)

J. S-, aged twenty-five, applied as an out-patient at the Middlesex Hospital with well-marked dislocation of proximal phalanx from metacarpal bone of right thumb. She stated that three weeks before Christmas she was lifting a kettle with her left hand, and dropped it; she put out her right hand to catch it, and this led to the accident. It was poulticed and then leeched, and she was under treatment for five weeks without any attempt being made to reduce the dislocation, but it was then said to be reduced, and the hand was put on a wooden splint, which was changed a few days after for a gutta-percha one. She wore this till she came to the hospital on February 15th. On the 19th chloroform was given and an attempt made to reduce it, but without success, a great deal of swelling being produced, which went down with an evaporating lotion. She said the projection caused by the dislocation was very much in her way, and she was very anxious to have something done to remove it. On March 6th she was again put under the influence of chloroform, and an attempt made at reduction, the tendons round the joint having first been divided subcutaneously. As this also proved unsuccessful, it was determined to excise the head of the metacarpal bone; this was done, and the thumb put into position. The hand was kept in a bath of chloride of zinc lotion (two grains to the ounce) for the night; after this, a lotion of sulphurous acid was used, the hand and arm being supported on a splint. By the 23rd the wound had nearly healed, and a gutta-percha splint was fitted to the part. When seen on the 20th of April she was able to use that hand.

COVENTRY AND WARWICKSHIRE HOSPITAL. CASE OF UNUSUALLY LARGE HERNIA. (Under the care of Dr. LYNES.) THE notes of the following case have been communicated to us by Mr. M. A. Fenton, M. B., house-surgeon.

Wm. B, aged seventy-seven, coal merchant, was admitted on March 21st, for retention of urine consequent upon enlargement of the prostate; also he had an immense double inguinal hernia. He gave the following history:The first hernia occurred on the right side about twenty years ago, the second about two years after. It appeared that the openings in the abdominal walls were very large from the first, as the patient stated the intestines came freely down into the scrotum immediately after the ruptures occurred. Being unable to obtain a truss which would keep the parts in position, he went about for some years without any support to the abdomen, during which time the scrotum continued to enlarge, more of the intestines

coming down into it, till it reached its maximum size some twelve years ago.

On examination the abdomen appeared flat and depressed, and evidently contained little of the intestines. The scrotum, distended to an enormous extent, reached nearly as low as the knees. The measurements of it were as follows: from the perineum behind over the apex or lower part of the tumour up to the external abdominal ring in front on the left side, twenty-three inches; on the right, eighteen inches; the greatest circumference, about half way down the tumour, thirty-three inches. The penis had altogether disappeared, its position being marked by an oval opening through which the finger could be passed to a depth of some inches before reaching the glans; the original skin of the scrotum could be discerned on the front beneath the aperture for the penis; the rest of the tumour was covered with hypertrophied skin, which was not at all tense, notwithstanding the great size of the hernia. In front the surface was nodulated, taking the form of the intestines which it contained; the vermicular action could be distinctly seen producing a wave along the surface over the course of the intestines; two waves could generally be seen, one following the other at a distance of about three inches. The patient was also suffering from chronic cystitis, from which he died about three weeks after admission.

The post-mortem examination, made twenty-six hours after death, revealed the following state of things:-The duodenum, after winding across the spine, passed into the left side of the scrotum through the inguinal canal, which was so large as to admit the hand and forearm easily; this side contained the whole of the jejunum, and about half the ileum, the other half passing back into the abdomen and down into the scrotum on the right side, where it terminated; this side of the scrotum also contained the cæcum and part of the ascending colon, the rest of the colon, the stomach, and duodenum being the only intestinal contents of the abdomen. The bladder was far advanced in disease; the internal surface was rough and corrugated ; the substance thickened and softened. The kidneys were much congested. Other organs healthy.

DEVON COUNTY ASYLUM.

TWO CASES OF ERYSIPELAS AMBULANS VEL ERRATICUM. (Under the care of Dr. SAUNDERS.)

