pushed it down into the stomach. I then gave the patient some water, which he was able to swallow.

Dr. G. R. White, Savannah (closing): I have nothing to add except thank the gentlemen for the points they have brought out in the discussion.

I did not know that Dr. Senn had anything to do with the Kader's operation, but shall be glad to add his name hereafter. I think the books speak of it simply as the Kader's operation.

I would thank Dr. Goldsmith for bringing out the point spasmodic stricture. There is a muscular stricture which is a very important factor and the performing of the gastrostomy relieves that so that very often the child begins to take food soon after the gastrostomy is done, and, in some cases, makes a complete recovery.

HIP JOINT OPERATION-REMOVAL OF HEAD OF FEMUR-FALSE JOINT FORMED AND YOUNG MAN WALKING.

BY J. T. GAMMAGE, M.D., PINEVIEW.

Gentlemen, it is my intention to present concisely my experience with one of the most treacherous diseases, viz., tuberculosis, together with some deductions as to the result of my work and observation.

The suggestions that I shall make and the deductions that I shall submit are the evolution of my experience. Although I hope none of us will ever arrive at that station in medicine or surgery that will stop further advancement, viz., a feeling of satisfaction that in doing our best is doing the best. I would not mention diagnosis, as this case had long been diagnosed before I ever saw it, and correctly so with a microscope, by Dr. D. H. Calhoun, of Seville, Ga., were it not for the fact that the history points out and leads up so closely to tuberculosis of the hip. As there are so many modes of treatment, consisting of apparatus, splints and bandages, I will give a few as outlined by Sajou and others before taking up the report of my case, arthritis of the hip. Hip-joint disease is a frequent and formidable affection, and one which, in many instances, will baffle the best medical and surgical care through months and years of suffering, ending in the destruction of the joint, and frequently in death. It is a disease of childhood, occurring chiefly in the period of rapid growth. Some authors claim that it

rarely occurs after the twelfth year, but in this case it occurred at the age of sixteen and showed rapid growth, as he weighed at that time 138 pounds. Causes: The causes of hip diseases are chiefly predisposing. Any dyscrasia which impairs nutrition in general favors the lodgment and proliferation of the bacillus tuberculosis, and tends to destructive ostitis and arthritis. Traumatism may precipitate the inflammatory process, yet the ordinary violence to which this joint is subjected will rarely induce coxitis, except in children affected with some constitutional disease. Excessive use or a blow may produce synovitis, but in a healthy patient rapid recovery is almost certain. If diastasis occur as a result of accident, ostitis ensues and the impairment of the joint follows, yet this is an exceedingly rare circumstance; rupture of the ligamentum teres, which must occur in a traumatic luxation, would not induce destructive arthritis in an otherwise healthy individual. Symptoms of hip diseases are divided into two stages. The first stage embraces all the phenomena of inflammation up to a positive, appreciable destruction of the structures which enter into the formation of this joint. The second stage embraces the phenomena of destruction, viz., shortening of the neck, rupture of the ligamentum teres and capsular ligament and luxation. Shaffer, Thomas, Sayre and others have devised splints and braces made of steel, leather, plaster paris, etc., which are too familiar to us all to require any description or further mention by me at this time.

Case 1. Mr. I. R. M., white, male age twenty, began January 11, 1904, at age sixteen, weighed 138 pounds at that time; height at that time not known. Fever and pain in dorsum with considerable localized pain in right hip, and any mobility produced excruciating

pain; fever lasting sixteen days and pain continued. Was treated by Dr. J. M. Dorminy, of Seville, Ga., for about five weeks; just about this time Dr. D. H. Calhoun was called in, in consultation, and a plaster paris cast was applied, pain slowly diminishing at expiration of six weeks cast was removed, with some pain continuing and some anchylosis.

According to Professor Gibney, the initial lesion occurs as an interference with or the arrest of nutrition near the diaphyso-epiphyseal cartilage, due to the deposit of tuberculous material at this location. According to Prof. John Wyeth, the initial lesion appears in the several centers of ossification about the same time. It is an ostitis rarefacians. The cancellous cavities become filled with embryonic cells, absorption of the lamellæ occurs, the inflammatory products undergo a slow process of fatty metamorphosis, may become caseous, or with a mixed infection, and terminate into pus formation, and did in this case. The ostitis commenced in the deeper portion and traveled in all directions, destroying the diaphyso-epiphyseal cartilage with separation of the epiphysis. While these changes were going on the lining membrane of the capsule became involved. The process was one of chronic synovitis, which terminated in inflammatory changes in the tissue proper of the capsule. The joint became filled with the product of inflammation, the capsule over-distended and weakened ruptured spontaneously in October, 1904, with a discharge of pus and a few spicules of bone, showing at this time it was a mixed infection; under the microscope of Dr. D. H. Calhoun, the pus showed numerous tuberculi bacilli, with pus cells and other germs. This rupture occurred on the posterior portion of the joint, as above stated, in October,

1904, leaving fistulous tracks connecting with the joint; this discharge kept up continually until September 14, 1905. Weight at this time, 120 pounds; was operated on then by Drs. Dorminy and Calhoun by making a twoinch incision in posterior portion in line with fistulous canal; removed few small spicules of bone, some pus; curetted, cavity washed out with antiseptic solution of bichloride 1/3000, and left draining; discharged pus showed a mixed infection continued until there was two more fistulous canals formed, and on January 12th he was again operated on by Drs. Dorminy and Calhoun by making a three-inch incision on the lateral surface; removed a few more spicules of bone and some pus, curetted thoroughly with sharp curette and washed out with a 1/3000 sublimate solution, but the condition continued to exist, a constant drainage of pus from both points of operation, together with the formation of another fistulous track leading to the joint, so at this time, June 20, 1907, the time that I was called, and the first time that I ever saw the young man, there was four fistulous openings extending to the joint, one posterior, one anterior, and two laterals, as above stated. June 20th, last year, I operated, assisted by Drs. Dorminy and Calhoun, by making a four-and-half or five-inch incision, beginning one inch above the joint and continuing downward directly over the trochanters, exposing cotyloid cavity and the entire head of femur, removing several small spicules of bone and the entire head of the femur, washed out thoroughly with a 1/3000 sublimate solution and packed with iodoform gauze; the treatment was continued by washing out cavity every third day with a sublimate solution and repacking with iodoform gauze, together with tonics and hypophosphites; his weight at this time was 118 pounds, showing a loss in weight at