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The following diagrams illustrate the method: Les cartes ou les p!anches trop grandes pour dtre reproduites en un seul clich6 sont filmdes d partir de Tangle sup6rieure gauche, de gaurhe d droite et de haut en bas, en prenant le nombre d'images n6cessaire. Le diagramme suivant illustre la m^thode : 1 2 3 1 2 3 4 5 6 »r( LECTURES ON CAUSES, PATHOLOGY, ANI> TREATMENT OF JOINT DISEASES. 1)EL[VERED AT THE McGILL UNIVERSITY MEDICAL COLLEGE, MONTREAL, CANADA, BY LOUIS BAUER, M. D., M. R. C. S., Eng., |)rof(!i$ar of ^ntitoms anb Clinicnl ^nrttrg ; fCirtntiatc of t)}t l^tin foih jitittt jntbiral JlorUtg ^Umbtr of tlft ^tto ^ork ^nt^ologitnl J^ocirtg ; of tl^t ^nttrici^n ^rbital ^saoiiiition ; 6aTrt»{ron>ring ^tUoIs of i\it IHonbon iRtbtcHl jSotittQ ; f,AU |$e:i(t1f ^tftctx of l\}t Sitj) of J^vooklnn, ttc, tit. nEPniNTMD FROM THE CANADA MEDICAL JOURNAL. NEW YORK: WM. WOOD & CO., 61 WALKEJ.. 1868. V ^>i D » % % CONTJiiNTS. Introductory Remarks. 1>AGK V LECTURE I. Causation of Joint Diseases. The strumous theory untenable. — Cruveilhier's experiments. — No pauper- ism, but joint diseases prevalent in the United States. — Frequency of joint diseases in childhood, among boys, in cities, and more northern latitudes. — Their rarity among adults, in the female sex, and in the south. — The anti-scrofiilous treatment utterly worthless. — Local and mechanical treatment effective. — Traumatic injuries the chief cause of infantile joint diseases 2 LECTURE n. "'kV Anatomical Charactkr of ooint Disbasbs. Chondritis of rare occurrence, if at all. — Structure of Synovial lining. — Its susceptibility to morbid action. — Richet's experiments. — Periosteum. — Physiological and pathological relation to infantile joints. — Epiphyses, their peculiar maintenance, and exposure to traumatic injuries 14 LECTURE in. Clinical Charaoter of Joint Diseases. General symptoms. — Pain, inflammaiory and reflexed. — Immobility. — Spasms — Contraction. — Malposition. — Fever. — Protracted course, — Synovitis. — EflFiision. — Loss of contour.— Fluctuation. — Suppuration. — Perfora- tion. — Hydrops articuli. — Penetrating wounds. — Periostitis and ostitis. —White swelling. — Affections of the knee-joint. — Morbus coxarlus Tl , , LECTURE IV. Proonosis of Joint Diskasrs. Axioms in. — Prognosis better now than formerly 41 I 3 % 3 ^ ▼Hi. CONTENTS. ' LECTURE V. Trbatmbnt of Joint Disbasis. Method of examining. — Importance of anaesthesia for diagnostic purposes. First stage. — Absolute r ,st of joints the first axiom. — Means of accom- plishing it. — Position f r.ffected articulation the next. — Treatment of penetrating wounds. — Second stage. — Rest and position imperative. Paracentesis of joints beneficial and harmless. — Treatment of hydrops articuli. — Tenotomy. — Free incisions. — Treatment of morbus coxarius. "Wire apparatus. — Stiffened bandages. — Portative splints and braces of Davis, Vedder, Barwell, Sayre, Andrews, and Bauer. — Their respective therapeutical value, — Treatment of affections of the knee joint. — Gutter splints. — Knee brace. — Third stage. — Exsection and amputation. — Their respective indications 42 LECTURE VI. Treatment of the SBQcsLifi of Joint Diseases. Stiffness and its treatment. — Malposition and Anchylosio. — Gradual exten- sion. — Tenotomy. — Brisement Force. — Louveier. — Dieffenbach. — Lan- genbeck, — Accidents, — Rhea Barton's operation.— Brain ard's plan.— Deformities of Hip and Knee-joint. — Their treatment 67 CASES. I.— Hygroma Bursale Traumaticum, of eight years standing : fibrous anchylosis of left knee.joint with flexed and inverted malposition 8<> II. — Traumatic diastasis of the lower epiphysis of left femur. — Remark- able deformity and malposition of the knee-joint. — Abnormal lateral mobility. — Total resection.— Recovery 89 III. — Morbus Coxarius in its third stage.— Consecutive abscess connect ing with the joint. — Complete prevention of malposition 92 IV. — Malposition of the right limb with more than four inches shorten- ing, the result of now extinct hip disease 95 I s I( t] tl n( 01 an av ■"«**''*!* 'V^'--. re< of cai ' --^t INTKODUCTIOK In the succeeding pages I have set forth the results of my researchss into the causes, pathology, and treatment of articular diseases. Whether they are equivalent to tLc* labours of upwards of twenty years, I cheer- fully leave to the verdict of the unbiassed portion of the profession. But those will be able to form a correct estimate of my humble eflforts in this line of scientific culture, who compare the crude state of surgical knowledge on the subject then existing, with the rapid strides it has made since the ground was first broken and prepared for the new seed. I have certainly passed through an eventful period, full of contentions against preconceived dogmas, and defended with the pertinacity of theo- logical fanaticism ; but I had also my gratifications when the new doc- trines, elicited by careful pathological and clinical investigations, forced themselves with irresistible logic into legitimate acknowledgment, and now actuate the surgical practice of the most prominent standard-bearers of professional advancement both at home and abroad. This acknowledgment is quite sufficient to satisfy literary ambition, and I can afford to treat with forbearance the literary piracy that has availed itself, without due recognition, of the results of my labours. The opportunity of placing my literary products on this subject on record in a more coherent and complete form, I owe to the kind invitation of the Medical faculty of the McGill University of Montreal, and I cannot allow the occasion to pass without expressing my grateful appre- TimTTBTyr - INTRODUCTION. '•,•„„„£ the liberal tospitality with which I have been treated by d*: W. aJof the leading practitioners of Montreal .n general. . • n , 1 4 Mr VrsvA of New York, have materially which I employ in the treatment of joint diseases. ','■ ■■ .-VC'" THE PATHOLOGY AND TREATMENT OF JOINT DISEASES. < (I i\ ■n Gentlemen,— In compliance with your gratifying invitation I pro- pose to discuss some important points pertaining to articular diseases. This is possibly the only subject with which I may hope to engage so distinguished an audience. The last ten years have been fruitful of material advancement both in the pathology and in the treatment of this class of affections, and their cultivation is still vigorously and diligently pursued. Notwithstanding all the achievements in that direction, the subject still remains in a state of transition, through the tenacity with which one portion of the profes- sion 'heres to the venerable teachings of the past, and the enthusiasm with which another portion declares itself in behalf of modern ideas. The time has certainly come when an understanding should be effected by means of unbiassed critical analysis and clinical experience. With this object I enter upon the present discourse. If, through inability, I should fail of realizing my design, I may at least hope to place the sub- ject matter in such attractive relief as to insure your permanent interest and active participation in the settlement of the pending questions. 