fracture of the thigh, further giving support by suitable splints or junk-bags. This also secures extension and counter-extension, which is an important point in the treatment of these cases. If the case is less acute, a splint or extension apparatus, making extension by ratchet and key, will be much better, as allowing exercise.

Pressure by bandages, etc., is also valuable when well borne, nor should daily frictions or massage be omitted. If there is much effusion the aspirator will prove useful.

Excision. And now comes the important question as to excision, which, however, cannot at this time be considered at length. It is admitted by all that in the cases in which this operation is justifiable, amputation is the safer operation. It is also pretty generally conceded that where bony anchylosis can be secured, this operation is rarely or never to be practiced. The most competent authorities have reached the following conclusions in regard to this operation.

As a rule it is never to be practiced in non-suppurative cases, in extensive gunshot injuries, in persons over forty (the age of pubescence being the most favorable), in very young children and in persons suffering with any marked constitutional disorder.

When, however, there is suppuration in the joint, which has denuded the bone surfaces, and where anchylosis is impossible, and other contraindicating conditions absent, the operation is proper and should be performed.

It is well to bear in mind the long period of confinement that must ensue after the operation, the possibility of failure and subsequent amputation, and withal that at best but a straight, stiff and shortened limb is obtained.

The Operation.-The operation is not difficult. After applying the Esmarch bandage, an incision is to be made from condyle to condyle, over or rather below the joint, through the ligament of the patella. The leg is flexed, and the end of the femur thrust out and sawed off, care being exercised not to remove the whole of the epiphysis. The head of the tibia is then treated in the same way, the same caution being observed.

It gives me pleasure to refer in this connection to an entirely new and valuable method of removing the diseased bone, namely

by the dental engine. This method was first adopted by some of the surgeons of the Homeopathic Hospital, Pittsburg, the credit being principally due my colleague, Dr. Willard, who will probably explain it fully in his paper.

After the tissues have been thoroughly cleansed the wound is to be closed; and now comes the important period of the treatment. The object sought is to secure most absolute immobility, and many means have been devised for this purpose. Wiring of the bone (Buck) is an excellent means, and should be practiced in most cases. Heron's, Watson's, Sayres', Salter's, Gooch's and many other forms of splint might be mentioned. The object is to keep the bones in apposition, the leg in straight position, and secure easy access to the wound. Any good form of swinging splint is to be preferred. Six weeks at least should elapse before the limb is disturbed, and then only with care. Nor should the immobility be disturbed until union has certainly occurred, which may take many months.

Internal Treatment.—However intractable we must admit this disease to be, it is also gratifying to note the success that attends purely homoeopathic (which does not preclude proper local) treatment.

The remedies which have proved most useful in the hands of many of my colleagues, as well as my own, are in the earlier stages: Bry., Rhus, Merc., Mezereum and Manganum. Later, Lyc., Calc. ost., Calc. phos. and Calc. jod., Sulph., Silicia and Fluoric acid. This of course does not complete the list of excellent remedies. Time must be given for the action of these remedies. The potencies I have found most useful have been the medium and higher. The thirtieth trituration of Lyc., the minerals and the metals have always given me the best success.

DISCUSSION.

SECTIONAL MEETING OF THE BUREAU OF SURGERY.

DR. R. B. RUSH, of Salem, O., was requested to act as chairman of the meeting.

DR. L. H. WILLARD, then said: The subject under discussion this afternoon is Exostosis, and we desire to call your attention to a case brought here by Dr. Ormes, which has already been presented for the consideration of the surgical bureau.

DR. C. ORMES being called upon described the case as follows: The patient was about sixteen years of age when he was first brought before the Society of Northwestern Pennsylvania, three years ago. Dr. Gilchrist being present examined the case and pronounced it one of exostosis of the lower third of the femur. After some discussion, and consultation with the friends, the patient was etherized, and an incision made, five inches long, which covered nearly the whole length of the diseased bone; a soft, spongy growth was discovered, about half of which was removed, it being deemed inexpedient to remove the remainder on account of the weakness of the patient, and because of the danger which must result to the shaft of the bone. The patient being put upon the indicated remedy, rallied and the wound healed very well. It was hoped that the remainder of the diseased bone would be absorbed so that its removal would be unnecessary, but at the end of two months the remaining portion of dead bone was removed. The patient again rallied, and his general health became completely restored. I had him under treatment after the operation.

