sharp pull, which caused her some pain at the time. She was quite positive that this was the beginning of her lameness. I found one inch shortening of the limb, a marked degree of atrophy (the measurements, unfortunately, were not recorded), a depression under the acromion process, pain on moving the joint, and a grating crepitation. Use of the arm, however slight, aggravated the pain, and she complained of being unable to rest at night. The faradic reaction was good, and, as compared with the reactions on the sound side, were normal. I made a diagnosis of chronic osteoarthritis of the shoulder, and employed about the same treatment as was adopted in the other case. A sling was employed, how ever, to afford some protection. After a month's treatment without benefit, I had Dr. Bull see the case in consultation, and he advised free movement under ether, but the patient objected, and it was not until Nov. 6, 1883, that she decided to submit to the treat. ment proposed. At this date under ether, in St. Luke's Hospital, Dr. Bull moved the arm about freely in all directions, encountering less resistance than he had anticipated. She remained in the hospital a month or so, and was discharged at her own request. During her stay in the hospital the usual daily passive motion was resorted to, and her failure to derive the benefit expected was naturally attributed to the lack of vigor in carrying out the after-treatment, and her desire to get home. From that time to the present she, too, has been under occasional treatment of a simple nature, and the improvement really seems more marked during the remissions of treatment. Since May 10, 1884, I have recorded measurements, and they are as follows: COMPARATIVE MEASUREMENT. In May, 1884, she could abduct the arm to an angle of 135 degrees. There was a little rotation and very little tenderness. From time to time I have noted a little increase in the arc of motion, and it is only recently that she has complained of any severe pain. This was on January 19 of the present year. I failed to find any extra heat or signs of progress of the disease. Her general health had suffered, however, and under a tonic her pains diminished. This case had been submitted to the usual treatment that authorities advise, but operative interference has at no time been suggested. She has been able to earn a living, and for a year or two has been free from exacerbations, with the exception of the slight pain recently, for which a cause was readily found. It has occurred to me, while observing the two cases I have just reported, that an exsection in the second one, perhaps, might at some time be indicated. Both have been seen by several of my surgical friends, but the conservative plan has been adhered to, and it is my impression that the final results will justify me in the plan that I have adopted. The arrest apparently of growth of the humerus in each of these cases seems due to a lesion at the epiphyseal line, in the cartilaginous layer separating the diaphysis from epiphysis. In the humerus the nutrient artery takes its course toward the elbows, and this may account for the arrest of growth in the shaft when the upper epiphysis is diseased. When we have an ostitis of the knee the epiphysis is usually elongated, and we have actual lengthening of the femur. In an analysis of sixty-eight cases of ostitis of the knee, Dr. John J. Berry, formerly of the Hospital for the Ruptured and Crippled, found the femur 1 inch longer than its fellow in 2 cases. Length of arm. "In 6 there was an average shortening of three-eighths of an inch, while in five there. was no change in length perceptible." (Trans. forthcoming that the epiphysis was detached. Connecticut State Med. Soc., 1883, p. 108.) His observations are but confirmatory of those of Hufland, Helferich, and Wagstaff. In synovitis the bone is either shorter or remains unchanged. A reason may be offered why the humerus does not grow in length by hypertrophy, while the femur does, apart from the direction of the nutrient artery. It is this: In an epiphysitis or diaphyso-epiphysitis of the proximal end of the humerus the reflex muscular spasm holds the head pretty well secured in the glenoid cavity, and the articulation is normal so far as the head of humerus and glenoid cavity are concerned. Pressure is not removed, and the epiphysis expands by hypertrophy rather than elongates. In ostitis of the lower epiphysis of the femur, the reflex spasm is most marked in the flexors, and the knee soon assumes a semi-flexed position, and later subluxation backward often occurs. Pressure is thus removed from the distal end of the femur, and hypertrophy in the vertical axis can take place without opposition. The absence of suppuration in the cases presented, leads me to suspect sclerosis ossium (Billroth), or condensing ostitis (Volkmann). Billroth declares that the causes of sclerosis are very obscure, and that it is rarely