"In the first place, the surface of the joint, suppose the knee, is to be carefully cleansed by a sponge, soft brown soap and warm water, and then thoroughly dried; next, this surface is to be rubbed by a sponge soaked in camphorated spirit of wine, and this is continued a minute or two, until it begins to feel warm, smarts somewhat, and looks red. It is now covered with a soft cerate made with equal parts of the ceratum saponis and the unguentum hydrargyri fortius cum camphora. This is thickly spread on large square pieces of lint, and applied entirely around the joint, extending for at least six inches above and below the point at which the condyles of the femur are opposed to the head of the tibia; over this, to the same extent, the limb is to be uniformly supported by strips of calico, spread with the emplastrum plumbi of the London Pharmacopoeia. These strips are about an inch and a half broad, and vary in length; some are fifteen inches, others a foot, others half these two lengths, and the shorter or longer are selected according to the size of the part round which they are to be applied. This is the only difficult part of the process. This adhesive bandage ought to be so applied as to preclude the motion of the joint, prevent the feeble coats of the blood-vessels from being distended by the gravitation of their contents in the erect posture, and thereby promote their contraction. Over this adhesive bandage, thus applied, comes an additional covering of emplastrum saponis, spread on thick leather, and cut into four broad pieces, one for the front, the other for the back, the two others for the sides of the joint. Lastly, the whole is secured by means of a calico bandage, which is put on very gently, and rather for the purpose of securing the plaster and giving greater thickness and security to the whole, than for the purpose of compressing the joint. This is an important point, as otherwise an application which almost invariably affords security and ease, may occasion pain, with all its attendant mischief.

"In some cases in which the skin is thick and indolent, sufficient irritation will scarcely be excited by the above applications, and this may be promoted by rubbing on a small quantity of tartar emetic ointment previously to the application of the cerate. This, however, is rarely necessary.

"In some cases, also, it is desirable more effectually to prevent the motion of the limb, particularly in children. This may be done by applying on each side of the joint, externally to the plasters, a piece of pasteboard, softened by soaking in water, and cut into the length, breadth, and form of splints. These being soft, will accommodate themselves to the figure of the joint, and, when dry, effectually preclude all motion.

"I think this form of splint is infinitely preferable to those that are made of wood. It affords a very firm support to the limb, and at the same time counteracts the contracting effort of the muscles in as great a degree as can be effected without exciting inflammation. I have met with cases in which the diseased surfaces have been so forcibly compressed, by means of wooden splints, as to excite inflammation, and thereby cause a more violent contracting effect of the muscles, the resistance of which has aggravated the disease." (p. 133-37.)

Upon this plan of treatment, LAWRENCE justly observes:-" A question naturally arises, whether this free application of mercurial ointment to a large portion of the limb is of use in all the various diseases to which joints are liable; for it is recommended by the SCOTTS, without any distinction as to the nature of the affection, whether originating in the synovial membrane, or in the articular surfaces, or from scrofulous disease of bones. This is a point that must be solved by experience, and I cannot say that I am possessed of such as will enable me to answer the question. I think we should be rather inclined to ask another question on the subject, and that is, whether this free application of mercurial ointment to so large a surface of the body, and that too to a surface which not uncommonly includes some portion of ulceration, can be considered as perfectly safe. That is whether there may not be an absorption of the mercury capable of producing certain effects upon the constitution." LAWRENCE says he has seen this treatment adopted in a few instances, and in one "that the life of the child was nearly lost by the effect produced from the absorption of the mercury on the system. It caused a serious affection of the bowels, which, in the first place, shewed itself by pain, griping, and purging, and which then put on the appearance of a dysenteric affection, the child lost its appetite, became extremely thin, got a white tongue, and, in fact, seemed to be sinking as fast as it could. The dressings were, therefore, removed, and the child sent into the country, where it quickly recovered." (pp. 515, 16.) These observations are sufficient to prove that this treatment must be pursued with some caution, as some persons are more readily affected by mercurial applications than others, and in such serious mischief may accrue. FRICKE (a) has seen good results from this treatment.

