Dr. J. H. POOLEY, of Columbus, Ohio, said:-I will go further than Dr. Sayre's proposition, and say that I believe the disease is not only not necessarily connected with a strumous diathesis, but never connected with it except by the accident of coexistence. What is scrofula? Take all the gentlemen in this room, one by one, and make each man give his description of scrofula, and you will have as many separate descriptions as there are separate describers. We hear a great deal about scrofula, and hardly know what we mean. I not only endorse the proposition of Dr. Sayre, but I would have framed it in stronger language.

Dr. HUNTER MCGUIRE, of Richmond, Va., said:-I think I can reconcile in one or two words the different views expressed in regard to the occurrence of scrofulous pus in hip-joint disease. I cannot believe that anybody here ever saw any other kind of pus in coxalgia than scrofulous pus, but it does not necessarily follow that coxalgia is of strumous origin. I was taught five and twenty years ago, and I think I have profited by the teaching since, that scrofula resulted very frequently from pain or irritation, or from the privations of life, such as insufficiency of food and clothing; so that, if a little child gets a fall, rapid coxalgia may follow, and then, in consequence of the pain and loss of appetite, struma may be developed, and there will then be scrofulous pus.

Dr. JOHN T. CARPENTER, of Pottsville, Pa., said:-The point at issue, it seems to me, is the local origin of constitutional diseases, upon which Professor Niemeyer has laid so much stress. I published a paper recently, in the Transactions of the Pennsylvania State Medical Society, in regard to the diseases of miners. Miners are subject to phthisis, and rarely live over 45 years. That disease, which we always believed to be constitutional, is caused by nothing but the inhalation of coal dust. We find solid carbon in the patients' lungs. The men die, and the old women live in the villages. Now, if their sons leave the mines and go into the agricultural districts, they live as long as other people. Here is a local origin of constitutional disease, and so it is with coxalgia. Every one of us knows that the first sign of constitutional disease in cases of coxalgia is an irritative fever, and thereafter sinuses form, and there is a discharge of pus, and phthisis may follow. The struma does not exist in the case until after long suffering and long disease. It is the consequence, and not the cause. Children whom I have treated by Dr. Sayre's method are now healthy and happy, and have never had any phthisis, or scrofula, or anything of that kind.

Dr. WILLIAM BRODIE, of Detroit, said:-Some years ago, when Dr. Sayre's views were first promulgated, I had occasion to see a great many cases of this disease in Detroit, and, with my friend Dr. Pitcher, had occasion to examine a great many people who came in from the surrounding country, all supposing that they were going to be cured by the new method. Some of these patients died of their coxalgia, and some from other causes. A great many post-mortem examinations were made, and I came to the conclusion that the disease commenced in the cartilage, and that, when this was absorbed, the bone itself became affected. I noticed in these cases the presence of a low grade of constitution, as if the patients had suffered from typhus, or were in an impoverished condition from cold. We know that children frequently lie exposed at night, or get into water, or get chilled in other ways, and then the external surface is affected, and a low grade of inflammation produced, which results in suppuration of the cartilage. I have always considered hip disease as scrofulous in its nature, but I believe that it originates in inflammation of the cartilage.

The President, Mr. JOSEPH LISTER, of Edinburgh, said:--The question whether this disease is or is not constitutional, must not be allowed to deter mine absolutely the treatment to be adopted. We must not say that because a disease is constitutional, that it is therefore hopeless to produce a permanent cure by treating it with local means. Take cancer, for example; that may be

in many cases constitutional, yet we know also of many cases of cancer which recover if operated upon early enough. There is a local manifestation of s hereditary taint, but if we take away the local manifestation, there may never be any other. This is the case also with struma. Glandular abscesses in the neck are strumous, and yet how many persons live to be healthy and sound after having these! It seems to me that if we have such a disease as struma at all, we have that disease in morbus coxarius. A child came to me in Glasgow to be treated for disease of the tarsus. He was treated with a long splint, and after a while, though still lying in bed, with the splint, several weeks afterwards, morbus coxarius showed itself. In that child there was a constitutional tendency which developed itself without traumatic cause. But I admit that traumatic causes are frequently operative, and we know the constant liability of children to be affected by traumatic causes.

