6th Jan., 1860.-She took the pills for four days; is now much better, less heavy, complexion clearer. Return to the Quinine and Acid; to paint the inside of the joint with tincture of Iodine.

Feb. 17th. The child well: the joint has not been inflamed.

June 8th.-Alice Blackman fell down stairs and came back to the hospital with a cut on the forehead, the skin scraped off her nose, and other little injuries; but she at the same time hurt her knee, and the pain in it makes her cry a good deal, especially at night. The inner condyle is altered in shape, as can be detected by the sense of touch; but it is hardly more protuberant; it is tender on pressure and hot. She cries when the knee is moved more violently than before. A nearly straight pasteboard splint to the outside of the thigh and leg; a blister above the inner condyle; to be dressed with zinc ointment; Iodide of Potass mixture to be taken three times a day.

20th. She has had another blister over the seat of pain there is less tenderness, but the child cries at night a good deal. It appears that she does not wake up suddenly, but has some difficulty in going to sleep: when she does wake, she does so with effort, and cries. It was evident that these were not the starting pains, but only the dull aching of the earlier stages. Ordered to paint the joint with Tra. Iodinii; to continue the mixture, and to take for a week the following, in pill, night and morning :

B. Quinæ disulph. ...
Hydrarg. c. Cretâ

STRUMOUS OSTEITIS AT
KNEE.*

25th.-There has appeared over the most prominent part of the inner condyle an increased tumefaction, which fluctuates; the fluid is deep. There are at present no pains which appear like starting of the limb. To take one grain of Quinine, in pill, night and morning: to leave off the Iodine. The joint was drawn at this time.

July 2nd. The whole joint is swollen and puffy; the enlargement does not depend upon fluid effusion into the cavity, but on periarticular thickening; the tenderness over the inner condyle rather less. The child looks better. Apply blister round lower part of thigh in front.

* The abnormal projection of the inner condyle is somewhat increased by a serous effusion under the periosteum.

6th. The pain over the condyle, and the fluctuating swelling, appear less; but as now the periarticular tissues are implicated, I desire to treat, also, that condition. Gave the child chloroform, and applied the cautery-iron in one line at the outside, two at the inside of the joint.

20th.-Child is better: the wound from cautery almost healed, and much less tenderness about the joint. To take one tablespoonful of Quinine Mixture three times a day.

17th Aug.-The joint has been strapped tightly for the last ten days, and the splint removed; the child does not now cry at night; the inner condyle seems scarcely, or not at all, more susceptible of pressure than that of the other side, and the periarticular fulness has disappeared. Sep. 19th. The child's joint perfectly sound.

CASE LII.-Jane Dickery, aged 13, a thin, weak-looking child, having finely-cut features, small bones, and veins plainly marked about the mouth and temple, was brought to me 30th May, 1860, with the left shoulder painful and swollen.

The swelling is very evident; it makes the shoulder look rounder, larger than the other, and somewhat pointed in front, and a little to the outer side. This is best visible when the patient sits upon a low seat and the surgeon looks down upon her from above; he then gets much the same view as is given in the accompanying drawing, which was taken with the child lying on her back. The shoulder is tender on pressure, and hot. She was ordered a teaspoonful of Cod-liver Oil, and two tablespoonfuls of

Quinine Mixture, three times a day; a blister to the front of shoulder; the arm to be bound to the side.

9th June.-Appetite improved. She has had, since last report, a blister behind the shoulder: there is a superficial abscess forming over the acromion of the other side.

16th.-Again a blister to the front of the shoulder; to be dressed with Oxide of Zinc Ointment. The following to be taken with the

30th.-Better: the abscess over the right acromion has broken and left an ulcer; it is quite superficial: to let the blister heal; the arm need not now be bound to the side, but is to be kept in a sling.

July 13th.-The shoulder has diminished in size very much; it is not now tender, nor hot. Passive motion and friction.

Sept. 7th.-There was some trouble in overcoming the stiffness, and difficulty in moving the shoulder; but it is now as freely movable as a healthy joint, though the head of the humerus has not regained its normal size; it is but little larger than normal. I procured an admission for her to the Walton Convalescent Hospital.

