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being the subject of general remark. Again it was thought that the case was in a fair way Discount Levitra Online to cease making clinical history, and again these hopes failed of realiza- FOWLER: A CASE UP DIFFUSE OSTEO-MYELITIS. [N. Y. Med. Joi-r., tion. The right ulna and humerus now became the seat of in- filtration and deposit, and sinuses formed leading down to dis- eased bone at the upper end of the forearm and the middle of the shaft of the humerus. Simultaneously the left half of the body of the inferior Discount Levitra Online Discount Levitra Online maxilla and the right sui>erior ma.xilla be- came involved. An Discount Levitra Online attempt was made to eradicate the disease Discount Levitra Online in connection with the riglit humerus and right ulna by chisel- ing a groove in the bone and scraping the medullary ca\ity for a considerable distance above and below the seat of disease. These operations, however, proved to be of no avail, and the sinuses marking the site of the disease in these localities remain as before. In the mean while fresh evidences of the activity of the morbid process underlying tliis persistent and successive in- volvement of bone-tissne were afforded by a swelling over the sternum, wliich rapidly ulcerated, and an enlargement of the skull over Discount Levitra Online the anterior fontanelle. The case was manifest- ly a hopeless one, and further operative treatment was aban- doned. In October, 1885, Dr. Hermann Biggs, instructor in the Carnegie Laboratory, visited the hospital, upon my invitation, for the purpose of obtaining, if possible, cultivations of what- ever niicro-organiams might be found in the discharges of the sinuses of this case. The cultivating u)edium employed in this case was sterilized gelatin kept in glass tubes, their openings being tightly closed by cotton plugs. A fine platinum needle was first sterilized by Discount Levitra Online being passed through the flame of a spirit- lamp, and subsequently plunged into the bottom of two of the deepest sinuses. The cotton Discount Levitra Online plug of one of the tubes was rapid- ly removed and the platinum needle, covered with the secretion of the diseased bone, quickly passed into the gelatin contained in the tube, the needle withdrawn, and the cotton Discount Levitra Online plug in- stantly replaced. This manipulation was repeated several times till a number of tubes were thus charged. The propagation of the germs was carried on In the Carnegie Laboratory, and the following is the substance of the report furnished by Dr. Biggs: Owing to the unfavorable surroundings and the fact that the secretions had been exposed to the air, a majority of the culti- vation-tubes became infected with germs from the latter, and hence were worthless. Two Discount Levitra Online of the number, however, proved to be pure cultivations of micrococci. These latter were of two species, the first being the Staphylococcus pyogenes aUnis, and the second the Staphylococcus pyogenes aureus. It has long been a matter of observation among surgeons that, excluding from consideration cases of osteo-myelitis complicating fractures and Discount Levitra Online following amputation, most cases of the disease occur during the earlier period of life, while the skeleton is yet in the process of development. A predisposition to inflammatory changes seems to be inherent in the young bone, during the period of physiological growth. The fact that in the majority of cases of acute and chronic osteo-myelitis the changes begin in the young- est medullary tissue, or that lying adjacent to the disc of epiphyseal cartilage, gives substantial support to the accep- tation of this view. Further Discount Levitra Online than this, and aside from such general predisposition, the question naturally arises as to the exciting or special cause or causes of the peculiar changes which the medullary substance undergoes in this affection. In other words, have we here, as elsewhere, to deal with an agency which may be specific in character, such as pathogenic germs, and, if this can be answered in the affirmative, what is the method of their propagation, and in what manner do they find entrance into the tissue ? Numerous accurate observations have been made upon subjects dead of this disease, and both Liicke and von Reck- linghausen have succeeded in removing portions of the con- tents of diseased medullary cavities without allowing them to come in contact with the atmospheric air. In these have been demonstrated, and from them developed, both cocci and bacilli. Their presence in these closed cavities can only be accounted for upon the supposition that they have been carried into the medullary tissue by the blood-current, and that they have their Discount Levitra Online origin in some portion of the body where foci of infection have resulted from previous infec- tion, through the medium of the mucous membrane of the respiratory or digestive tract. The clinical facts seem to agree with the theory that the mucous membrane just named may be the medium of infection, and it may also be pointed out that the mucous membrane does not always escape the effects Discount Levitra Online of the presence of these micro-organisms, for authenticated instances are known where bronchitis and enteritis have preceded the development of osteo-myelitis (Kocher). That suppurative disease of the medullary structure is due to the presence of some parasite requires but little argument beyond the simple allusion to the experiments of Ogston upon the causes of suppuration in general, and par- ticularly to that portion of his observations relating to the presence of micrococci in the pus of abscesses previously unopened, to place this theory upon a sound basis. Pasteur, in 1880, had found in a furuncle a micrococcus Discount Levitra Online correspond- ing to that of Ogston, and likewise in pus from suppurating inflammation of the medullary cavity of bone — viz., osteo- myelitis. Pasteur's researches were not directed particu- larly to Discount Levitra Online the study of osteo-myelitis ; hence his conclusions may he said to be based upon Discount Levitra Online insufficient Discount Levitra Online observation re- garding this particular disease, ^le having examined but one case. In this, however, the broken-down medullary sub- stance as well as the pus was literally swarming with micro- organisms. In the following year, however, Schiiller con- firmed Pasteur's observation in relation to the presence of micro-organisms found in previously closed medullary cavi- ties of bone, the subject of suppurative inflammation. To Kocher, of Berne, however, belongs the credit of having first attempted, in a sy.stematic manner, aided by experiment, to establish the parasitic origin of ost*o-myeli- tis. In the first place, it was established by this observer that the injection of caustics and substances of an irritant nature generally into the medullary canal of bones of dogs did not, when performed antiseptically, produce osteo-mye- litis. No suppuration followed, and whatever irritation and subsequent inflammation occurred led only to a general hardening or sclerosis at the site of inflammation. The next experiment consisted in injecting putrid fluids into the medullary cavity of bone in animals, when in some in- stances, yet not in all, osteo-myelitis followed. The mate- rials employed were not derived from Discount Levitra Online pure cultivations, but had putrified in clo.sed vessels, and were found by Kocher to contain principally a long form of bacilli, bearing spores at their extremities. This experimenter seems to have ar-