An experience of the writer within the past year in connection with the treatment of a patient with a spinal lesion was so disastrous to the patient and so distressing to the writer that a series of investigations were started in the hope of bringing some relief to the patient and at the same time of preventing such happenings in the future. It is this study which represents the basis of this communication, and in order that it may be fully understood the case that led to it is first reported.The patient was a man thirty-nine years of age, with nothing in his family history or previous history of importance, except an attack of hypertrophic arthritis (osteO-arthritis) of the lumbar spine seven years previous for which it was necessary for him to wear a support for several months. From this he entirely recovered and had up to the time of the accident led a very active life, both physically and mentally.In January, 1910, when very tired from a long stress of work, in lifting a heavy object he strained his back, producing a distinct displacement of the sacro-iliac joint upon the right side. The condition was recognized at once, and under nitrous oxide anesthesia the bones were replaced without difficulty, there being a perfectly definite slip as the replacement occurred. This was followed by a fairly normal recovery, so that in about three months the subjective symptoms had largely disappeared.At that time, after a fairly long car journey, he carried a very heavy suit case in one hand, without change, for a distance of over half a mile, with the result that the back became painful, so that two days later he was seen by the writer because of pain and sensitiveness in the lower back. At that time the sacro-iliac joints were shown to be strained, but the bones were not displaced. The next night, in turning over in bed, he felt a distinct slip exactly similar in all its sensations to that felt at the time of the first displacement.In the morning, after having a restless night, he was able to get up and take his usual tub bath.On trying to get out of the tub, in leaning forward and straining to get up, something slipped in his back, entirely different from anything he had before experienced. The body was drawn forward and to the left; there was intense pain so that it was with great difficulty that he was able to get back to his room, and the suffering continued until he was seen by the writer four hours later. At that time the body was held bent forward and to the left. There was extreme tendernesss in the sacral region, with pain extending into the legs, the right being much worse than the left.Supposing that the condition represented a sacro-iliac displacement with the extreme lateral deformity which is sometimes seen, under light ether anesthesia the sacro-iliac joint was manipulated and slipped into place, a perfectly definite slip developing with the replacement. From this the expected relief did not come, the body was still drawn forward and to the left, and the severe pain continued. Supposing that the continuanc...

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The above condition is seen almost entirely in girls or women, and i.s duo, in large part, to the fact that the line of pull of the quadriceps extensor muscle is not straight, this feature being increased in its effect by an unnaturally long patella tendon, knock knee or an imperfectly developed articulai-surface al the end of the femur. Eleven cases of this condition, seven operative with thirteen operations, and four nonoperative, have heen seen and treated by the writer, and the observations made in connection with the treatment of these cases represents the basis of this paper. The first feature, or the indirect muscle pull, is in part normal anatomically. The tubercle of the tibia with the attachment of the patella tendon is distinctly to the outside of the central portion of the patella when the knee is extended and the muscles arc at rest. As the action of the muscles, together with the joint motion, is studied, it-is seen that during flexion the patella, is drawn forward over the articular surface between the condyles of the femur and inclines slightly but distinctly to the outside of the me-Kia. 1 (Gray). than line. As extension lakes place the patella ascends, inclining slightly toward the inner sido until, when extension is complete, the line formed by the, origin of the reclus Icuioris, the center of the patella, and the tubercle of the tibia makes an obtuse angle (Fig. 1). As the muscle contracts tin; natural tendency is to straighten this line, with the necessary result that the patella is drawn outward, representing, as it does, the only movable point in the line. This can easily be demonstrated in any normal joint if the knee be fully extended and the quadriceps muscle be alternately contracted and relaxed. The lateral movement of the patella is distinct, the limit' outwardly being controlled in part by the ligaments, but more particularly by the outer ridge of the troohlear surface of the femur, which is distinctly higher in its upper and anterior surface than the same ridge at the inner side (Fig. 2). Against this the patella impinges, ami displacement further is impossible as long as all the parts are normal. Fig. -2 (Gray).If for any reason the line of pull becomes less direct or the articular ridge less perfectly formed; if the capsule be weakened by the distention following some acute injury; if the patella tendon be abnormally long so that the patella is drawn above the outer edge of the trochlear surface of the femur; or if the joint can be hyperextended so that, during the muscular pull the patella is lifted away from the femur in any one of these conditions the stability of the joint, so far as the patella is concerned, must be materially lessened.The displacement of the patella, which results from such a mechanical condition, may occur frequently with simple motion or muscular contraction, or may develo]) only when attended with the application of considerable force and when combined with some lateral strain, the east; or difficulty of the displacement depending, of course, upon the deg...

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light upon forms of insanity that are now hidden mysteries, and will discover rational and effective methods of treatment for them. I do not forget that there are some alienists of good repute, aud with deep interest in their professional work, who do not take so hopeful a view. I fully recognize also the difficulties that stand in the way of the solution of these problems in mental pathology; but if we remember what has been accomplished in medicine and