thickened. The mother wished the finger to be removed, as it rendered the whole hand useless. On examination, I found there was false anchylosis of the joint; the flexors were, however, so tight, that to endeavour to straighten the finger without their division would have been useless. I explained the possibility of restoring the use of the part, and passed a tenotome under the flexor tendons, divided them from within outwards, about the middle of the first phalanx, and bound up the hand without straightening the finger.

31st. Straightened the finger and put it on a straight splint.

Nov. 4th.-Let passive motion be used, and put the finger on the splint again.

14th. The same plan has been adopted of frequently using passive motion. The straight splint has been kept, because it seemed better to forestall any possible recurrence of retraction. She is now to leave off the splint, move her finger about, and use it in the day, but to have the splint at night for another fortnight.

Dec. 31st.-Saw this patient, who has full use of the hand, and no deformity but a slight enlargement of the joint.

CASE LXI.-John L, aged 10, had suffered when five and a half years old from knee-joint disease, for which he was treated in Shropshire. The knee is bent at an angle slightly acute; the bones are in their proper position. It was in consequence of this malposition that I was consulted, February 7th, 1859.

There is some slight mobility in the joint; it can be flexed a little, so little that the movement is felt rather than seen; it cannot be straightened in the least. The boy is healthy and strong, but walks with crutches. Chloroform was administered by Mr. Harrison, and it was then possible to attain greater mobility of the joint; it was found that the patella was not anchylosed by bone to the femur. The flexors strongly opposed any efforts to straighten the limb; the biceps was chiefly tense; a tenotome was passed in on the outer side of the thigh, and the tendon divided about two inches, or a little more, from its insertion; the posterior edge of the fascia lata was cut through from the same puncture and without removing the knife, and the tense inner hamstrings were also divided.

12th. The small wounds in the skin having soundly healed, chloroform was again administered. When fully under its influence the patient was turned over so as to lie upon his face, the front of the thigh lying along on the table, a pillow beneath it. Mr. Harrison held the thigh firmly, so as to exercise counter-extension. I placed my left hand in the bend of the knee, behind the tibial condyles, my right at the back of the malleoli, and sawing simultaneously upon both began to straighten the joint. When the limb had moved through a certain small space a rather sharp breakage sound was heard, followed by a dull rending, and the joint became much straighter. When it had been extended to about a right angle and a half, or 135o, I could get it no further. Examination showed that it was the firm anchylosis low down of the patella which prevented further straightening. A little consideration induced me to turn the patient on his back, to place a book about an inch thick under the tibial condyles, and to direct

my coadjutor to make firm, but not violent, traction on the tibia below. By these means I hoped to prevent either dislocation of the tibia backwards, or rupture of the epiphysis, while I was pressing the knee downwards. The parts resisted much less than might have been expected, and in a short time I had the satisfaction of feeling the patella yield, and of restoring the limb to a perfectly straight position. The splint, previously moulded to the deformed posture of the limb, was applied, and the patient taken to bed. Ice-cold water to be applied to the limb.

15th. The boy had some, but by no means severe, pain for about sixteen hours after the operation. I took off the splint and moved the joint a little; some pain was produced, but motion was not carried far-a Liston's splint with a screw at the back.

22nd.-Much more movement can now be borne, and he can place a little weight on the foot.

August. The patient had very fair mobility of the joint, and the muscles of the limb are daily increasing in size; he walks with one stick only.

CHAPTER XVIII.

ON THE REMOVAL OF DISEASED JOINTS.

A.-On the Circumstances which justify Removal of a Joint.— There is a certain state and period of joint-disease, which not only warrants the surgeon to recommend removal of the part, but which renders any other course unjustifiable. The variety of circumstances which call for operative interference may be summed up in the following manner.* Removal of a joint may be called for: to save life in the height of an acute disease; to shorten the wearing processes of a chronic and incurable disease; to rid the patient of a deformity and encumbrance.