recog. nized with certainty during life. In specimens reported by Macnamara, I am unable to find any sclerosis limited to the epiphysis. The lesion is a diffuse one, and it is sometimes called a diffuse hypertrophy of bone. Mr. Jonathan Hutchinson has placed on record in the Brit. Med. Jour. for July 25, 1885, a most remarkable case of arrest of growth of one humerus: "In the case which I am about to relate,the humerus of the left arm measures eight and a half inches against twelve and a half of its fellow. This very remarkable difference has resulted from an injury, followed by inflammation and ankylosis, at the age of a year and a half. The injury is believed to have been slight, but it was followed by inflammation, and the arm was said to have been kept at rest for six months. Thus, there is no proof It is certain that the result has been bony an kylosis between humerus and scapula, and the remarkable dwarfing of the bone which I bave mentioned. The arrest of growth has affected the scapula and clavicle as well as the humerus, but in them it has resulted in slenderness only, not in diminution of length. The whole clavicle is thin, certainly not more than two thirds of the thickness of the other, and the long and slender acromion projects. sharply over the shoulder. The humerus is slender, as well as short, especially in its up. per part, and the rotundity of its head is quite lost. There is no very obvious wasting in the lower part of its shaft, and the two elbows seem to be much alike. No difference that can be measured exists in the forearms hands. The subject can do anything below the elbow, and his power of moving the scapula is also remarkably great. The deltoid is, of course, quite atrophied. He can barely get the hand to touch his mouth, but can manage his fork well. He can put his hand behind his back, and fasten buttons, etc., though with some difficulty." or My experience in the forcible movement of the shoulder joint under ether in cases where the movements are so restricted, has led me to look with little favor upon this plan of treatment. It is difficult to draw the line between cases that should be treated this way and those that should not, and I am convinced that the differential diagnosis of shoulderjoint diseases, is not fully mastered. I am willing to admit that the fault may be my own, yet I find in my intercourse with fellow practioners that my own experience is not unique. The older surgeons are slow to reccommend this treatment. Some four or five years ago, I took considerable credit to myself in diagnosticating periarthritis in the shoulder of a man, who was referred to me by my friend Dr. Bull. The movements of the joint were very nearly perfect. In extreme flexion and extension, however, resistance was encountered, and the patient complained that his sufferings were greatest when the arm was not in use. If, for instance, he walked along distance, pain came on and soon became so great that he had to brace himself against the fence or lamp-post in order to get relief. At night he had learned to prop his arm on pil. lows in order to secure sleep. Ether was administered, the few adhesions were broken up, and his recovery was perfect. With this case in my mind, and a series of similar cases recorded by Duplay Gaz. Medicale de Paris, 1872, No. 37, I felt quite sangine in treating a patient referred to me by Dr. Webster, in September of last year. CASE III.-RHEUMATIC SCAPULO-HUMERAL PERIARTHRITIS; BRISEMENT FORCE THREE TIMES WITHIN SIX WEEKS; NO RELIEF; PAINS AND STIFFNESS AGGRAVATED.-This gentleman gave me the following history: In May, 1882, without known cause he began to be annoyed with pains in his left shoulder. He had been sleeping in damp apartments, and had at times suffered from what he supposed were rheumatic pains. From May until September the pains about the shoulder had increased, and were aggravated by certain movements, such as abduction and extension. On examination I found no atrophy, no extra fulness, no joint tenderness, and indeed the shoulder differed very little in appearance from its fellow. On deep pressure under the acromion process and over the back of the shoulder I found some tenderness. The rotation was about one-half the normal, and he could abduct the arm to an angle of forty-five degrees without tilting the scapula. I fail to find any history of pain when the limb was at rest, and in this respect the case dif fers from the one I have just narrated. I advised, however the employment of force, and on September 9, under ether I moved the joint in all directions, getting a distinct "snap" as I performed extreme abduction. I determined to employ passive motion myself every day, but by September 23, the re sult was extremely unsatisfactory; so on this date I repeated the operation under ether, and on October 3, did so again. At this time I adopted a different after-treatment, namely, hot fomentations and rest until