the wound heals by the first intention no bad symptom may follow; but when the incision remains ever so little open, suppuration of the joint with the whole string of evil consequences is very likely to come on. Benjamin Bell first proposed making the incision valvular by drawing up the skin at the part to be incised before cutting into it. If, when the operation is complete, the integument be allowed to return, the wound will be closed.

Monsieur Goyrand, of Aix, carried out a subcutaneous mode of cutting out these bodies, by two distinct operations. The first consists of fixing the body in some superficial part of the articulation, passing a tenotomy knife through the skin, and making in the synovial sac an incision through which the cartilage is pressed into the periarticular areolar tissue. The second operation is performed some days afterwards, when it is judged that the wound in the synovial membrane has healed. It consists simply in cutting down directly upon the loose cartilage now outside the joint and extracting it. Some skill is necessary for the performance of the first operation, because the mobility of the body and its power of gliding away are so considerable. Before attempting it, therefore, the surgeon must carefully have learnt the habits of the cartilage; must know in what direction it chiefly tends to slip, and in what places it most readily hides. He should endeavour to press it as far away as possible from the line of junction between the bones, to the place where the synovial membrane is reflected away from the periosteum. The choice of locality is not always with the surgeon; for sometimes even the greatest skill will not suffice to make the cartilage take up the position which may be most desirable. This is at the knee, over the inside of the head of the tibia; at the elbow, above the inner condyle. When the body has been coaxed into the best possible place, a curved needle or a tenaculum is to be inserted into it on the side towards the joint; and the tenotome, passed in some distance from its opposite extremity, is to incise the synovial membrane as far from the juncture of the bones as possible. The opening is not to be too extensive, but sufficiently large to allow the body to be squeezed through it and away from the insertion of the tenaculum. After completion of the operation,

the limb is to be put slightly bent upon a splint.* If there be more than one body, they are all to be brought if possible to the same part of the sac.†

The second operation is not always necessary, for the body may diminish rapidly in its new place, and cease to give any trouble; when it is necessary, the proceeding is excessively simple, consisting only in cutting directly down upon the body and taking it out. It is well to let a number of days elapse, so as to be quite sure that the wound in the synovial sac has healed.

Eight years ago, Mr. Syme published "A new Method of treating False Bodies in Joints," which apparently consists in all the same steps as the first operation above described, except that the body is not squeezed out of the sac, but is retained by bandages to contract adhesions; but it is rather difficult to see wherein the advantage may lie.

The elbow is to be bent at right angles. Mr. Syme affirms that he hit upon this plan at the same time as M. Goyrand, but the account of his procedure

did not appear till long after M. Goyrand's cases were published in 1841. Edinburgh Medical Journal, Nov.

1852.

ON DISEASES COMMENCING IN THE

BONE.

CHAPTER X.

ACUTE ARTICULAR OSTEITIS.

THE diseases of joints hitherto examined commence in the soft parts, that is, in the synovial membrane and the subsynovial tissue; another set of these maladies begins in the bones. Like those already described, these all originate in inflammation: and osteitis, or inflammation of bone, is a disease that has been known from time immemorial. But in the present instance, as I wish to designate those osseous inflammations, which, being situated close to a joint, affect the integrity of that mechanism, I have taken the liberty of naming the particular malady to be considered Articular Osteitis, that is, inflammation of a joint-bone.

The heading of this chapter may be remarked as singular in another way, since neither Stanley, our great English authority on bone diseases, nor Paget, nor systematic writers on surgery, have separated osteitis into the acute and chronic divisions, as they have done with other inflammations.* There is, however, doubtless a wide line to be drawn between different degrees of rapidity in bone inflammation, and if the distinction be worth anything in other tissues, so is it worth at least as much in this. The most chronic form of osteitis is probably the slowest of all diseases, while a highly acute species of the malady has lately been described by Klose as occurring in joint ends, and occa

* American authors, e.g. Gross (System of Surgery') make no such distinction, neither do I find such in the 'Compendium de Chirurgie Pratique,' by Denon, Villiers, and Gosselin. German authors, however, (see Wernher, and also Angelstein's Handbuch der Chirurgie,')

have perceived as much difference in the rapidity of inflammations of the bone as of any other tissue, and have made two classes-acute and chronic. While Stromeyer, in his 'Handbook of Surgery,' separates them into peracute, acute, and chronic.