2 I. CAUSATION or JOINT DISEASE. On this point, there is a decided clashing of views. By far the larger number of practitioners, the leading members of the profession among them, are of the opinion that most cases of this class are the result of con- stitutional disorder, of whi^h the articular affection is but the localized symptom. To this theory the most prominent authors on surgery are committed, and it is promulgated from the professorial rostrum and at the bed-side. Time and usage have even rendered it popular with the laity. A few modern enquirers, comparatively insignificant in name and posi tion, not only take exception to this theory of causation, but assert that articular maladies are excited exclusively by local causes, and that the constitution bears no part in the causation. They further maintain that where the constitution suffers, it suffers from the ulterior effects of the local disease. As long as etiological views on this subject so widely diverge, there can be no uniformity of treatment ; nor can a compromise be effected between views so diametrically opposite. The only way of deciding between two, of which only one can be right, is to analyse the grounds upon which they are respectively placed. I hope the venture on my part in doing so will not be deemed presumptuous, for the conflict of etiology exists, and its settlement is certainly desirable. Too much has been al- ready conceded by the old school to warrant a proud denial ; and no party can feel aggrieved when appeal is made to the decision of" stubborn facts." Scrofulosis, rheumatism, gout, syphilis, scarlatina, pyemia, and other diseases have been enumerated as constitutional causes of joint affections. To strumous disease, however, has been assigned the first rank, inasmuch as it has been linked with the numerous and diversified cases that happen during childhood. From my own experience I have to infer that not less than ninety per cent of all articular affections occur before puberty. Inasmuch as scrofulosis is not limited to childhood, and is supposed to extend beyond puberty, a few more per cent nmy be added to the origi- nal proportion, making a percentage of about ninety-five. Thus the theory of constitutional causation narrows itself t^own to the theory of strumous causation, and with this we shall have essentially to deal. In entering upon our investigation, gentlemen, we meet with the sin- gular fact, that notwithstanding the general acceptance of, and acquies- cence in, the stated theory, nobody seems to know accurately what stru- mous disease really is. There are certainly no two writers that fully agree in its definition, nor does scrofulosis rest upon any firm pathologi- 3 to gi- the of xu- lUy cal base. Even its cl'.nical character is rendered so indefinite that im- plicit faith and a goodly stretch of imagination are required to realize its attributes. This is the status of modern literature on the subject, and in extending our researches over a more remote literary period, we are not less surprised to find that the scrofulosis of the present is a materially different malady from that of the past. The pathological school of the humoralists has identified this disease with a distinct morbid principle, a materia peccans, contaminating nutrition throughout, and stamping all other incidental lesions with its peculiar unalterable character. The fol- lowers of that school very consistently resorted to starvation, vegetarian- ism, and to mercurial and autimonial preparations, for the purpose of free- ing the system of that c?eMs efc machina. With the physiological school the agent of strumous disease was mollified to a mere imperfect formation of proteine compounds. They very wisely adopted opposite treatment with a view to regulate the chemical transactions of the body, and to correct the catalytic combinations of the proteine. Both schools accept- ed perverted hygiene and diet as the remote causes of strumous disease, and consistently believed that it was a disease of pauperism. Again : both schools insisted upon strumous diathesis and an hereditary trans- mission. These last views are fully compatible with the humoral ist principle of pathology, but indefensible from the stand-point of the phy- siological school. Certain appearances of patients may indicate perverted nutrition, and a i lorbid principle, thereby engendered, may, like syphilis, be transmitted t( generations. But a diathesis for the formation of low-graded proteine combinations is a senseless construction, and the hereditary transmission of such compounds is equally without meaning and inconsistent with the chemical tenacity and restitutive powers of in- dividual life. Science in its advancement has already made some substantial inroada upon the strumous domain, and narrowed its borders at some vulnerable points. Porrigo capitis and sycosis menti, formerly claimed as specific strumous forms, have now been proven to be caused by insignificant vegetable parasites. The very prototype of scrofulosis, viz., keratitis scrofulosa, has been reclaimed by modern ophthalmologiEts as an inde- pendent and exclusive local lesion readily yielded to local appliances. And new incursions are threatened from oUier sides. Help was evident- ly needed to uphold the loose cohesion of the scrofulous architecture and to save it from pathological downfall. It was but too readily found in tuberculosis. By incorporating the latter with strumous disease, some anatomical tangibility was secured. Gradually the new pathological ele- ment has prevailed so completely, that but the name of the old scrofulous doctrine remains. In talking about strumous infiltration, tuburcular in- jiltration is meant ; and in fact in its former and present application, the tubercular element has completely superseded the strumous one. The transition from one to the other has been effected so clandestinely as to be noticed but by very few. The alliance between scrofulosis and tuber- culosis proves, if anything, that neither had ever acquired a self-sustain- ing existence. Both diseases are clinically and anatomically different in character. One is said to prevail among children, the other amongst adults ; and only exceptionally is this rule reversed. The organ which one chooses is but rarely sought by the other. Their very presumed causes differ most essentially, — one said to be the result of poverty and sanitary defects; the other having no respect for gradations of wealth and station. They differ e\3n in geographical distribution. Notwith- standing all these differences, they arc, by tacit understanding and ac- quiescence identified as the same disease. It would be unjust, however, to say that this transition has been effected totally without opposition. Of late the pathological character of tuberculosis has been subjected to various and close investigations. Its identity with pus has been asserted by Cruveilhier. The results of his experiments upon rabbits demonstrate at least this much, that pus is susceptible of undergoing the very same metamorphosis as tubercle, from the semi-fluid condition to perfect inno- cuous calcification. Thfe strongest advocates of genuine tuberculosis have been forced to admit that there are often pus corpuscles, where the external appearance of the object denotes tubercular substance. Few au- thors have had better opportunities of studying the pathological anatomy of bone and joint diseases than Guret of Berlin, his investigations extend- ing even over the veterinary field. If I correctly interpret his statement, he has met with no tubercle in joints and bones at all. What other au- thors had pronounced to be tuberculer infiltrations and caverns, he recognised as purulent infiltration the result of osteo-myelitis, and as bone abscess the sequence of circumscribed ostitis. And Virchow, one of the most esteemed pathologists of our time, considers himself justified in stating that tubercle is fully compatible with the acknowledged changes of inflammatory products. Again, gentlemen, i,? there any peculiarity about tuberculosis that could be established and accepted ? You are aware that the so called tubercular cell has been asserted, but the microscope has failed to prove its reality. If the microscope cannot substantiate any peculiarity, how much less can the naked eye ( For there is certainly no difference in appearance between tubercular matter and cheesy pus, and the suspicion of identity must necessarily accrue from 3uch conformity. At any rate our knowledge on the subject is not final !S m and exhaustive ; and we may justly look for further disclosures rather detrimental to, than confirmatory of, the genuine character of tuberculosis. But, to return to the starting point of our discourse, I shall find ample occasion to show, that the stumous theory in its practical application to articular diseases, is worthless and rather injurious than otherwise, as it certainly has long diverted us from a course of investigation that alone could lead to practical results. Consistently with the received opinions the lower classes of society must come in for their full share of joint afibctions simply because they are supposed to contend with poverty and hygienic neglect. If this assertion had any show of correctness, it would imply that where we find joint diseases, there we ought to expect poverty and hygienic neglect. But clinical experience in a great measure contradicts the assertion. These afiections happen in all classes of society. They do not pass the mansions of the rich, nor are the agricultural districts exempt from their visitations. Yet with all it must be allowed that there is, in the abject domestic condition of the industrial classes of Europe, a plausible reason for assuming that they arc more subject to chronic derangements of nutrition than the wealthy portion of society. Nor can the action of such nutritive derangements upon local diseases be altogether denied. At any rate, our patliological associations tend to confirm this supposi- tion ; though it may be clinically diflScult to qualify the exact measure of those constitutional colourings of local lesions. Those who have had the opportunity of personally investigating the actual social status of the European proletariate and pauperism agree that it is deplorable in the extreme. They occupy in cities the worst of dwellin.5S, in the lowest of ([uarters ; their rooms are overcrowded, their articles of food are of in- ferior quality ; multitudes subsist from offal ; their opportunities for cleanliness are limited and little resorted to ; their very existence is a contest for the necessaries of life. Many of the working classes and paupers domiciliate in places inaccessible to air and sunlight, in damp, and musty basements where but fungi thrive.