In the first of these, the surgeon is called upon to form a rapid decision, and to act upon it. He has nothing to do with collateral considerations, but has simply to judge; Whether the system will succumb to the disease before the part can be restored? and, whether any operation will place the patient in a better position? The answer to the first question must be decided according to the principles of general surgery, whose consideration hardly comes within our scope. The amount of febrile excitement and exhaustion must be contrasted with the amount of power, and the result compared with the quantity of local repair necessary before the violence of the irritation will be subdued, and with the probability of so excited a system performing those actions at all. It must be remembered, that few local surgical conditions can be worse, than a joint acutely suppurating, the cartilages detached from the inflamed bone, the deep cavity full of purulent matter, putrid, or on the verge of putrefaction; the bone cancelli filling themselves with pus, the limb swollen by acute oedema, the patient almost prostrated by the pain. The general condition will be that which always accompanies such local manifestations: a low typhoid fever, ending very probably in purulent infection. We have seen that

* Malignant and sarcomatous disease are not noticed.

in the early part of suppurating synovitis, free incisions into the joint at some depending part greatly relieve all the urgent symptoms, and may save the limb. Such treatment is scarcely successful except in the commencement of the disease; its value, and the chance it may afford, are not to be neglected; if, after a time, the oppression of system be diminished, we may postpone the consideration of operation; and if ultimately that last resource must be resorted to, the patient being in a less oppressed state, will bear the operation better. If a free outlet for the pus do not speedily relieve, removal of the part will probably be the only hope; and while the surgeon should not hurriedly decide to sacrifice the limb, neither should he postpone his decision until danger from purulent infection be imminent.

In considering the state of parts implicated in a suppurative synovitis, we have very much answered the question, as to whether operation can put the patient into a more favourable position. Certainly, the clean edges left by the blade are much more tolerable to the patient than the condition above described; and when there is some systemic power left, it frequently happens, that in twenty-four hours, the typhoid symptoms have disappeared, and the patient seems restored to life. On the other hand, when vitality has been much depressed there is hardly any rally, the wound suppurates unhealthily, does not unite, and the whole condition appears hardly improved by the operation;—if the shivering of purulent infection have come on before ablation, the patient has but a very poor chance of escaping with life.

The difficulty of accurately and justly judging, under the circumstances above noted, becomes facility when compared with the discernment to be used when a chronic disease has entered into such a stage, that operative interference comes at all into question. The slower form of malady, gives the advantage of allowing the surgeon a longer time for decision, so that he can positively try the reparative powers against the morbid state. On the other hand, so many points must be considered, all of them bearing with different weight and in different direction upon the question, that it is scarcely possible to epitomize within a small compass, the mode in which the subject of removal or non-removal should be considered. The most

essential questions are: Is the constitution capable of ultimately conquering and healing the disease? If so, will the limb be of value, or an encumbrance? In the worldly circumstances of the patient, is it possible for him to await a long, and perhaps a doubtful, process of cure?

The first of these three queries, that on which the others hang, is most difficult to answer, whenever the question arises at all; that is, whenever there is such a nice balance between disease and health as to render the issue doubtful. Of course we have the same comparison to make between the constitutional vigour and the repair necessary, but both points are very difficult of judgment, and must be separately estimated before they can be contrasted.* In the first place, the diathesis, whereto the long continuance of the chronic disease is owing, must be taken into account. A rheumatic malady connotes one constitutional evil, a strumous disease another; and the effect upon the system of allowing the persistence of a topical evil is different in both. It has been already pointed out (p. 167), that persons suffering from the former kind of arthritis are liable to a peculiar form of bronchitis, and we know that in such diathesis atheromatous degeneration of the arteries, or disease of the heart, is a common occurrence. It would be false to affirm, that the joint disease had any direct effect in causing or hastening such changes, but the irritability, confinement, and wearing of the system, which are always produced by long continuance of a joint disease, certainly place the body in a condition which favours the progress of such morbid actions. The effect, however, of local rheumatic disease upon the general system, is much less marked than that of a strumous malady. Some persons look upon the scrofulous diathesis as an entity which necessitates diseased action somewhere, and they even believe that, by removing its manifestation in one part of the body, we only transfer its appearance to another place. The actual fact is, it seems to me, very different indeed; as I believe that scrofula does not consist of a materies morbi which must have exit, but in

Although in a verbal description of the mental processes to be gone through this separation holds, the surgeon does not divide so entirely his local from his general investigation, since

some part of his knowledge concerning the constitutional condition must be gathered from the phase of the local malady.