Nov. 2, I then resorted to massage and the Paquelin cautery. A record of the notes in detail is unnecessary. It is enough to state that I had the full cooperation of the patient at every step of the treatment, and that no details were omitted in carrying out any plan adopted. By November 9, we both concluded that there had been no improvement. It was a fact, however, that the sufferings of the patient had been aggravated and that his shoulder was much stiffer than when the treatment was begun. At my request he called to see me yesterday and reported that he had done nothing in the way of treatment for three months. He has dur ing this time had comparatively little pain; he finds his arm more useful, and I find to-day an increase of the arc of motion; there is no joint tenderness, no crepitation, no atrophy, no shortening, no infiltration. I do not believe that passive motion is called for in chronic ostitis of the shoulder, or in chronic rheumatic periarthritis where the adhesions are extensive. It was my intention to submit the patient last named to a long course of iodide of potassium in large doses, but his stomach rebelled even with the usual precautions, and the drug was discontinued. Refore concluding the cases which bear upon the title of my paper, I desire to present the following, which is interesting from a diagnostic point of view. On October 19, 1885, Dr. Henry Schweig referred to me a male child two years of age who was brought by Dr. Nasher, under whose care the patient is at present. At the time of my first examination I found a slight atrophy at the shoulder, restricted movements, especially in outward rotation. The little fellow was so frightened at that time that I failed to make a satisfactory examination, but at the next visit, November 10, I found the signs such as can be shown this evening. At the back of the shoulder was a small cyst-like body apparently bursal. The pectoral muscles seemed contracted, and it was difficult to execute complete external rotation. The scapula seemed smaller than its fellow, the shoulder dropped a little, and the albuminoid crepitation of the joint was exaggerated. There was about three-quarters of an inch shortening of the limb. I could not make out any evi dence of old fracture on careful handling of the bones, but the doctor informs me that at the time of birth the attending physician reported a fracture of the scapula. From the slight degree of shortening and from the in. ward rotation of the limb, I am led to infer that a diastasis occurred at birth, and that by the action of the subscapularis, the latissimus dorsi and the teres major, repair in a normal position was prevented. This to my mind seems the most plausible explanation. My paper has already exceeded the limits I had intended, and I shall have to omit a discussion of the mechanical appliances best suited for ostitis of the shoulder. Indeed, the anatomy of the joint and the position of the limb seem to demand very little in the way of support. It has been my aim to dwell chiefly upon the clinical history of the disease and upon the inefficiency of passive motion." I saw a case of fibrous anchylosis of the knee which was afterwards forcibly straighented at one of the clinics in St. Louis, so I was told, in which the result was death within thirtysix hours, notwithstanding the precautions taken. The surgeon thought there was absolutely no danger. In this case I am satisfied the operation was done too soon. At least when I saw the case three or four days before the conditions was unfavorable for operative procedures of any kind. ORIGINAL ARTICLES. SOME OF THE CAUSES OF NON-SUPPU- BY GEORGE W. WEBSTER, M. D. Read before the Chicago Medical Society, July 18, 1887 re flammations of the middle ear originate in And even many aurists have yet to learn that the way to most successfully treat many of these non-suppurating diseases of the middle ear and the resulting loss of hearing, is by a thorough, skilful treatment of the diseases of the nose and throat. I know of few other conditions, in this line of practice, in which the results of surgical interference and treatment are more apparent and gratifying to both physician and patient, notwithstanding the fact that a well known author in a recent work on diseases of the ear says that the time spent in making a rhinoscopic examination is time lost. If an excuse for this paper is needed it is found in the fact, as I have just stated, that all authors do not agree with me in the above statements, and, also, that their truth, together with the utility of proper treatment, such as I shall attempt to point out, is not always recognized, and, especially in our public institutions, does not always receive the attention merited by the importance of the subject. I hope it will elicit such discussion as will enable me to judge of the opinions of the members of this society on this subject. If I am right in my statements, it