* The combined effects of these unfavorable surroundings upon mind and body are so appalling to the humanitarian as to be remembered with painful sympathy. They give rise to the most aggravated forms of so called strumous disease with which the public hospitals and dispensaries are crowded. It is but na- tural to associate so conspicuous a morbific agency with a class of diseases seemingly devoid of other causes, and reacting heavily upon the nutritive standard of the patient. * According to the latest statistics, 10 per cent, of the entire population of Berlin, live in cellars and basements. 6 I i' In contemplating the financial condition of the same classes in the United States, we have no difl&culty in finding an entirely reversed status. Here the demand for labor far exceeds the supply, and its compensation has therefore for years past been very remunerative, so as to furnish ample income to every individual who aspires to an honest living by handiwork. The " Trades Associations " have, under these circumstances readily succeeded in controlling employers and in imposing upon them their own erms for labour. However premature the eight hour labour movement may have been, this much is to be inferred from it, that the working classes are almost the sole arbiters of their own affairs, much to the oppression of the other factor of industry. So great has been the demand for hands, as to necessitate the employment of thousands of women anu children. Nothing servos as better evidence of the financial thrift of labour than the acknowledged prosperous condition of the Sav- ings Bank. Hence the domestic state of the working classes is infinitely superior to and beyond all comparison with that of their trans- Atlantic order. In fact the humblest labourer here finds himself in the possession of enjoyments which would be estimated as luxuries in Europe. How ever imperfect the tenement houses may be when compared with the dwellings of the wealthier classes, still they are comparatively spacious, well-lighted and accessible to current ventilation. The food of the work- ing classes is bounteous and wholesome, and there are very few families but have animal food at least once a day. Copious water supply to tene- ments ensures all facilities for cleanliness ; and public baths are accessi- ble to all at a moderate rate. A glance at the attire of our industrial classes on a Sunday, gives us volumes of proof of the comparatively easy circumstances by which they are surrounded. What might have been anticipated a priori from their superior conditions is confirmed by prac- tical observation, viz., that our industrial classes exhibit a better general health, a robust appearance, and none of those excessive forms of nutri- tive derangement which are comprised under the collective term of strumous disease. The contrast existing for instance between the populations of New York and Vienna can scarcely be overdrawn. In the Austrian metropolis almost every person one meets looks sallow, anemic, attenuated, physically impoverished, aHflictcd with swellings, ulcer- ations, and cicatrices of the cervical glands, of which in our midst there is hardly a trace. The comparison to which I have drawn your attention, gentlemen, is between Europe and the United States, with which I am best acquainted. Whether my remarks apply equally to your prosperous Provinces, you can decide best, Notwithstanding the superior advantages, facilities, and prosperity of our industrial classes, and notwithstanding the fact that scrofiilosis in general has found amongst them but a limited ground of development, we meet, at least in the Northern States, with numerous cases of articular diseases for which constitutional" causes cannoo be assigned. What therefore is plausible for Europe is inadmissible with us, and this very circumstance was the first shock which unsettled my belief in the theory of strumous causation. In defence of the old theory it may bo urged that tuberculosis prevails in the United States, and satisfactorily accounts for the occurrence of joint diseases. Such an argument can not be ac- cepted as tenable, though the facts appropriated as premises may be con- ceded. For it so happens that tuberculosis is met :with North and South, and apparently much more frequently in the latter. Among the negroes of the South, for instance, glandular affections are quite common and easily accounted for by their principal vegetable diet and hygienic indif- ference. If therefore the proposition be correct it will follow that joint diseases are more frequent in the South and especially amongst negroes than in the Northern section of the country. This is however not the case : on the contrary the further one proceeds South the less he meets with articular diseases ; and according to the statements of competent surgeons of that region, they become perfect rarities near the Bay of Mobile, the Gulf of Mexico, and the West Indies. But irrespective of this geographical limitation of joint diseases, we have a right to demand ocular demonstration of the tubercular dejjosit alleged to be the corpus delicti. They are very few physicians who pretend to have seen tubercle in the affected structures. Thus, for instance, Professor Gross, who is one of the warmest advocates of the theory of tubercular causation, owns that he has never met with tubercular depositiotis in joints. lie finds sufl5,ci- ent evidence for his opinion in the fact that a patient dies from tubercu- losis after having suffered from joint disease. This sort of logic must pass for what it is worth. It has never converted me. For by the same reasoning we might come to the conclusion that a furunculus, a parony- chia, or a fracture, happening to a consumptive patient, are of a co-ordinate character with tuberculosis of the lungs. Gentlemen, I hare submitted to your mature consideration my doubts as to the correctness of the time-honoured and prevailing opinion of stru- mous and tubercular causation. All I can desire of you is to look upon my arguments as suggestive. For ray part I have bid adieu for ever to the old theory as an unsafe guide. Now if the facts adduced are true, and my reasoning consistent with them, and if I have made out a clear case against the strumous or tubercular 8 causation of joint diseases, it follows that there must be causes other than those heretofore assigned. To find them out and to prove them as such will be " the next business in order." I have already observed that about ninety per cent of all articular aifections fall upon the period of infantile development. The proportion is however very different in diflFerent ages of childhood. An aiticular disease is certainly a rarity among infants, — we seldom see it before the expiration of the third year. From that age upwards to the fifth vear, these affections become more numerous and attain perhaps their highest numerical proportion at the sixth. Then they commence to diminish gradually, and at about the tenth year they are reduced to but few recent cases. Towards puberty these are probably as rare as during the infantile period. I "jeed not state that these facts are based upon a careful statis- tical record of my own, and are borne out by the experience of well em- ployed surgeons. I think it is apparent that the strumous theory does not oflFer a satisfactory explanation of these facts, for the prevalence