CASE LIII.—I was asked on the 28th June, 1860, to see Master F., aged 13, who had been suffering four years and a half from knee-joint disease. He is pale, thin, and dark; has slight ashen discolouration about upper lip.

The disease began, the mother and boy both affirm, by a fall, though they acknowledge that the fall was not remembered till after the disease had begun. The first commencement was pain at the inner condyle, which prevented the boy's walking in the day and sleeping at night: after a time this pain, under treatment, disappeared, and came on again three years ago. As nearly as I can determine by questioning, startings came on nine months ago; they are now so bad that he hardly gets any sleep, and often when he is reading or otherwise amusing himself in the day, there comes one of the starts so violent that it incapacitates him for a time from all employment. He has been taking a grain of Opium, of late, every night; it does not make him sleep better, but renders him more drowsy in the morning.

The knee is swollen and puffy; the swelling does not, however, hide the form of the bones altogether: it is the most prominent over the inner condyle, which projects considerably, and where hard effusion can be felt nearer the skin than elsewhere; there is an abnormal amount of fluid in the joint, but the swelling is not due to that cause, but to periarticular enlargement. A sinus, near the lower and inner edge of the patella, leads into the joint; no rough bone can be felt, but there is no doubt that the

T

inner part of the femur, at least, is carious. The leg is bent at less than a right angle.

I gave an unfavourable prognosis, but agreed to do what was possible. The solid opium was omitted, and instead the following draught at night:

R. Chloroform

mij.

Two tablespoonfuls of the Mixture three times a day :

The joint was strapped and the leg tightly bound on a splint, with a screw at the back, that it might, if possible, be got a little straighter.

7th July. He has slept better of late, and the starting is less; this may be partly attributed to the strapping, but it is impossible to make the knee in the slightest degree straighter by the screw without producing great pain. To-day chloroform was administered: I divided the necessary tendons and fascia, and straightened the joint: ordered cold lotions to be kept on the joint. Let him, immediately (5 P. M.), have ten drops of Laudanum, and let the draught to-night contain twenty drops, instead of only ten drops, of that tincture.

1st Aug. Not a bad symptom showed itself after the operation; a splint was applied three days after its performance; the slight swelling that came on disappeared under strapping; the starting pains have returned and are now severe; they did not commence to increase till a fortnight after the joint had been straightened: the extending splint was carefully applied and bandaged to the limb.

Sept. 14th.-The starting pains began to decrease from the time when the extending force was applied: in five days they had quite disappeared. On the 14th of last month, a fortnight after the application of the extending force, the night draught was discontinued. The sinus is closing: I begin to hope that the caries may be subdued. The boy's health is much improved.

Oct. 21st.-I have now applied another means of extension by means of splint, consisting of thigh and leg piece jointed together with a hinge (see Chapter XVII.), and have allowed him to move about on crutches; at night this is removed, and the extending apparatus as before applied.

CHAPTER XII.

CHRONIC RHEUMATIC ARTHRITIS.

PATHOLOGY.

THIS disease, since Dr. Haygarth described one of its appearances as nodosity of the joints, has been regarded with much interest by a large number of careful observers. Among the most zealous and trustworthy of the authors on this subject may be reckoned my colleague, Mr. E. Canton, of the CharingCross Hospital; Mr. Robert Adams and Dr. Smith, of Dublin. The malady is, in general, either a sequela of acute rheumatism, a result of exposure to cold, a gouty diathesis, influenced by some cachectic condition of system; or it may be traceable to uterine disorder, and is combined with either luxurious or very scanty feeding. Sir B. Brodie observed it among the upper servants, hall porters, and tall footmen, of large London houses: Mr. Adams, among the damply-lodged and potato-fed peasants of Ireland: it is also a very common disease in Holland. As far as I am aware, it does not exist in hot dry climates. It rarely attacks one joint alone; but generally invades them symmetrically, picking out the same articulation on either side in succession, until a large proportion of the joints of the body are rendered fixed and useless. Sometimes the disease affects only one joint, being produced by accident or other cause. Such a circumstance very rarely happens, except at the hip, where it has acquired the name of Morbus coxæ senilis, Coxitis sicca, &c.*