behooves us then to recognize all the causes, either direct or indirect, exciting or predisposing, that we may be able to treat them intelligently, and in accordance with the modern ideas of pathology, and also to remove those causes capable of removal. Some of the principal recognized causes of non suppurative diseases of the middle ear are about as follows: Hypertrophies, of whatever nature, including hypertrophies of the turbinated bodies, pharyngeal tonsil, faucial tonsils, hypertrophic rhinitis, adenoid vegetations of the vault of the pharynx, exostoses and deviated and deflected septum, polypi, fibroid growths, or any condition the nose or throat that prevents free nasal But, that most of the non-suppurative in- respiration. Also measles, diphtheria, ty That the nose, throat and ears are closely related anatomically, physiologically and pathologically is a fact that needs no demonstration at my hands. of phoid fever, scarlet fever, indigestion, preg- the hypertrophy extending to the mouths of nancy, improper clothing, wet feet. bad hy- the Eustachian tubes, causing a thickening of gienic surroundings, in short any or all con- the lining of the same, either at the orifice or ditions which tend to induce and maintain entire length of the tube, this tending to precongestion and inflammation of the mucous vent entrance of air to the middle ear, and membranes. the air becoming absorbed, we have then the atmospheric pressure on the external surface of the drum-head, tinnitus aurium, vertigo, sometimes adhesive inflammation, anchylosis of the ossicles and variable degrees of deaf The first principle in treatment should be to lessen the congestion and inflammation, and where they have terminated in hypertro phies remove them. The consideration of all these causes and conditions, and the treatment of each, would be material sufficient for many papers, and I will, therefore, ask your attention while we speak of some of the first mentioned causes, viz., those which interfere with free nasal respiration, beginning with hypertrophy of the turbinated bodies. In this condition we may have either a hypertrophy of the anterior end, the middle, the posterior end, or a general thickening of the entire turbinated body, and oftentimes a thickened, hypertrophied condition of the mucous and submucous tissues lining the entire postnasal space. In diagnosing these conditions it is of course essential that we have a good light, a large head mirror or reflector, tongue depressor, small throat mirrors, nasal speculums, a fair knowledge of the normal appearance of the parts to be examined, the requisite skill and patience to make the examination, and a reasonably tolerant patient. For a tongue depressor I much prefer the modified "Tuerck" instrument, as it has a metal core for strength, is covered with hard rubber and does not corrode, is easily cleaned, and the short handle allows the little finger to rest in the hook at the end, giving a firm hold and a better control of the patient's head. I much prefer a small rhinoscopic mirror except in very tolerant patients with roomy throats. In a small percentage of cases a palate hook will be of service, and is best tolerated if it be flat and wide. I notice, however, that the more skill I acquire in making examinations, the less frequently I make use of the palate hook. Hypertrophic rhinitis causes deafness by ness, Then again the hypertrophy may, and often does, interfere with nasal respiration, and cause deafness as follows: With every inspiration and act of swallowing we have, as Lucae has shown, a tendency to create a vacuum in the postnasal space, with a conse. quent congestion which must sooner or later result in thickening and hypertrophy of the mouths of the tubes, and then all the other phenomena just pointed out, with, in many cases, a total loss of the hearing power. Then again, we have, as has been shown by Weber Leil, of Berlin, a paralysis, or partial paralysis of the palate tubal muscles, and this also tends to prevent the entrance of air to the middle ear in the normal manner. Just how this paralysis is caused is not quite clear to my mind, and I hope some one here to-night can throw some light on this subject. This condition can be easily diagnosed as follows: Adjust the catheter and attempt to inflate in the usual manner, and air fails to enter the middle ear. You then direct the patient to phonate or swallow. At certain movements of the palato-tubal muscles, the air enters suddenly, and again you fail completely, although you know the catheter is in the proper position in the mouth. of the tube. This, Weber Liel explains by saying that the muscles have suddenly dragged open the mouth of the tube, and then as suddenly allowed it to close again. I find that in these and many other cases I can inflate easily by pouring two or three drops of chloroform in the bulb of the ordinary Politzer apparatus. This bulb I have had |