(a) Above cited.

243. In the second stage, thickening and loosening up of the ligaments having already occurred, exudation existing, and the affection of the bone having begun, the actual cautery and issues must be employed, after the proper subduing of the inflammatory symptoms, for the purpose of restraining, by external derivation, the deep-seated disease, and encouraging the absorption of the unnaturally secreted fluid. Three or four streaks are to be made with the prismatic cautery heated to whiteness, extending from the middle of the buttock over the joint, avoiding the skin upon the trochanter; and upon the skin behind the trochanter the flat of the iron is to be firmly pressed, for the purpose of making an issue. The burnt part is to be covered with soft linen, and, in severe pain, with anodyne bread poultices. When the slough has separated, the discharge is to be kept up with irritating ointments, of which, ung. sabin. is best. For the purpose of making an issue, a tolerably large patch behind the great trochanter is to be rubbed with caustic potash, slightly moistened, until the skin is brown (1). After some days the crust falls off, and a sufficient quantity of peas are to be introduced to keep up the suppuration. The suppurating part must be frequently touched with caustic.

Repeated and perpetual blisters, rubbing in tartarized antimony ointment, as also the application (2) of hot steam (a), and the introduction of a seton through the skin (3), especially in the region of the groin, if the pain more attack this part, and extend along the crural nerve, (FORD, BRODIE, LARREY, and others,) may reasonably be regarded as inferior to the more powerful means before mentioned.

The result of the burning is often remarkably quick. RUST objects to the use of caustic, that by its destructive operation on organic matter it does not produce sufficient excitement to effect an alteration of the soft and hard parts of the joint; numerous observations, however, prove the efficiency of issues. In the comparison of these two remedies, the momentary and severe operation of the hot iron is not merely to be considered, but the continued derivation, which is better supported by the issues than by the actual cautery. I therefore give the preference, in the second stage, to issues, if there be not great lengthening of the foot; but I prefer the actual cautery, or the burning cylinders, (recommended by ALBERS, LARREY, and others,) in all cases where the limb is much lengthened, the muscles relaxed, and where there is great swelling from collection of fluid. VOLPI (b) has not observed any effect from the application of the actual cautery, when the signs or precursors of coxalgy were first manifested not at the hip but at the knee-joint.

[(1) BRODIE'S observation, that "the good derived from the issue does not seem to be in proportion to the quantity of pus discharged from its surface," will, I am sure, be admitted by every one who is frequently in the habit of using them; and I fully agree with the opinion, "that sometimes more abatement of the symptoms is produced in the first few days after the caustic is applied, and before the slough has separated, than in several weeks afterwards," which, I presume, depends upon the fresh irritation produced by the new issue upon the skin; whilst, on the contrary, when an old issue is long kept up in one spot, the parts accommodate themselves to the intrusion, and after a certain period the issue is, as it were, naturalized, and causes no further inconvenience, and, consequently, no more benefit, as it fails to keep up the irritation required to create a diversion from the disease in the hip-joint. "This circumstance," says BRODIE, first led me, instead of employing beans for this purpose, to keep the issue open simply by rubbing the surface occasionally with the caustic potash, or with the sulphate of copper; and, after an extensive trial of both methods, the latter has appeared to be decidedly preferable to the former. The pain produced by the caustic is very considerable, but the relief of the symptoms is such, that I have known patients to be in the habit of making the application themselves, saying, that "they knew they should be better by the next morning." Besides, the issue managed in this way is more easily dressed than ken; in DZONDI's Esculap., vol. i. p. 87; pl. i. 11. Leipzig, 1821.

(a) Die Dampfmaschine, ein neues Heilmittel, oder über die Anwendung des Strahls der heissen Dämpfe des siedenden Wassers zu ärtzlichen Zwek

(b) Above cited, p. 30.

where beans are used; and the inconvenience arising from the beans slipping out under the adhesive plaster, and from any accidental pressure of them against the sore surface, is avoided." (pp. 148, 49.) I have not any practical experience of this plan, being always in the habit of using glass beads, which quietly rest in the cavities they soon form for themselves, and when the wounds are disposed to heal, I brush them over slightly with caustic potash, which I have not found to give very much inconvenience; but I think BRODIE's plan is likely to be preferable.—J. F. S.