of the disease is not supposed to be restricted to any particular period of child- hood. We must therefore look for a more consisteint explanation. The period of infancy is that of special parental protection. The child is mostly under direct charge of the mother or nurse, independent locomotion not having then commenced. The second and third year of infantile life en- joy less or more the same protection against accidents and injuries. With the fourth year a new epoch commences. The child is curious and in quisitive ; it wishes to examine and to touch everything ; it climbs upon chairs and tables ; it trusts to its own guidance and escapes from the protecting eye of its mother ; and it is thus exposed to all sorts of falls and mishaps. With advancing age and knowledge of its surroundings the child becomes more appreciative of danger, and more careful and timorous in its ventures. At a later period, when judgment and pru dence assume their sway, accidents and particularly falls become of i'arer occurrence. Reasoning from these facts I cannot but conclude to regard traumatic injuries as the sufficient cause of joint diseases during child- l\ood. With this suppo-ition coincides a cordon of additional facts equally demonstrative, viz : 1. Joint diseases are not limited to any particular class of the popula- tion, Yior to cities; on the contrary they occur amongst all classes of society and in agricultural districts as well as in the densely populated foci of industry. 2. Joint diseases conform to certain latitudes. 3. Certain joints are more often afiected than others. ■; ; 4. Boys are more subject than girls, and sanguine and impulsive chil- dren more than phlegmatic and indolent. 5. We rarely fail to trace the attack to traumatic antecedents. 6. Constitutional treatment per se has proved of no avail in articular affections. 7. In fine, positive results follow the exclusive local treatment of these lesions. At 2 I do not mean to imply that climate exercises any direct or speci- fic influence upon the numerical distribution of articular diseases, not- withstanding the undeniable facts previously adduced. But inasmuch as the temperament, usages, diet, domestic habitations, tastes, employments, &c., of the inhabitants differ according to latitude, we may be justified in speaking thus of the generative causes of disease. In comparing there- fore the Northern and Southern States of the American Union we notice differences in this respect most material in their ulterior pathological con- sequences. The temperament of the purely Southern people is less sanguine and excitable than that of their Northern compatriots. The calmness of the Southern man is the result of his climatic constitution, and is in every respect natural, whereas the imperturbability of the New Englander is the effect of incessant social and religious discipline. The diet in one section is greatly farinaceous, in the other more nitrogenous. The habitations of the one are spacious but low, whereas the other dwells in four story buildings. There the streets and the environs of dwellings are left as nature provides ; here they are paved and improved in various ways with hard surfaces. Ease has pervaded society in the South, whereas ours has been marked by constant bustle, expansion, restless and ambitious strife and collision of interests. Our employments are greatly those of a commercial and manufacturing people, theirs are those of an agricultural community. In other w6rds our pursuits engender toil, emulation and egotism, while the ircondition is simple, calm, and primitive. The same contrast exists less or more between the inhabitants of cities and agricul- tural districts. What bearing, you may wonder, have these differences upon the statistics of joint affections ? Simply this that a Northern child is more impulsive, ambitious, and quarrelsome, beci. -le he is confined, restrict- ed in space, imposed upon and brought into collision with other children. His animal diet renders him stronger and more irritable. Hence his lia- bility to casualties. Again a fall from a high staircase, or from a horse, waggon, fence, &c., to a hard side-walk, pavement or ice occasions more serious effects than the same fall upon soft ground. At 3 it is to be noted that among all joint diseases those of the knee are most numerous ; next in number come those of the hip joint ; next i^; le ! ■' I'!! M .hi is; those of tho bones and joints of the spine ; then those of the elbor ; then those of the tibio-tarsal articulation, &c. These well known and acknowledged facts are not accidental and the old theory fails to account for them. It has always been alleged that strumous discnse has particular affinity for the spongy and reticular structure of bones. If this be so, the tarsal, carpal, and vertebral bones should engender the disease more readily than any other portion of the skeleton. Yet as we have seen the numerical preponderance happens at the knee and hip articulations, both these joints being more than any other exposed to injury by falls, blows, and other accidents. The proposition under the heading 4 needs no special comment. The fact that boys are more subject than girls to articular affections must be accounted for by their greater exposure to injuries. It is incompatible with the theory of strumous causation, because girls are more exposed than boys to the causes of that disease. At proposition 5 it is worthy of recollection that at certain periods of childhood accidents are of very common occurrence, though they are generally disregarded as causes of disease, unless they immediately eventuate in great pains, contusions, wounds or fractures. The proof of connection is sometimes difficult, because weeks and months may elapse before the pathological effects clearly manifest themselves. In rare cases one follows the other so closely that the mutual relation is patent and unmistakeable. That apparently slight injuries may suffice to lead to grave consequences, I have had frequent opportunities of observing- Allow me to relate but two instances in exemplification. A little girl fell backward flat upon the sidewalk. She immediately experienced violent pain at a certain portion of the spine, and had to be f \rried home. I saw her soon after the fall. One of the spinous pro- cesses (the 5th dorsal) not only projected perceptibly, but was painful to the touch. The advice to keep the patient in the recumbent posture for at least three months was followed but for a short time, and the child was permitted to resume locomotion. At the end of six weeks, during which time the dorsal protrusion had noticeably increased, I was again invited to see the case. The little girl was then suffering from intense pleuritis of the left side, which eventuated within three days in copious exudation into the pleural cavity with dislodgment of the heart. Death soon ensued. • The view I held and expressed was that the recent disease was on- nected with the fracture of the spine ; that most probably an abscess had formed at the injured point in the column, and had discharged its 11 contents into the pleural sac. The father, in order to relieve his mind from the indirect imputation of neglect, repressed his aversioa to an autopsy. I need not assure you, gentlemen, that my diagnosia was in every particular verified. There was, indeed, a fracture of the fifth dorsal vertebra, though of very limited extent, a mere chipping off- of a wedge-shaped fragment still connected with the next lower interver- tebral fibro-cartilage. There was next an ab^oeps in front of the frac- ture and beneath the periosteum, with, as it were, two compartments, one on either side of the spine, communicating through tlie fracture. The left compartment, the larger of the two, had effected a perforation into the left pleural cavity. * Besides this, disintegrations of bone, cartilage, and adjacent structures in general occupied the affected locality. The other patient was a middle-aged man, a music teacher, of German extraction. When under the temporary influence of liquor, he fell from an elevation of about five feet, and struck violently the internal circum- ference of his right knee joint. The intense pain that set in forthwith, soon sobered him, and impressed him strongly with the apprehension of grave injury to the articulation. A physician was immediately called, but failed to discover ony injury. I saw the patient the third day after the