THE following notes and remarks have been forwarded us by J. Wilkie Burman, M.D. Edin., late assistant medical officer:

CASE 1.-No. in register, 2995; female, married, aged fifty-nine. Admitted in 1865. In September, 1870, erysipelas commenced in the face, spread from thence to the scalp, thence down the back of the neck to the chest and arms, and gradually extended downwards over the abdomen to the distal parts of the lower extremities. The eruption faded away, and was followed by desquamation, in the order of its appearance, and finally disappeared at the feet, where several small abscesses formed. The illness extended over five weeks, patient lying for some considerable time in a low typhoid state, and at times in an apparently hopeless condition, but by the free use of stimulants and nutrients a slow and tedious convalescence at last commenced, and eventuated in complete recovery.

Strong nitrate of silver was applied on several occasions at the margin of the progressing erysipelatous blush, but perchloride of iron, chlorate of potash, and simple salines, without effect. The medical treatment was principally by

such as potus imperialis ad lib.

CASE 2.-No. in register 3049; male, single, aged fiftyone; admitted in 1865. In February, 1871, he was attacked with erysipelas, which, commencing on the face and scalp, pursued a course very similar to that in Case 1, differing, however, in the non-formation of abscesses in the feet, and in the occurrence of general dropsy without albuminuria. His illness was prolonged for a period of two months, and his life was frequently despaired of, the typhoid condition being both more marked and persistent in this than the former case, and the patient remaining for many days with a dry glazed tongue, quick and weak pulse, and hot and dry skin. He was only "pulled through" by a lavish use of stimulants and concentrated nutrients. The medical

treatment was the same as in Case 1, with the exception of special treatment for the dropsy. With the subsidence of the eruption the dropsy gradually disappeared, and, though much reduced in weight, the patient ultimately made a good recovery, losing, however, a considerable quantity of hair from the scalp.

Remarks. This very peculiar and dangerous form of erysipelas has been little more than mentioned as one of its varieties by most authors on surgery. The best accounts of it are given by Dr. Pirrie in his "Principles and Practice of Surgery," p. 82, and by Campbell de Morgan in Holmes's "System of Surgery"; but in each of these cases merely a short paragraph is dedicated to its consideration. So far as the writer can ascertain, there are only two similar cases on record-viz., one by La Motte (Cooper's "Surgical Dictionary," article Erysipelas), and the other by M. Vidal ("Médecine Opératoire"). Besides the general progressive nature of the disease, it is peculiar on account of its very severe and prolonged constitutional symptoms, which are of a low type, and call for an eminently sustaining treatment. The local symptoms are not of much moment, though the whole thickness of the skin is involved; for the worst topical occurrences in the two cases above described were small abscesses in the foot of one, and small bullæ here and there on the skin of both as the disease progressed.

HÔPITAL LARIBOISIÈRE.

OSSEOUS CYST OF THE LOWER JAW.

(Under the care of M. VERNEUIL.)

THERE is at present to be seen in the wards of Dr. Verneuil at Lariboisière Hospital, an interesting case of tumour of the jaw. The patient is a man twenty-seven years of age. The tumour. is situated on the right side of the lower jaw. Externally it presents the size of a large pigeon's egg, and is quite painless even when pressure is exerted. It is depressible, soft, and elastic in certain parts, and hard and bony in others. It forms part of the jaw and is immovable upon it. It has taken about a year to reach its present size. Near the tumour is the carious root of a molar tooth. M. Verneuil does not hesitate to classify this tumour with the osseous cysts described by Dupuytren. The idea of a dental abscess must be excluded, as there has never been any pain, and as the tumour is quite independent of the gum; indeed there can be no doubt that it is seated within the bone. On the other hand, there are no symptoms to suggest the idea of a cancerous tumour. M. Verneuil proposes to puncture the tumour with the aspirating syringe, so as to examine the contents of the tumour, and thus add to the safety of his diagnosis. He will then cut off a bit of the tumour from the surface which it presents in the mouth, with the object of bringing on suppuration within the tumour, and thus promoting a healing process.

HÔPITAL LA PITIÉ.