(2) A very clever but simple apparatus for local steam-bathing invented by DUVAL(a), has been used in some of our hospitals for the last few years, and well deserves being more extensively adopted, on account of the facility with which it can be employed and the great benefit attained by it, especially in chronic diseases of the joints. "It consists

of a reservoir for the water, capable of containing a little more than a pint, supported upon three metallic rods, and having a coverlet, which is furnished with two openings, one at the centre and one towards the side. From that in the centre arises a tube, terminating in a hollow globe, having attached to it and communicating with its interior three short branches, furnished with movable lids. A similar branch is connected with the opening at the upper edge of the reservoir. Beneath in a pan, supporting the parts already described, is placed a spirit-lamp, having four burners, and these, when lighted, quickly vaporize the water in the reservoir above. The steam is then conducted to the globe, and thence by means of short pipes slightly curved, and which may be connected with any one or all its branches at pleasure, to the part of the body required. The force and the quantity of vapour expelled is regulated by a key at the side of the principal cylinder, and which will diminish or enlarge its diameter, much on the principle of the ordinary stop-cock, while its escape upwards is entirely and instantly prevented by exposing the opening at the edge of the reservoir. The way in which it is used for joints is as follows: the patient covers the wrist, for instance, with a piece of flannel large enough for its edges to fall on a pillow, which is placed to support the fore arm. The nozzle of one of the tubes is then placed beneath the funnel, and the steam allowed to escape. The joint thus enveloped in steam has usually been allowed to remain for about half an hour; the application being made once a day or oftener, as the circumstances require. It may be also used as a vapour-bath, thus: the patient lies supine in bed, and three or four arches of wood or other convenient materials are placed across the body, so as effectually to raise the blanket from any contact with it. The apparatus is supported on a stool at the foot of the bed, and one of the pipes allowed to project into the arched cavity, which soon becomes filled with vapour. In this way all the inconveniences attending a removal to and from the bed are of course got rid of." (p. 205.)

(3) "The objections which may be urged," says BRODIE," against the application of caustic to the skin of the groin do not hold good with respect to a seton in this situation. I was led to adopt this treatment some years ago, partly from observing that the skin of the groin is nearer to the hip-joint than the skin elsewhere; partly from an expectation (though not a very confident one) that the making a seton over the trunk of the anterior crural nerve might be particularly calculated to relieve the pain referred to those parts to which the branches of that nerve are disturbed. The results of this practice more than realized whatever hopes I had entertained of its success. In many cases the seton occasioned very speedily a complete relief of the pain. In other cases, indeed, it failed in producing the like good effects; but these cases have borne only a small proportion to those in which it has succeeded. On the whole, I am led to conclude, that where the pain is very severe, the seton in the groin is more calculated to afford immediate relief than the caustic issue; but that it is not so efficacious in checking the progress of the disease, as it is in lessening the violence of its symptoms; and that the caustic issue can be better depended on for the production of a cure." (pp. 150, 51.)]

244. The good effects of this treatment is shown by the diminished pain, and by the gradual return of the foot to its natural length. Its effects are to be assisted by rubbing in, at the same time, mercurial or iodine ointment. The observance of complete rest is here also indispensable. If, from this improvement, there should be again a relapse without any decided cause, the prognosis is very unfavourable. The repeated application of the actual cautery is sometimes effectual. When all symptoms of the disease have subsided, the patient must still be kept quiet for a long while, and the suppurating parts must not quickly be checked. During convalescence sulphur

(a) Provincial Med. and Surg. Journ., Dec. 1840.

baths may be advantageously used, and issues inserted in the arm to keep up continual derivation.