accident. There were no superficial traces left by the fall. The articulation was hot, swelled, flexed, and extremely tender to the touch. From time to time, spastic oscillations appeared, and terrified the patient, who was pale and dejected from w'ant of food and rest. I placed him under chloroform, extended the extremity, and secured the position by appropriate appliances. The trouble yielded without any further treat- ment ; and, for aught I know, the patient recovered from an attack that might have permanently affected the articulation. The interval of time between cause and effect, is, after all, more ap- parent than real. Many cases, especially those of affections of the spine, commence in so insidious a manner, and the initiatory symptoms are so general and indefinite, as to be excusably misinterpreted not only by the parents, but even by the professional attendant. Among other cases of the kind, I remember one in particular, which had puzzled the physicians for a number of months, until a correct diagnosis was obtainefd. The patient is a little boy of fine organisation, of a most impressible and active nervous system. His agility and daring even to this day are extraordinary, notwithstanding the conspicuous posterior curvature which has gradually become establislied. He may have been five years old, or thereabouts, when he sustained a fall from a fence six feet high, causing at the time considerable alarm to him and his parents. But no percep- tible disturbance of his health immediately following, all fears were dis- 12 missed and forgotten: A few weeks after the occurrence, the patient exhibited signs of general ailment, decrease of appetite, pallor, weakness, disturbed rest, irritable temper, and indisposition to join in the frolics of his playfellows. Occasionally the pulst- became accelerated, with con- temporaneous thirst and increase of temperature. He complained of a transient pain in the stomach. His alvine evacuations were sluggish, badly mixed, dry, of light colour, and offensive odour. The abdomen was often distended with gas. The urine was pale, aud deposited a whitish sediment. These symptoms prevailed for months without ma- terial change. The diagnosis of an ''affection of the liver" was not without plausibility, inasmuch as that organ had become enlarged in all its diameters. At the end of the eighth month, frequent and painful hiccough was observed, and tenderness of the back became manifest on motion of the spine. In fine, his gait became awkward, and the move- ments of his body restrained and stiff. He craved for rest and support, which he obtained by placing his elbows on suitable objects, and his head upon the palms of his hands. Ten months after the accident my services were called into requisition. At this juncture it was easy enough to re- cognize the nature of the complaint. The marked prominence of several spinous processes at the thoraco-lumbar region of the spine ren- dered the diagnosis both transparent and conclusive. To the experienced practitioner, it may seem surprising that the diagnosis was not sooner accomplished, and the disease of the spine arrested by appropriate means. The entire train of symptoms pointed at a local lesion of progressive ten- dency : and a searching examination could scarcely have failed to reveal the locality of the affection. Nevertheless when we recollect the difl&cul- ties in the premises, the aversion of children to manual examination, the disinclination of parents to see their offspring thoroughly handled by the surgeon, and last but not least the limited field of general practitioners for fully observing and becoming conversant with these insidious cases, we will be sparing in our censure even if it should be warranted. It cannot be denied that in the case submitted, there was an uninterrupted connection between the accident and the subsequent disease, I have made the same observation in many cases that have come under my charge and have no doubt that other observers have the same experience. Nevertheless I am far from denying that joint diseases may arise from constitutional disorder likewise. But according to my clinical researches their number is proportionately insignificant. In cases of this character we find originally more than one joint affected, though the disease may eventually fix itself upon one articulation. This appertains more parti- cularly to rheumatism, gout, and especially to pyemia. When on the 13 i other hand but one joint suflfers from the beginning to the end, and the constutional symptoms supervening are in conformity with the inevit- able reaction of the local process upon the general system, then it is rational to infer that the local aflfection is of strictly local causation. Every candid practitioner will agree with the aphorism enunciated under 6. It is certainly a simple fact that the anti-scrofulous treatment of'joint diseases has disappointed both him and his patients. My own clinical training coincides with that period in which the old etiological views held unbounded sway. They consequently regulated my action at the bedside. I followed with full confidence and scrupulous exacti- tude the doctrines of my distinguished preceptors Rust and Von Graefe. I coveted cases of this class, which seemed to be tacitly alighted by the more experienced members of the profession. But all my efforts were in vain. I accomplished no material change that could have been claimed as the result of devoted services. My cases took the usual course to complete obliteration of the respective joints, — malposition of the affect- ed extremities, suppuration, caries, exhaustion and death. Nay more, I had the mortification to perceive that I could but rarely control the in- tense pain usually attendant upon such cases. Similar admissions have been made by other experienced practitioners, and I am led to believe that the negative results of anti- scrofulous treatment of joint diseases is now generally conceded by that portion of the profession whose opinion has any value. In the seventh aphorism, I broadly assert without fear of contradicion that in the treatment of joint diseases, local appliances scarcely ever fail of modifying or subduing the morbid process. For the last ten years I have held these views, and practically tested them at the bed side ; and I can candidly and most emphatically assure you that the results thus at- tained have been most satisfactory in ever particular. In but few cases have I ever had any need for constitutional remedies. Most of them yielded" readily to local means ; and with the local improvement the pre- vailing constitutional disturbances subsided. When thus rest and appetite were insured, the patients increased in weight, and rapidly im- proved in appearance and feeling. I need hardly state that my thera- peutic views on this point were slighted for a number of years by those men to whom the profession look up for precept and example. But when Dr. Davis' portative extension apparatus became generally known, the professional mind underwent a material change and then turned its at< tention to the subject. A few years ago the New York Academy of Medicine discussed the subject of hip disease at successive meetings. Most of those who participated in the discussion admitted in emphatic ■'151 14 terms the therapeutic efficacy of that instrument, retaining at the same time the old tubercular theory of causation. Nobody seemed to notice the contradiction between theory and practice, and it was then and there that my views gained the ascendency. I simply stated on that occasion that but one could be right. ** If hip disease were the consequence of strumous invasion, a portative extension of but few pounds could have no eflFect whatever in relieving or cur.ng that complaint ; .and if it actu- ally had the effect alleged, it would be the most undeniable proof against the constitutional character of the disease." Ti attempt to refute my logic was as feeble as it was unsuccessful, and from that date it may be said that the new theory was admitted to scientific citizenship. I shall not on this occasion enter more extensively upon the subject, inasmuch as I have to recur to it when speaking on the treatment of articular diseases. II. ANATOMICAL CHARACTER OF JOINT DISEASES Gentlemen, — All the anatomical components of a joint may separate- ly and collectively become diseased. Their morbid susceptibility varies however in a material degree. The