Dr. GROSS said:-Have you ever seen suppuration in disease of the hip-joint, in which there was not scrofulus pus?

Mr. LISTER said :-I must confess that I have. In affections dependent upon strumous disease, there are great varieties of pus. The treatment which I have adopted has been, if there has been flexion of the limb, to extend it on a long splint, and keep the patient at rest. In the great majority of these cases in Edinburgh, perfect cures are obtained. In Glasgow, a considerable number of the cases are cured, but not so many as in Edinburgh. Then, again, in Manchester the number of cures is a minority. Now I believe the reason for this is that Edinburgh is a more healthy place than Glasgow, and that Manchester is a less healthy place than Glasgow.

Dr. SAYRE said:-I can hardly find language to express my feelings of regret whenever I am compelled to differ in a professional point of view from my distinguished friend Dr. Gross. But we must not let personal friendship, or personal respect and veneration, guide us in the expression of our opinions upon points of science. It seems to be conceded that an injury is often the exciting cause of the disease. Now, with regard to the matter of predisposition, I say that the ordinary teaching has been erroneous, and I believe that the doctrine has led to bad results in treatment. If the disease is necessarily of constitutional origin, it cannot be cured by local means. You must get rid of the constitutional poison or taint. If it is of constitutional origin, the development of some constitutional cause, the treatment ought to be constitutional, to affect the blood and the whole body. What has been the result of the belief in the constitutional origin of hip-disease? The use of internal remedies to correct the constitutional taint, and of local applications to the parts that are simply irritating. Dr. Gross has referred to the character of the pus: I happened to be present at an autopsy in a case of hip-disease in Berlin, made by Prof. Virchow, where an examination was made of the lungs, and heart, and intestines. In the specimens taken from that case there was not a trace of tubercular matter to be found. It was simply a case of pure chronic coxalgia. The pus was not of the kind referred to by Dr. Gross. Had that case been carefully examined and properly treated, in my judgment it would not have terminated fatally. The trouble was a local one, and the constitutional effects of the local trouble were mistaken for its constitutional origin. Prof. Gross will remember seeing a little child whose hip I exsected in Brooklyn. If there ever was a strumous condition, that child's condition was certainly entitled to be called so. In fact the child was almost dead at the time of the operation. It had lain in an exhausted condition for five or six years, with continued suppuration, yet by removing the cause of the trouble, without any constitutional treatment, or medicine of any sort or kind except something to eat and fresh air, from being a dead child, the child is running about to-day in perfect health. I sent its picture as a Christmas present to Dr. Gross himself. Now, in reply to the remarks of Dr. Richardson about cases of congenital dislocation, I may say that congenital dislocation has never been seen, although it has been described by Dr. Carnochan and others, and I believe that I am justified

in saying that the term is a misnomer. There is no congenital dislocation, but an arrest of the development of the acetabulum, the bone having never been completed. It is a congenital displacement, from an arrest of development, but not a congenital dislocation. The dislocations that occur in the adult are immediately recognized and attended to, and after reduction the parts are kept at rest until all danger of inflammation has passed; whereas the slight injuries which cause hip disease in the child are overlooked, and attention is not called to them until, by continued irritation, inflammation has supervened; and the general health frequently becomes involved before the slight local injury is recognized. Moreover, in the adult the head of the femur is much less vascular than in the child.

Dr. HINGSTON said:-We are told that hip-disease may originate from injuries to the cartilage and bone, and also from ruptures or injuries of the ligamentum teres. Now, I am wholly prepared to admit that in the first set of cases local treatment would probably suffice to effect a cure, but I wish to know if the same degree of probability applies also to cases originating in lesions of the ligamentum teres?

