tunity, after the subsequent death of the patient, to examine, by dissection, the reduction and condition of the joint.

247. If collections of pus take place, which are often very far spread, and accompanied with much pain and increased hectic consumption, they must be opened with a sufficiently large cut, and care taken in the application of warm poultices for the proper escape of the pus; and the powers of the patient are to be kept up by tonic remedies and good diet. In scrofulous persons, the cod-liver oil is particularly advantageous. If collections of pus take place after acute coxalgy, a speedy cure often takes place under the preceding mode of treatment. The same course must be pursued with fistulous passages.

Different opinions are held as to the treatment of these abscesses, in reference to their dispersion by the application of caustic (FORD,) of seton (WEND, VAN DER HAAR,) of actual cautery (RUST.) BRODIE and JÆGER have never seen any result from the actual cautery, and my experience is the same. The greatest number of Surgeons leave the opening of these abscesses to nature, in which case the pus flows out more slowly, and the hectic consumption does not increase in the same degree as in the artificial opening: they advise only, in great and continued tension, and constant uncontrollable pain, a simple puncture; whilst others recommend an early opening. The aperture itself is advised to be made by caustic, (SABATIER, FICHER,) by the red-hot trocar, (LARREY,) and by the actual cautery (RUST.) The latter further recommends drawing a seton through the whole joint, by means of a trocar and an edged probe, in order that, after remaining there a few days, it may produce a severe inflammatory process in the deep-seated parts, a mode of proceeding which is certainly more likely to hasten death than improvement. Larger incisions, as recommended specially by BRODIE, JÆGER, and others, have certainly the preference over the above-described mode of treatment, and more simply and satisfactorily support nature in throwing off the diseased bone, and so on. Injections of decoction of bark, of oak bark, or of walnut leaves, with tincture of myrrh, turpentine, and so on, are useless, and nearly always injurious.

[As regards the opening of abscesses at the hip, BRODIE notices, that "an abscess connected with any joint, but particularly one connected with the hip, does not form a regular cavity, but usually makes numerous and circuitous sinuses in the interstices of the muscles, tendons, and fascia, before it presents itself under the integuments. It is, therefore, less easy to evacuate its contents, than those of an ordinary lumbar abscess; and, indeed, it can seldom be emptied without handling and compressing the limb, in order to press the matter out of the sinuses in which it lodges. But this is often attended with very ill consequences. Inflammation takes place of the cyst of the abscess, and pus is again very rapidly accumulated. Small blood vessels give way on its inner surface, the bloody discharge of which, mixed with the newly secreted pus, goes into putrefaction, and exceedingly irritates the general system." (p. 160.) He, therefore, states:-"The practice which has appeared to me to be, on the whole, the best, is the following:-An opening having been made with an abscess lancet, the limb may be wrapped up in a flannel wrung out of hot water, and this may be continued as long as the matter continues to flow of itself. In general, when a certain quantity has escaped, the discharge ceases; the orifice heals, and the puncture may then be repeated some time afterwards; but where the puncture has not become closed, I have seldom found any ill consequences to arise from its remaining open." (p. 161.)

On the whole, I think it preferable not to meddle with abscesses of the hip-joint, unless they excite much constitutional irritation, until the skin is on the point of ulcerating; then they may be punctured, and rarely untoward symptoms follow.-J. F. S.]

248. If, under this treatment, the general and local condition improve, if separate pieces of bone are thrown off, which are removed in the usual way, one or other opening, however, generally remains fistulous, and may so continue, without detriment, for years; often closing after repeated separations of bone, or, in younger persons, they close on the approach of puberty. If the carious destruction, however, continue, and the hectic consumption be in no way checked, examination must be made with the finger merely, of the caries of the head of the thigh-bone, and if the soft parts are not too much undermined and destroyed, the cutting off the head of the thigh-bone;

and, in greater destruction of the soft parts by the burrowing of the pus, provided the powers are not too much exhausted, the exarticulation of the thigh-bone is the only, although very doubtful, means for the possible recovery of the patient. The circumstance of the hip-socket being usually affected in carious destruction is principally against this operation.

The amputation of the head of the thigh-bone (as recommended by JÆGER) has been proposed by KIRKLAND, RICHTER, and VERMANDOIS, instead of the more dangerous exarticulation, was successfully performed by WHITE, and, without benefit, by HEWSON, KERR and BAFFOs performed the exarticulation of the thigh-bone without advantage. In both cases the hip-bone was affected; in BAFFOS's case, however, death occurred three months after, and when the wound was perfectly healed. CHARLES BELL's proposition (a) to saw through the neck of the thigh-bone, in order to produce anchy losis by the quietude of the head of the thigh-bone (!) is decidedly less suitable.