DR. WILLARD asked if this exostosis communicated with the medullary canal, to which Dr. Ormes replied that it did not, although tending towards it, the upper portion of the bone being of a more spongy nature.

DR. C. H. VON TAGEN, of Chicago: Exostosis is a surgical disease that I have had some experience with, and in which I take great interest. I am interested in all bone diseases, have had a number of cases, and desire to call attention to a case that I had two years since at Cleveland. This case was very remarkable on account of the number of exostoses, there being five or six situated on the humerus, extending from the shoulder down the shaft of the bone, and also seven or eight on the femur of the same side, commencing at the trochanter and extending downward; these exostoses varied from the size of a cherry-stone to that of a large walnut. I removed them all. The largest was on the femur, and in each one I examined carefully to see if the exostosis extended into the cancellated texture or deep portion of the bone, as far as the medullary structure. It did not, nor have I ever seen one extend so deeply.

In this case the disease covered considerable space; but perhaps in the case before us it may have been a different form of exostosis, as it is described as of a soft variety. In a certain case operated on last winter the exostosis was located at the upper posterior third of the tibia, near the popliteal space, near the joint; the upper portion projecting beyond the attachment of the joint, interfered with its motion and in time would have produced anchylosis. The incision was downwards, and all the excrescent bone was removed; it was as large as a good-sized pear, and had a very dense neck. In this case, though of nine years' development, there were no signs of an extension to the medullary structure. I have used homoeopathic remedies as a preventive of their return in all cases after the removal of exostoses, and have found that Calcarea phos. is an excellent remedy. There are cases reported as having been cured by its use, but I believe it will only cure in the incipient stage, and not after the disease has developed to any extent. In the present case if the medullary structure was involved it would illustrate an important physiological point. I have, however, had twenty or twenty-five cases of exostosis, and have never noticed any such implication.

DR. BIGGAR: This is a case of great importance and should be thoroughly investigated, and if possible it should be determined whether or not it is amenable to internal treatment. This is evidently a case of diseased bone, but its real character might be in dispute. As to whether you would regard it first as an enchondroma and subsequently as an exostosis, depends altogether upon the history of the case and upon the microscopic examination of the cells. I think it is a species of enchondroma afterwards becoming exostosis and multiple in character, for there seems to be nodes felt in passing the hand over the bone, or unequal sur

faces, which leads one to that opinion. If this is correct, then there is a more formidable disease to combat than if it were simply exostosis.

DR. RUSH asked if Dr. Biggar saw the case.

DR. BIGGAR. I saw the case and am giving my opinion as to the diagnosis. I do not care as to whether it is scrofulous, strumous or syphilitic; the object now is to determine the real condition and then to treat it. I should, as a surgeon, think an operation absolutely necessary in order to remove the diseased portions of the bone. I saw Dr. Gilchrist, and think the case was admirably treated after the operation to hinder the growth from returning. He did not for some unforeseen reason remove all the diseased bone. In some cases there is a redevelopment, and here we find a case of redevelopment of a malignant disease. I should, in the first place, had I had the care of the case, have insisted on an operation; but there are cases where remedies can be used before a resort is had to the knife. I would like to see a combined effort of the physicians and surgeons present to study this disease, for if it can be cured by remedies it will redound to the credit of homoeopathy. I do not know what remedies the patient has had, and as we are not asked especially regarding treatment I will not enumerate the remedies I should give in a like case.

DR. BIGGAR was requested to give his remedies, and resumed: The remedies which I would select in this case would depend on two things. I would first decide as to whether there was present an excess of phosphate or of carbonate of lime; this can only be determined microscopically, and then the prescription can be more accurate. If lime is indicated give either Calc. carb. or Cale. phos. Hygienic measures should be thoroughly attended to, and a judicious diet, not stimulating, but adapted to the diseased condition, consisting of such food as milk, cracked wheat and meat, administered. At present I should advise no application but trust to the use of remedies.

DR. N. SCHNEIDER, of Cleveland: It places a man in a difficult position to ask him for his diagnosis in such a case. The history of the case would influence my diagnosis very much. If I understand correctly, when this man was three years old his father discovered this disease, not from any pain or subjective symptoms but simply by manipulating the limb; he found that a portion of the shaft of the bone was larger than it ought to be. The condition thus continued painless for years, until at last the child's health began to break down. Now, was this depreciation of the child's health due to the local trouble, or to a general constitutional dyscrasia, and was the local trouble due to a constitutional dyscrasia?