Dr. SAYRE said :—I can answer that question by a practical illustration. Five or six years ago a case of coxalgia was brought to me by Dr. Jourdon for excision. There was an open abscess, which had gone through all the various stages, the disease having originated from a blow two and a half years before. At the time I saw the case the child was hardly in a condition in which it was deemed advisable to operate, and so I thought it better, in order to save the child, to get it in a better condition. In the mean time, to make the child as comfortable as possible, and put it in a condition for treatment, I brought it out of its surroundings, and got it out of doors to build it up a little. When the time came for the operation, the child was so much better that I concluded to give it a chance without excision. I made a free incision into the joint, and took away a comparatively small portion of the bone only. Repair took place; the child got entirely well; and ran around a year and a half without any splint, and with only slight deformity, and with a tolerable degree of motion. Some year and a half ago, through exposure, the child got into a very bad condition, and the physician in attendance informed Dr. Jourdon that it was going to die. The child did die, and I have the specimen. The head of the femur and the ligamentum teres have entirely disappeared; a new covering had been formed, of what I do not know, but it was smooth, hard, and cartilaginous. So that that child lived two or three years without any ligamentum teres at all.

Dr. PosT said:-With regard to the necessity of resorting to excision, we all have known of advanced cases of the disease in which there has been a favorable result. I was called, two or three years ago, to see a patient in Jersey City. The knee was thrown up almost to the chin. It was impossible to place the child in a position even approximately straight, in consequence of the extreme pain which the effort gave him. He was almost ready to die from the constitutional disturbance attending the advanced stage of the disease. He was placed under the influence of ether, and the limb brought into as straight a position as possible. It was during cold weather, when there was a fire in the grate, and I put a poker in the fire, and made a thorough application of it behind the great trochanter. Improvement began from that time; and some time afterwards the child was brought to me free from deformity. Here was an entire recovery, and this case goes to show that excision is not always absolutely necessary.

Dr. SAYRE said :—I have only advised the operation in cases in which the disease progresses in spite of proper treatment.

Mr. LISTER said :—I think that a distinction between the stage of effusion, and the stage of suppuration, would be more in accordance with the general pathology of the subject. I believe the last stage of hip-joint disease is invariably the stage in which suppuration is present. Where effusion exists

without suppuration, a permanent cure may result by drawing off the fluid. If the case has gone on to the condition in which sinuses present themselves, I should be prepared to endorse the proposition that excision is the proper treatment; but if there is suppuration without an external opening, I am bound to express my strong conviction in favor of merely opening the abscess. I know of numerous cases in which the abscesses have been treated antiseptically, and in which the patients have recovered. Certainly in these cases the treatment had better results than if excision had been resorted to. I remember one patient, a healthy young woman in Glasgow, whose two limbs became exactly alike, except that there was the mark of the small incision made in opening the abscess; and this result was a great deal better than if excision had been adopted.

Dr. HINGSTON said :—I wish to ask Dr. Sayre if he can tell from the position of the sinuses, whether the acetabulum or the head of the bone is diseased? Dr. SAYRE said:-I cannot; the pus will, in either case, gravitate in the easiest direction.

On motion, the conclusions of Dr. Sayre's paper, with the exception of the second, were adopted as expressing the opinion of the Section. With the second conclusion, the Section could not unanimously agree.

REPORT OF A CASE OF SUB-PERIOSTEAL EXCISION AND DISARTICULATION OF THE ENTIRE INFERIOR MAXILLARY BONE FOR PHOSPHORUS

NECROSIS.

BY

JOHN W. S. GOULEY, M.D.,

PROFESSOR OF DISEASES OF THE GENITO-URINARY SYSTEM IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF NEW YORK, surgeon to BELLEVUE HOSPITAL, ETC.

THE record of the case I have the honor of presenting was intended to be incorporated in a paper on extirpation of the entire inferior maxillary bone, which I have in course of preparation, and in which I am desirous of including as many as possible of the illustrative cases contributed by surgeons of different parts of the United States and of foreign countries. I venture to report it now in order to recall attention to the subject, and thereby elicit information regarding cases, the notes of which I have not as yet been able to obtain, and also to gain access to unpublished cases. The following is a list of names of surgeons whose cases have appeared in divers journals and surgical works, or have been communicated to me by the operators. The operations were done for tumors, as well as for necrosis; some of them were intra-buccal, but the majority were by external incision, at one or at two sittings, by one or, as in three instances, by two different surgeons at a considerable interval of time.