[COULSON mentions,as an instance of spontaneous reduction of a thigh-bone dislocated by hip-disease, the following case, communicated to him by BARRY of Richmond. It will be seen, however, from the account, that the replacement was not effected spontaneously, but rather by the nurse lifting the head of the bone over the edge of the socket into its proper place. It is, however, a very interesting—

CASE.-I. S., aged forty years, who had been for a number of years employed in carrying the produce of a market-garden to town, and generally by night, and had of late years suffered from rheumatism and occasional hepatic derangement, was, in February, 1836, labouring under the most aggravated form of ulceration of the cartilages of the hip-joint, induced by a fall from a cart on the frozen ground about a month before. In the following month luxation had taken place on the dorsum ilii ; the head of the femur can be felt, and the limb is shorter by about three inches and a half, with a slight inversion of the foot." Suitable treatment was adopted, and in the May following extension was made for a few days, "to relieve the pain caused by the unusual action of the m. glutei, and for about four days the intention was fully answered by these means; but the extension becoming a source of irritation, was discontinued two days after, being 2nd of June; and about seven weeks from the time of extension, while the female attendant was helping him to turn in bed, with her right hand on the inside of the thigh, and her left between the acetabulum and the new position of the head of the femur, the bone was felt by her hand rushing past this intermediate space. Next day," says BARRY, "I found the limb restored to within half an inch of its proper length, with neither inversion nor eversion of the foot, and pain gone. The patient says he heard the sudden snap,' and exclaimed, at the same time, that mischief had been done! It was, as has been seen, unlooked for reduction. In November following, the man walked about on crutches, and had not any pain." (pp. 103, 4.)

DUCROS's case already mentioned appears to have been cured by continued extension for fifty days.]

II.-INFLAMMATION OF THE SHOULDER-JOINT.
(Omalgia, Omarthrocace.)

249. This disease runs through the same three stages as coxalgy.

The pain, at the onset a more constant symptom than in coxalgy, is tearing, darting at one part or other and descending to the elbow. It is felt when pressure is made with the finger in the arm-pit directed forwards. The arm wearies with but slight motion, and the pain is increased every time it is moved, especially when raised. No disease is distinguishable on the shoulder. The pain increases after some time, especially at night. The sensibility and weakness of the arm become very great.

250. Gradually the arm becomes bent at the elbow-joint, and sticks out from the body; every movement of it becomes painful: it grows flabby and wastes. The shoulder sinks in, and loses its rounded form; the folds of the arm-pit also grow deeper; between them the head of the bone is felt, and the arm-pit is more filled. The diseased arm seems longer when compared with the healthy one. Often also, the shoulder swells, becomes more (a) London Medical Gazette, 1828, Jan.

rounded, and the skin itself reddened and hotter. Febrile symptoms accompany the exacerbations which occur at various periods.

251. If the head of the bone escape from the socket, the curved form of the shoulder is entirely lost; the acromion juts out; in the arm-pit, the sunken head of the bone is felt, which gradually softens above towards the collar-bone, so that the arm is somewhat shortened and directed backwards, and its motion hindered: or, the swelling of the shoulder increases, becomes harder and more painful on pressure, and on every motion of the arm.

Here, as in coxalgy, collections of pus take place, which, in the end, burst, and form fistulous passages. Carious destruction of the head of the upper arm-bone, of the socket, of the ribs, and so on, occur, and profuse suppuration, which destroys the powers of the patient. In favourable cases, a new socket is formed for the head of the upper arm-bone, or it anchyloses with the shoulder-blade.

252. On examination of the joint after death, the cartilaginous covering of the head of the bone, and of the socket of the blade-bone, is found either partially or entirely destroyed; carious destruction of the bone, which generally does not reach far down the shaft of the upper arm-bone; frequently the head of the bone is swollen up, covered with fungous growths, its cells enlarged and filled with blood or yellowish red exudation; the capsular ligament and surrounding tissue thickened and loosened up, the synovial membrane degenerated; pus poured out into the cavity of the joint, and into the various muscular interspaces.

253. The etiology, prognosis, and treatment, correspond with those laid down in coxalgy.

III.-INFLAMMATION OF THE KNEE-JOINT.