articular cartilage occupies obvious- ly the lowest point in the scale. In conformity with its purely physical office, it is elastic, only indifferently organized, and devoid of nerves and vessels. Its nutrition is therefore of a low order, accomplished chiefly by transudation and imbibition. Reasoning from these premises it might a priori be assumed that this structure possesses but a trifling suscepti- bility to independent morbid action. This supposition receives addition- al strength from experiments upon animals by Redfern, 0. Weber, and others who found thatjneither physical violence nor chemical irritants have much lasting effect upon articular cartilage. The intervertebral fibro- cartilages are of higher organization, and are therefore endowed with a more decided susceptibility to morbid changes thanjthose of joints. I have made clinical observations to this effect, and I have recorded one case of inflammatory disintegration of so striking a character, that no reasonable doubt could be raised against it. In advanced diseases of 16 joints and of the spine it is impossible to determine whether the cartilage or some other structure has been first affected. The destruction is com- monly so general as to leave no room for speculation. I am inclined to believe that the cartilage suffers but rarely from primary lesion, but that it often participates in the affection of the subjacent bone, and is subject to disintegration from purulent maceration. That the cartilage displays but a passive character in the so called ar- thritis de/orm,ans progressiva is now well understood. The synovial lining is a sort of intermediate structure. It does not I' aform to serous membranes with which it has heretofore been classed. Its greater thickness, albuminous secretion and layered epithelium bring it nearer to the anatomical structures of mucous membranes from which it differs by the absence of mucous follicles. The Haversian glands are no glands at all, but synovial insaculations filled with fat. Gosselin's fim- briae have thus far not met with general acceptance, nor have their functions been fully ascertained. According to Richet the healthy synovial membrane is very vulnera- ble. Injections of irritating fluids into the joints of animals are prompt- ly followed by great vascularity, hyperemia, pinkish and purple disclora- tion, and opacity of the synovial lining with serous infiltration of the adjacent connective tissue. The vessels frequently cluster around the articular cartilage, sand by anastomosis form as it were a continuous wreath from which returning twigs branch over the margin. Occasion- ally the synovial membrane becomes so oedematous and pouched as to circumvallate the cartilage as chemosis does the cornea. By degrees the entire surface of the joint becomes roughened and. granulated. The epithelium luxuriates and is converted into pus corpuscles which are suc- cessively thrown off and the articular cavity is filled with purulent fluid (pyarthrosis) ; similar pathological changes may often be observed to follow penetrating wounds, with this difference however that in the be- ginning the synovial fluid forms a material constituent item of the dis- charge, and reappears occasionally when the process is subsiding. From these experiments it would seem that the synovial lining, notwithstand- ing its destitution of nerves and vessels, is highly susceptible to morbid action of the peracute type. But clinical experience has collected many facts to the contrary. Thus, for instance, some penetrating wounds close by first intention without inconvenience to the injured joint, although blood may have been left behind and air may have entered. Many a time have I performed articular puncture by trochar and knife without a single bad effect, having of course, as much as possible, prevented the entrance of air. i 16 1 1 In hydrarthrosis, Nekton has freely resorted to injection of iodine, and others have followed his example. According to the i statements, only a moderate reaction usually ensues. Free incisions into affected joints have been made, checking the disease, and saving extremities. Amputations in contiguity leave always a portion of the joint, and some surgeons prefer these operations on account of better statistical returns. These facts constitute a formidable offset to the rule based upon Eichet's investigations. It is not unlikely that chemical irritants, applied to a healthy articular surface, will readily lead to a rapidly advancing synovitis, and repeated applications of this sort will bring about those progTcssive changes, of which Richet gives so graphic an account. But it does not follow that atmospheric air would give rise to the same disturbances. According to my experience, the dangers of penetrating wounds have been altogether overrated. In the course of the last few years I have attended a considerable number of cases, many of them formidable, and have in every instance obtained satisfactory results. This may have been due, in part, to the healthy condition and tolerably good sur- roundings of my patients, but not les^ to the more appropriate treatment that has found its way into surgery. From . clinical observation, how- ever, I have received the impression that the synovial membrane has a dangerous afl5.nity for disturbing causes of a constitutional character. Rheumatism, syphilis, and pyemia, in particular, select this structuro in preference to the other components of joints. Of late much has been said and written about tubercular synovitis ; Foerster has never met it, and he is certainly no superficial observer. Nor have I had an oppor- tunity of examining a single case of this description, although I may say, without boasting, that I examine as many cases of joint diseases u j any well-employed surgeon. If, moreover, tubercular synovitis is of a nature similar to that of tubercular meningitis, it means little more than initiatory changes in the subsynovial tissue towards suppuration, — namely, hyperplasy of connective tissiie. Still I do not pretend to ex- press a conclusive opinion upon what has so sedulously evaded my most inquisitive pursuit. Some authors believe that the synovial lining suffers most severely from incidental traumatic injuries. I beg to dissent from this opinion. If both constitutional and local causes expend their force upon the synovial membrane, all joint diseases would resolve themselves into synovitis, and the other components would pass clear of primary disease. Both clinical aim- anatomical observation refute views so untenable. Most injuries befall the prominent portions of joints — the bones and their periosteal coverings, because they are most exposed, and because 17 lG ,0 they oflFer static resistance. And even if the synovial sac comes in for its lesser share, the consequences cannot be beyond speedy redress. Inflammation, excited by a transient cause, would soon terminate in copious secretion of synovial fluid ; and this, in turn, would be absorbed. A moderate admixture of purulent elements would not materially afiect final resolution. Permanent disintegration of the synovial lining, or of the other constituents of the joint, could not well be ascribed to a com- paratively trifling and transient cause. In the anatomical consideration of joint diseases, there has not yet been assigned to the periosteum that importance which it so fully deserves. In the first place, the periosteum continues as part of the joint from one bone to the other, constituting the so-called fibrous capsule. Next, it partly covers the epiphyses and condyles of the cylindrical bones, and consHtutes the means of their maintenance, growth, and develop- ment. From the first anatomical relation results the direct transmission of disease ; and upon the other depends the structural condition of an essential articular component. In the course of m^ surgical practice, I have observed cases of joint disease that could be traced to no other cause than traumatic periostitis. Some of them involved both limb and life. I will relate one in striking exemplification. A lad of thirteen years, in perfect health, an*! without any noticeable morbid diathesis, was struck with a medium-sized cobble- stone at the middle of the tibial crest. Judging from the lesser age of the boy who aim?