In this stage, also, I do not consider the use of warm bathing proper, (RUST, BRODIE, and others,) on account of the motion therewith connected. The use of mercurial ointment has been prescribed in various ways: FRITZ (a) employs LOUVRIER'S treatment, but not so as to produce salivation; RUST rubs in daily one or two drachms; JÆGER justly considers this as too strong a dose, inasmuch as it frequently produces too speedy salivation, which, in scrofulous subjects especially, is always to be avoided; he therefore rubs in mercurial ointment, in increasing doses from ten to sixty grains, to which he adds about five grains every three or four days, so that altogether from one to three ounces are used; and, when salivation has commenced, he changes it for iodine or white precipitate ointment.

[BRODIE very justly lays great stress not only on rest but also on the patient's position. He says (b):-"When the cartilages of the hip are ulcerated,the patient should be confined to his bed or couch, being never allowed to move from it on any occasion. If left to himself, he is generally inclined to lie on the side opposite that of the disease. There are, however, good reasons why this position should be avoided, if possible. It necessarily distorts the pelvis and increases the disposition to a lateral curvature of the spine. It also, in those cases in which the round ligament of the joint is destroyed, facilitates the escape of the head of the femur from the acetabulum and the production of dislocation. Something may be done towards preventing this last by interposing a pillow or thick cushion between the knees; and it is difficult to do more than this, after the patient has already been lying on his side for a considerable time: otherwise he should be placed on one of the bedsteads invented by Mr. EARLE, lying on his back, with the shoulders and thighs somewhat elevated and the latter as nearly as possible parallel to each other. On some occasions, however, it is convenient to fix the pelvis by a strap or bandage, passing over it, from one side of the bedstead to the other; and even the thigh may be fixed in the same manner. At a later period when, in consequence of the extensive destruction of the articulation, the muscles begin to cause a shortening or retraction of the limb, I have found great advantage to arise from the constant application of a moderate extending force, operating in such a manner as to counteract the action of the muscles. For this purpose an upright piece of wood may be fixed to the foot of the bedstead, opposite the diseased limb, having a pulley at the upper part. A bandage may be placed round the thigh above the condyle, with a cord attached to it passing over the pulley and supporting a small weight at its other extremity. I will not say that the effect of such a continuance is to prevent the shortening of the limb altogether; but I am satisfied that it will, in a number of instances, render it less than it would have been otherwise, at the same time preventing, or very much diminishing, that excessive aggravation of the patient's sufferings with which the shortening of the limb is usually accompanied." (pp. 145, 6.)]

245. The general treatment in the first two stages of coxalgy is directed by the degree of the inflammation, and the nature of its cause. In severe acute inflammation, whether the origin be traumatic or otherwise, more than proper antiphlogistic treatment and attention to diet is superfluous. If the inflammation be chronic, the choice of internal remedies is to be directed according to the cause. In rheumatic and scrofulous patients, I have always found cod-liver oil in increasing doses, and, in torpid scrofulous subjects, the internal use of iodine, (after LUGOL's plan,) the most efficient. We may consider that both these causes are combated by the various remedies which have been recommended in coxalgy.

JÆGER recommends tartar emetic in large or small doses, ZITTMANN's decoction in divided doses; RUST, DIEFFENBACH, and others, use cod-liver oil; also the decoct. ballota lanata, the extract. pampinorum vitis viniferæ 3j. to 3ij. daily, or a saturated decotion, or the recently expressed juice, (FRANK, RUST, and others,) calomel, kermes mineral, sulphur. aurat., turpentine, and so on.

FRICKE recommends, in coxalgy, (in the above given sense,) rest and fixing of the limb by an apparatus. If the thigh remain longer, this passive treatment is not sufficient, and a two-fold condition must be distinguished; 1st, an irritable state of the nervous system, in which the patient complains of this and that, has disturbed digestion, chyli(b) Third Edition.

(a) Salzb. Med.-Chir. Zeitung, 1828, No. 37.

fication and assimilation, and stoppage of the bowels, for which mild purgative remedies of various kinds, warm baths, and, locally, warm poultices must be used; 2nd, muscular weakness, for which there should be advised, as most efficient, rubbing in volatile ointments, blisters, plasters of tartar emetic, dry cupping, stimulating baths, and steam of hot water, moxas, and actual cautery applied superficially only.