(Weisse Kniegeschwulst, Tumor Albus Genu, Gonalgia, Gonarthrocace.) 254. The pain is at first generally very trifling; the patient feels rather a stiffness of the knee-joint, and the pain only comes on with active motion. Sometimes it is confined to one spot, sometimes spread over the whole joint. This state may often continue for a long while, with alternate improvement and relapse; the pain at last increases, and the joint begins to swell. Frequently the pain is severe from the first, and the swelling soon appears. In many cases it is elastic and fluctuating, but has not the form of the joint; in others it yields but little to pressure, and is often so hard that it might be taken for bone. In proportion as the swelling of the knee increases, the leg becomes more bent; walking becomes very painful, or quite impossible; the skin over the swelling is shining white, exceedingly stretched, and at last bluish through the swelling of the veins. The pain now increases to a great degree; the swelling becomes at some parts distinctly fluctuating; the skin grows red and thin: it bursts, and discharges thin pus, mixed with cheese-like flakes. The openings often close and break out afresh. In general, the powers of the patient sink very rapidly; a probe passed into the joint shows carious destruction; hectic fever, with colliquative diarrhoea, comes on with more severe pain in the knee-joint, and death ensues, if the limb be not removed in proper time. The duration of the disease is uncertain.

255. What has been already said as to etiology applies here. The difference in the course of the disease depends on whether it has commenced as inflammation of the ligaments and synovial membrane, or as ulceration

of the cartilages of the bones. Hence arises the earlier division of white swelling of the knee-joint into rheumatic and scrofulous. In the former, the disease of the knee is more general, and the swelling occurs more quickly after the setting in of the pain; the synovial membrane, and the soft parts of the knee, are primarily attacked: in the latter, the pain is fixed to one particular spot, and the swelling, which retains the form of the knee, takes place later, and is more hard.

This difference in the swellings of the knee is confirmed by examination of the diseased joint after death. The soft and hard parts of the joint are often completely changed, and so connected together by a tough thick lymph, that they form a perfectly fungous mass. The synovial membrane is often inflamed and ulcerated, and the cartilage at the same time degenerated into a red spongy mass. All the soft parts of the joint are often thickened, as is also the cellular tissue on the external surface of the capsular ligament. The cavity of the joint is filled with brownish flocculent fluid. The cartilaginous surfaces are often partially or entirely destroyed, and the bones are carious. The head of the shin-bone is more usually affected with caries than the joint-end of the thigh-bone. The soft parts of the joint may be completely destroyed, and the carious ends of the bones exposed.

[The following is a brief account of the symptoms by which diseases of the knee may be distinguished :

In synovial inflammation of the knee-joint, the swelling, which at first depends only on the increased quantity of fluid contained within, is readily and "distinctly felt to undulate when pressure is made alternately by the two hands placed, one on each side. When the inflammation has existed for some time the fluid is less perceptible than before, in consequence of the synovial membrane having become thickened, or from the effusion of lymph on its inner or outer surface; and, in many cases, where the disease has been of long standing, although the joint is much swollen, and symptoms of inflammation still exist, the fluid in its cavity is scarcely to be felt. As the swelling consists more of solid substance, so the natural mobility of the joint is in a greater degree impaired. ***The swelling is not that of the articulating ends of the bones, and therefore it differs from the natural form of the joint;" * * depending “ in great measure on the situation of the ligaments and tendons which resist the distension of the synovial membrane, in certain directions, and allow it to take place in others;" thus, "the swelling" says BRODIE," is observable on the anterior and lower part of the thigh, under the extensor muscles, where there is only a yielding cellular structure between those muscles and the bone. It is also often considerable in the space between the ligament of the patella and the lateral ligaments; the fluid collected in the cavity causing the fatty substance to protrude in this situation, where the resistance of the external parts is less than elsewhere." (pp. 24, 5.)

The swelling from synovial effusion is easily distinguishable from the large fluid swellings of the bursa of the knee-cap by the latter being always in front and of a rounded form, whilst the former is on the sides of the knee-cap. It may, however, be confused with collections of fluid in the hamstring tendons, which sometimes occur, as those tendons pass on the sides of the joint to their insertion in the leg; but the nature of the latter is shown by their more circumscribed extent, and by not undulating through the joint.—J. F. 8.