*:! the blow, from a distance of about twelve yards, the force could -^ot have been very considerable. The impression upon the leg was apparently insignificant. The pain was trifling, and no bruise or indentation appearing, the patient paid no attention to the injury during the succeeding five or six days, and continued at his duty as an errand- boy. Subsequently he found locomotion impracticable, his leg having become painful and so swollen that he could not get 'ais boot on. A physician was now sent ^.'y the father of the offender. Tiie attendant failed to penetrate the nature of the lesion. Thus twelve days more were irretrievably lost in paltry applications. When better advice was finally obtained, the disease had made considerable advance, demanding more than anything else extensive and deep incisions. These wr not resorted to to a sufficient extent. I was called in at about the sixth week after the accident, and found the patient in a most critical situation, and fearfully reduced. Then no alternative to amputation remained, for the limb and the corresponding knee-joint were so extensively and irrecover- ably diseased that no attempt at saving the .limb could be entertained. The specimen revealed the following state : — Almost entire destruction 1 :^; t I \i ; 'J 18 of periosteum of the tibia, exposure ami discoloration of that bone ; the remaining portion of the periosteum towards the knee-joint undermined, allowing the passage of a stout probe inlo the articular cavity at the lower insertion of the fibrous capsule. The latter was itself perforated by ulceration at the external and posterior walls, and the joint exhibited the pathological changes of advar -"^d pyarthrosis. The patient had a speedy recovery, and has for the last six years enjoyed the most un- qualified health. Now, gentlemen, this case proves indeed more than I have claimed. Here a lad in perfect health receives nn injury at a point remote from the knee-joint, which lights up an inflammation of the perios- teum. Not being recognised and controlled, the inflammation proceeded to suppuration ; the matter spread below the periosteum in every direc- tion, until it reaches the capsular apparatus, and finds access to the joint. As soon as the diseased structures are removed, the patient regains his former health and strength, precluding every suspicion what- ever of constitutional disease. This is certainly a clear case of traumatic periostitis, involving an articulation ; and the chain of evidence is con- tinuous from the very starting point to the finale. This case is by no means as isolated and exceptional as might be supposed, although in others the clinical history may not always be found so plain and transparent. The foregoing belongs to a class of cases that are generally insidious and protracted. For a long time they cause but little inconvenience to the patient, and therefore they are slighted at the time when appropriate treatment could scarcely fail to arrest their progress. Thus with very little change they pass on for many months, until an acute period is reached and the joint is found to be extensively diseased. The ori^nal traumatic cause is forgotten ; it appeared at most to be insignificant, and in the estimation of all parties concerned, could not have given occasion to consequences so severe. Meanwhile the constitution of the patient has materially suffered, the vital forces arc dep.'essod, the appetite has become indifferent, weight has decreased, in fact nutrition has gradually and proportionally declined, as the local disease has extended its sway. This is the history of most cases occurring during childhood, and it is this class that has been set down as the result of strumous causation, in default of any other known cause. Now, gentlemen, must iherc not be a general predisposition attached to the physical condition of infantile development, that favors diseases of joints, and disappears at puberty ? No one seems to have paid much attention to this query, and hence the preponderance of joint affections in childhood has remained unaccounted for, up to this very day. It is still an enigma unsolved. ce 19 Laying aside all the fetters of established doctrines, let us try to find out some of the anatomical diflFerenccs existing between the joints of children, and those of adults. Perhaps they may furnish us the key to a correct understanding of the matter. All we meet is the cpiphysal contrivance which serves wise purposes in the giowth and development of the osseous architecture, but allows the c^uphyses themselves to be liable to mechanical derangement. We need but to look at a vertebra composed as it is of seven different pieces held together by cartilaginous discs and periosteum. By this arrangement it is rendered a very elastic body capable of accommodating itself to many exigencies. But its resistance is limited to its elasticity, and the single pieces may under certain circumstances become disjointed or somewhat altered in mutual relation. Diastasis is a solution of continuity solely appertaining to the period of childhood. At an early stage of infantile life the different epiphyses of the skeleton present a marked peculiarity in the mode of their maiatenance, and there is reason to believe that this mode partially continues to within a short time before puberty. Careful injection of the nutrient vessels of the bones of infants and children, demonstrate pretty clearly that the epiphysis receives no vascular complement from that source. In fact the vessels pass only to, and not through the epiphysal cartilage. On the other hand the vessels that enter the epiphysis have no communication with the nutrient artery of the shaft. They are, as it seems, completely isolated from each other by the cartilaginous disc. Most epiphyses arc supplied with blood from the periosteum, with which they are in part covered. Those epiphyses to which the periosteum can not approximate closely enougl., have a special source of nutrition. Thus for instance the head of the femur receives its supply from a branch of the obturator artery which enters the notch of tne acetabulum atid accompanies the so called ligamentum teres, to its destination. The nerve takes the same course. A rather complex mode exists at the knee joint through both periosteum and the ligamenta cruciata. After the skeleton has attained its full development, a>id the epiphy,ses have become continuous with their respective bones, nutrition is perfected by anastomosis of the several vessels. But the intermediate parts of some bones seem never to achieve a full share in nutrition, thus we know that fracture of the femc^iil neck but rarely heals by bony union. It is very necessary that we become fully acquainted with all these physiological facts as they servo to throw light upon a field hitherto obscure. The epiphyses constitute the most prominent part of the joints, and re- ceive most of the violence of traumatic injuries, the soft parts being thus ■mi i! 20 ,:.?'. in a measure protected. At the limited space of contact with the offend- ing force, the integuments and the periosteum are contused and ecchy- mosed, and the nerves of the joint less or more injured. The integu- ments may soon recover ; at any rate their structural derangement would be of but little consequence. Not so with the periosteum. If the extra- vasation of blood takes place in the usual way, that is to say beneath the latter, it constitutes in my estimation a serious trouble. Irrespective of ecchymosis, the eventual cause of subperiosteal suppuration, the very pre- sence of blood denotes disruption of the vessels intended to supply the nutritive demand of the epiphysis. The extent of the part borne by in- juries of articular nerves (sensitive and trophic) in exciting articular diseases has as yet not been clearly ascertained. A case previously de- tailed gives strong evidence to this eflFect. The same injury to any other part of the bone might be comparatively harmless, and would generally eventuate in exfoliation, because the nutrition of the bone depends only in part on the periosteum. It would seem therefore that even apparently trifling contusions at the epiphysis should be viewed with deference and treated with becoming care. But if they give rise to subperiosteal sup. puration, there is in two ways imminent danger for the joint : — first, by the matter spreading below the periosteum and forcing its way into the articular cavity ; and secondly, by instituting necrobiosis of the epiphysis in part or in toto. The latter mode is obviously the more frequent. The destruction or