246. If the head of the thigh-bone become displaced, and the disease arrested, an artificial joint may be produced by continued rest; and, when the patient begins to walk, he must support the foot as much as possible, at first with crutches, and afterwards with a high shoe corresponding to the shortening of the extremity. The great degree of lameness, and, in children especially, the frequent contraction of the thigh, have led some to attempt the reduction of the luxation; and the results which have thereby been obtained, are well suited to determine on careful attempts at reduction, and then to keep the limb in a straight position, which is best done with HAGEDORN's apparatus for fracture of the neck of the thigh bone. If the reduction cannot be effected, we may attempt to keep the limb in its proper place, and the head of the bone in the neighbourhood of the socket, by gentle, gradually increased, and continued extension, by means of the apparatus just mentioned, or of some other kind, and so decidedly improve the direction and length of the limb in the course of the cure.

Owing to the nature of the circumstances under which the reduction is here attempted, it frequently does not succeed; and, indeed, when not employed with the greatest circumspection, very serious consequences may ensue. But, upon these grounds, to reject these experiments, and to consider their success impossible, (PETIT, CALLISEN, and others,) or to imagine that if they actually succeed, the head of the thigh-bone cannot be fixed in the hip-socket, is opposed, according to JÆGER (a), to all the under-mentioned observations. BERDOT (b) reduced, by pressure, the head of the thigh-bone, dislocated upwards; HAGEN (c), by means of RAVATON'S reductor. FICHER (d) and THILENIUS (e) relate similar cases. MOZILEWSKY (f) undertook the replacement thrice with success; in the first case he succeeded in a luxation of several inches, and of several weeks' standing, without difficulty, but it was necessary to maintain it by constant pressure; in the second, it was not until after nine months', and, in the third, after five weeks', continued extension. SCHNEIDER (g) replaced the head of the thigh-bone, but it was always again dislocated, in spite of the splint which he applied. B. HEINE (h) employed continued and gradually increased extension for a year, in a girl eleven years old, who had a spontaneous luxation of eight years' standing, with a shortening of three inches, and a considerable lateral curvature of the spine; the head of the thigh-bone not only retained its place in the joint, but the thigh moved as perfectly as the other, so that the girl could dauce. F. HUMBERT and M. N. JACQUIER (i) profess, by means of a proper apparatus, to give to the short limb similar length with the healthy one, to restore the head of the bone to the socket, and to confine it there till, by increased muscular energy, the necessary connexion and firmness are attained. TEXTOR's observation of a case of long standing dislocation of the head of the bone, being driven back into the joint by a fall upon the rump, is extremely interesting: this he himself related to me. VOLPI, SCHREGER, VON WINTER, HARLESS (k), and FRICKE (1), have recommended gentle and continued extension, with proper fixing of the limb. There would be always decided advantage if, in cases in which replacement does not succeed, the head of the thigh-bone were brought down from the back of the hip-bone into the ischiatic pit, and there fixed. J. HEINE (m) has communicated most interesting and successful observations upon four cases in which he happily effected the reduction with permanent success. In one case he had the oppor(a) As above, p. 597.

(b) Act. Helvet., vol. iv. p. 236.
(c) Wahrnehmungen. Mietau, 1772.

(d) Salzb. Med.-Chir. Zeitung, 1807, vol. iv.

p. 381.

p. 316.

HUFELAND'S Journal, 1816, May, p. 102.
SCHREGER; in HORN's Archiv., 1817, vol. i.

(9) Chirurgische Geschichten, Chemnitz, 1763, vol. ii. p. 77. (h) JEGER, above cited.

(i) Essai et Observations sur la manière de réduire les Luxations spontanées ou symptomatiques de l'Articulation Ilio-femorale, méthode applicable aux Luxations anciennes par cause externe. Paris, 1835. Atlas folio.

(k) Jahrb. der deutschen Medicin, vol. iii. parti. (1)Fünfter Bericht über die Verwaltung des allg. Krankenhausses zu Hamburg.

(m) Ueber spontane und congenitale Luxationen, u. s. w. Stuttgart, 1842.