The pain in this complaint, though increased by motion, and by pressure with the fingers, is not, at least in the early stage, increased by pressing the cartilages together; but when adhesive matter is effused, and the cartilage is ulcerating or absorbing, there is pain more or less severe according to the mischief going on. In the pulpy disorganization of BRODIE, as already mentioned, (p. 217,) the disease begins with a slight degree of stiffness and swelling, without pain, and the symptoms gradually increase. The form of the swelling is "less regular, is soft and elastic, and gives the sensation as if it contained fluid; * * * but if both hands be employed, one on each side, the absence of fluid is distinguished by the want of fluctuation." (p. 103.) There is not generally much pain till abscesses begin to form, and the cartilages ulcerate. The progress of the

disease is slow.

"When the cartilages of the knee are ulcerated," says BRODIE, "there is pain in the affected joint; at first slight, and only occasional, and. in the early stages of the disease, it is completely relieved by remaining in a state of rest for a few days, but it returns as soon as the patient resumes the exercise of the limb. By degrees the pain becomes constant, and very severe, particularly at night, when it disturbs the patient by continually rousing him from sleep. The pain is referred principally to the inside of the head of the tibia, but sometimes a slighter degree of pain extends down the whole of that bone. The pain is aggravated by motion, so that the patient keeps the limb constantly in one position, and generally half bent; and he never attempts to support the weight of the body on the foot of this side." It is distinguished from inflammation of the synovial" membrane in this, that the pain in the former is slight in the beginning and gradually becomes very intense, which is the very reverse of what happens in the latter." From most other diseases of this joint it differs, in that "the pain in the first instance is unattended by any evident swelling, which comes on never in less than four or five weeks, and often not until several months have elapsed from the commencement of the disease." (pp. 167, 68.) The swelling BRODIE describes to “arise from a slight degree of inflammation having taken place in the cellular membrane external to the joint, in consequence of the disease within it. The swelling is usually trifling, appearing greater than it really is, in consequence of the wasting of the muscles of the limb. It has the form of the articulating ends of the bones, that is, the natural form of the joint. No fluctuation is perceptible, as where the synovial membrane is inflamed, nor is there the peculiar elasticity which exists where the synovial membrane has undergone a morbid alteration of structure." (p. 170.) When ulceration of the cartilages has taken place, striking the heel so as to jar the knee, or rubbing the ends of the bones together, though but slightly, causes severe pain, and if there be much destruction of cartilage, a grating sensation is conveyed along the leg to the surgeon's hand. "The progress of the ulceration of the cartilages," BRODIE observes, "varies, with respect to time, in different cases; but it is generally tedious. In one case, where violent pain had existed in the knee, with little or no swelling, for two years and a-half previous to amputation, I had," says he, "an opportunity of examining the diseased joint, and found the cartilages destroyed for only a small extent; a drachm and a-half of pus in the articular cavity, and no morbid appearance of the soft parts, with the exception of a very slight inflammation which had been induced in the synovial membrane, and the effusion of a minute quantity of coagulable lymph into the cellular texture on its external surface." (pp. 174, 75.)

Since the observations referring to ulceration of cartilage, from pressure of adventitious membrane, have passed through the press, I have had the opportunity of examining with the microscope, both the adventitious membrane and cartilage, in the case of a boy aged ten years, whose knee having been affected with disease for four years, was removed by the wish of his friends on the 17th of this month, (May, 1845.) In this case I saw distinctly the vascular loops in the adventitious membrane, already quoted (p. 232) from GOODSIR'S paper; and also the peculiar degeneration in the cartilage which my friend RAINEY has described as follows:

"A vertical section through the joint on one side of the patella exposed adventitious membraneous structures, extending from the synovial membrane towards the interior of the joint, and lying against the articular cartilage, which was excavated in such a manner as to have the exact form of the membrane in contact with it. These structures were of different forms and degrees of thickness in different parts of the joint, and always continuous with the synovial membrane.

"In some parts of the joint, the articular cartilage of the femur, and that of the opposite part of the tibia, were completely destroyed, and the denuded osseous surfaces of these bones, connected by a newly formed fibrous structure, which was sufficiently long to allow of considerable motion. The free surface of the articular cartilage was, in some parts, covered by a thin layer of membrane, which admitted easily of being detached, in other parts excavated, as before observed; the opposite surface was either completely detached, or only loosely connected with the bone. Some abscesses communicated with the joint.

"The microscopic examination of the membranous productions showed that they were vascular, the vessels forming loops towards the cartilage, which I have observed in other cases that have been better injected. But what seems most interesting is, that the absorption of the cartilage is preceded by its fatty degeneracy, diminishing in degree from its free surface to the one connected with the bone.

"This degeneracy is first perceptible by the division of the nuclei of the cartilage cells into several minute spherical particles of oil. These particles increase as the nuclei

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