sionally spreading to the shafts of bone, which is really as acute an action as most with which we have to do. Whether the disease occur in one situation or the other, it is founded in a very cachectic condition of system; it is rare, and in the shaft is generally the result of accident, as of a compound fracture exposing a large portion of bone, or deep laceration laying that tissue bare. But any osteitis, even the most chronic, may put on more rapid, and at last highly acute symptoms, which shall end in death of the bone. and plentiful suppuration, with some destruction of the periosteum, ulceration and suppuration of the surrounding parts, &c.* The whole course of the disease is generally completed in from a week to a fortnight, ending, if the bone have been small, usually in its death, and separation by the surgeon; if large and deep, in purulent absorption, and death of the patient. The frequent necrosis of the last phalanx from neglected whitlow, with redness and phlegmonous inflammation of the finger, is a good example of the former and slighter occurrence. But when this malady attacks a larger and deeper bone, its symptoms are very severe, whether it be the result of accident or of a great chill happening in a debilitated constitution. The disease is ushered in by very severe rigors, great pain in the back, and the other prodroma of all violent febrile attacks; soon afterwards there arise great rapidity of pulse, heat and dryness of skin, a dry and coated condition of tongue, anxious expression and sleeplessness. The affected bone, whichever it may be, is the seat of intense pain, and of a swelling which is always hard, and in deep bones is also deep seated; the skin itself is red, except when the bone be very deep, and at all events is very hot; when the osteitis is extensive the pain is so severe that it quite exhausts the patient, and renders him comatose or semi-comatose. Low muttering delirium appears very early in the disease; the tongue is dry, brown,

It is only due to Stromeyer that the following extract should be appended:-"These conditions are evidently connected with purulent phlegmonous erysipelas, which arises from similar causes, and with which peracute osteitis has, even in outward appearances, the greatest similarity if it have its seat in a superficial bone, for instance, in the front of the tibia. Unhappily, indeed, on this account, acute inflammation of that bone is usually

mistaken for erysipelas, until the practitioner finds by the exposure and death of the bone that he has to do with an osteitis. In traumatic erysipelas, after amputation, the great projection of the bone is evidently due to a highly acute osteitis, the periosteum and the insertions of muscles have all separated from the bone, and yet, strangely enough, an inflammation of this structure has never been thought of."-'Handbuch der Chirurgie,' 1e Band, 3te Lieferung, p. 418.

swollen and cracked. The affected limb is held immovable; indeed, the patient avoids all motion for fear of disturbing the part; very soon the swelling becomes softer, shows evidence of suppuration, and, except when very deep seated, as at the femur, fluctuates. At last intense coma comes on, the patient sinks and dies. On examination of the limb, the bone will be found lying loose in a quantity of pus, which fills the periosteum; it is of a dirty-yellow or grey colour, and has a very bad odour; its surface is rough and crumbles. The periosteum is softened, the attachments of the muscles have separated, and the inter-muscular spaces are infiltrated with a blood-stained serum or a thin ichor, which discolours the muscular tissue. The internal organs show, according to Stromeyer, signs of purulent infection, the lungs and liver being studded with secondary deposits.

In my own practice only one case of such extreme severity has occurred.

CASE XLIX.-John Murphy, aged 63, came to me at the Charing-Cross Hospital, August 1858, having met with an injury to the middle and fore fingers of the left hand, they having been crushed between pieces of machinery. The fore finger had sustained a simple fracture of the first phalanx; the middle finger was crushed and much lacerated; the metacarpo-phalangeal joint was torn open; the proximal end of the phalanx was fractured and thrust through the skin at the inner side, and the end of the metacarpal bone was broken and partly protruded through the wound. The accident had occurred two hours before; the man had fainted, and he had been taken to a druggist and had some medicine (restorative) and brandy administered; he then went home, and subsequently came with his son to this hospital: neither of the two men were quite sober. He utterly refused to come in. I explained to him and his son the necessity of removing the crushed finger, to which he consented, and they promised to return the next day, or at least that the son should come to me.

The operation was extremely simple, since, by nipping off the end of the exposed metacarpal bone, sufficient sound integument could be procured to cover the rest.

For ten days I heard nothing of this patient, nor did I know where he lived; on the 10th day his son came to say that his father was very bad. I went at once: the poor man had been utterly neglected; the whole hand, arm, shoulder, and chest were red and swollen; the bandage on the hand, which had never been removed, was so tight as to cut deeply into the flesh bullæ had formed in various parts. The lips of the wound had partly ulcerated away, partly retracted, so that a portion of the metacarpal bone was visible, which was black, or rather ash-grey. The man could only with difficulty be aroused; the tongue was dark-brown, in places