A FEW days ago, on visiting the surgical wards of La Pitié, we heard M. Lannelongue make some practical remarks touching a case of flat-foot (in a girl of twelve) which he was examining. These remarks were elicited by a recent publication of Duchenne of Boulogne, in the Archives de Médecine, in which the writer lays great stress on the impotency of the peroneus longus in the production of talipes valgus. M. Lannelongue emphatically demurs to this view, and in explaining the mechanism of the production of splay foot, lays stress on two points-pain in the joint, and contraction of the peroneus brevis. In this case (an incipient one) he thought that rest and immobility of

the foot would suffice to effect a cure.

Among the cases now under treatment in the wards of M. Broca, two are especially worthy of being noted.

PHOCOMELIA IN A CHILD OF SIX MONTHS.

The patient is a little girl of six months, and presents two congenital deformities-an umbilical hernia of the size of a pigeon's egg, and a peculiar deformity of the left lower limb. From the child's birth there seemed to be a total absence of the right thigh, and the corresponding leg

appeared to proceed directly from the body. Gradually, however, a hard projecting part, representing the knee, was seen to grow from the inner part of the groin; and, at present, on pulling the leg, the knee is brought down, showing a rudimentary thigh, in which the femur is very oblique, and is directed backwards and outwards. It measures about four centimetres in length. When the child is viewed from behind no thigh is discoverable, and the popliteal fold is confounded with that of the buttocks. The knee-joint is movable; it is habitually flexed, and extension movements are very limited. They, however, allow of the leg being put in a vertical position. The child is robust, and doing quite well. M. Broca considers surgical intervention in this case as highly useful, and recommends continuous extension by means of an appropriate apparatus during the whole period of growth. He thinks that the employment of such means is necessary in all analogous cases, where continued flexion canses arrest of circulation and proves an impediment to growth.

ELEPHANTIASIS OF THE LEFT LOWER LIMB AND OF THE

RIGHT LABIUM EXTERNUM.

The patient is also affected with hydatid cyst of the liver. The case is of interest from the fact of its appearing in Europe. The skin is hard, horny, with a brownish hue and deep folds of the surface; the foot is quite characteristic of elephantiasis. The disease broke out in youth, about twenty years ago, and has since followed a gradual progress, attaining its present development without ever causing any obstacle to walking.

Reviews and Notices of Books.

A Treatise on Diseases of the Bones. By THOMAS M. MARKOE, M.D., Professor of Surgery in the College of Physicians and Surgeons, Surgeon to the New York Hospital, &c. pp. 413. New York: D. Appleton and Co. 1872. DR. MARKOE's treatise "does not claim to be a complete compendium of all that is known on the subjects of which it treats," but we would willingly have exchanged some of its completeness for a little more originality. As a compendium of the current views on osseous pathology, we have little fault to find with the book; but we would rather have had more of Dr. Markoe's own views, and less of

Stanley, Paget, Billroth, Barwell, and Heath, and particularly more original and fewer borrowed illustrations. Hypertrophy and atrophy of bone, inflammation, and suppuration are duly described; and on the subject of osteomyelitis Dr. Markoe upholds the views of Roux respecting disarticulation, and believes Mr. Longmore's views to be "unsound and founded on an erroneous pathology. The tubular sequestra of which he speaks, and which he regards as always the result of osteo-myelitis, have in fact no connexion whatever in most cases with this formidable disease." (p. 53.)

We rejoice to find that rickets "is a disease so rarely seen in America that the author has no experience which would entitle him to speak of it authoritatively from his own observation." Under these circumstances, Dr. Markoe has done wisely in drawing his description from Sir W. Jenner's graphic account of the disorder. Caries is described as "a disease of the cancellous structure of bone, characterised by a chronic or subacute inflammation terminating in suppuration, which is partly infiltrated and partly collected into abscesses, the cavities of which abscesses, after they have discharged their contents, have a tendency to ulceration, whereby sometimes extensive destruction of bonetissue results." The author divides caries into primary or idiopathic, and secondary or symptomatic, by which latter he means the carious condition of the articular ends of long bones due to old-standing disease of the joint. In the treatment of this form the author lays stress upon the ap