detachment of the entire epiphysis by this process is very rare, — more frequently, one of the condyles is implicated, enlarged^ osteoporotic, and very tender. From thence the disease radiates to the remaining structures, and thus the joint becomes compromised. I have but lately exhibited to the New York Pathological Society, a specimen illustrating this process. A small sequestrum in the internal condyle of the femur was evidently the proximate cause of the extensive trouble to the joint, amounting to an almost complete obliteration of its cavity by adhesive synovitis. Primary diseases of the epiphysis are not of frequent occurrence, and least of all osteomyelitis. The process of gradual destruction is most simplified at the hip-joint, and its varied phases may best be studied there. A few anatomical re- marks will be necessary. The ligamentum teres must be accepted as a ligament in an anatomical point of view, on account of its being endowed with a considerable complement of fibrous structure. Besides this, how- ever, areolar tissue and fat enter largely into its composition, encompas- sing the nerves and vessels passing to, and from the head of the femur. No anatomist has as yet been able to demonstrate the office of the round liga- 21 mcnt. The head of the femur fits so accurately in the acetabulum that it is held there by atmospheric pressure, or, as others think, by cohesion. This bone may dislocate in any direction without the ligamentum teres being ruptured; it consequently places no restraint upon the movements of the thigh bone. Some instances are known where the joints lacked it altogether, without marked impediments resulting. Again it has been ruptured in the act of violent dislocation and the returned head of the thigh bone moved almost to the same perfection as before. Thus it would appear that this ligament bears no part in the action of the hip point. Another oflSice must have been assigned to it. To all appearance it acts as the protector of those nerves and vessels which form the nutritive apparatus of the head of the femur. Without this protection the nutrition of the femoral epiphysis could not be effected. Collectively I look upon the ligamentum teres therefore as the essential nutritive appendix of the head, and its destruction during the epiphysal period as tantamount to the destruction of the head itself. From the composition of the round ligament a high degree of susceptibility must be inferred. In fact, none of the articular components can bear any comparison to it in this res- pect. Besides the ligamentum teres is subject to contusion from violence to the gieat trochanter, whilst the thigh is in the position of adduction and eversion. And upon the trochanter falls are generally received. Boyer has already expressed the belief that morbus coxarius emanates from the round ligament ; but for want of pathological facts, he did not succeed in convincing his contemporaries. The scrofulous theory very soon preponderating, overawed his views,which well deserved consideration. Perhaps no articulation has suffered more from the dogmatism of the humoralist school than the hip joint ; and the fiction culminated into a system in morbus coxarius. There were explanations in it for every single symptom. Very few of these are destined to survive the present <3entury. ^ It cannot be denied that morbus coxarius may possibly be caused by primary synovitis or periostitis with subsequent centripetal perforations. But the majority of cases must necessarily result from primary disinte- gration of the round ligament. Among the reasons for this opinion, of which I have already enumerated a few, stands in the boldest relief the pathological fact that the round ligament is invariably destroyed at a time when the remaining components of the joint have suffered but moderate disintegration. Next comes the striking fact that the head of the femur is invariably reduced excentrically in size, and in a few excep- tiona! instances thrown off in toto. That the origination and frequency of morbus coxarius in childhood has the closest connection with the \ 1 I !1 I 11 rm oo epiphysal construction admits of no doubt in my mind ; and it explains satisfactorily the comparative rarity of this affection during adult life when the epiphysis is completely united with the shaft, its nutrition thereby perfected, and the liability to accident lessened. Gentlemen, I shall here close my discourse on the pathology of joint diseases, and not inflict upon you a reiteration of all that is said better in the works of Sir Benjamin Brodie, Robitansky, Paget, Gurlt, and other distinguished pathologists. Moreover, the practical benefit of being thoroughly versed in the ulterior structural changes attending joint diseases, is indeed of questionable value. If you see one joint in the last stage of its malady, you have seen them all, so littla difference be- tween them is presented. My chief object has been to acquaint you with the initiatory changes of joint diseases, and thus lead you in a practical direction for the prevention of their destructive advancement. But even in this, I have had to consult brevity and terseness in order best to utilize the limited time at my disposal. III. CLLNICAL CHARACTER OF JOINT DISEASES. All joint diseases have some symptoms in common. Of these pain is the most prominent ; usually the first to appenr, and the last to disappear. Clinical observation discerns two kinds of pain — one emanating directly from the diseased structure ; the other proceeding in a circuitous man- ner from the spinal cord, and ?uanifesting itself in parts not directly con- nected with the affected articulation. The fonuer is known by the term of structural or injlammatory pain ; the latter as rejlex. The structural pain varies in extent, intensity, and duration, according to the tissues implicated^ and to the nature and ex- tent of the malady. In some instances the pain may occupy but a small and c'lcumscribed place; in others it miy be diffu.«ed over the entire articulation, and extend even beyond it. its intensity may vary from the sensation of heat and '••jness, to the degree of burning, lancinating and pulsating ; and be eq\ lly variable in its continuance. The morbid condition of the affected structures does not always furnish a satisfactory explanation of the degree of pain ; but too often one ia out 23 1 of keeping with the other. Thus, for instance, a mere ephemeral rheu- matic synovitis, and in hysteric affection?, the pain, for the time being, is very intense and largely diffused, whereas, in hydrarthrosis but little inconvenience to the patient arises from a similar source, The general affection of an entire articulation, with advanced disintegration of the various tissues, may exist for months, and yet be attended with compara- tively little suffering, whilst on the other hand, affections apparently trifling, may create a storm of symptoms and intense agony. In structural pain therefore, but a conditional seraiotic importance can be attached. In this respect the same axiom rules as in the healing art generally — " that but the congruity of symptoms is the base of diagnosis." Notwithstanding all this, some general rules can be recognised as a guide at the bedside : 1st. The structural pain is commonly proportionate to the nervous en- dowment of the tissue affected. 2nd. The pain increases and diminishes in proportion to the progress and regress of the disease. 3rd. The pain is rendered more intense by false position of the articu- lation. 4th. The pain increases when the affected structures become subject to centrifugal distension by effusion of whatever composition, and to irrita- tion by pus, loose sequestra, and foreign bodies. 5th. The pain is augmented by touch and motion. 6th. Whatever induces and increases pain, hastens tlie advance of the articular disease, and vice versa. The so called reflex pain is obviously of a neuralgic character. Being excited by the local disturbance, the morbid impression is conveyed to the spinal cord, the common centre of irradiation ; thence it is reflected backward to the muscles appertaining to the affected joint, and sometimes to the next articulation ; as for example, the almost pathognomonic pain at the knee in coxalgia. The latter mode is rather an exception, and an isolated clinical fact, which may be explained in this manner : " that the same nerve (obturator) supplies both joints with sensitive fibres, warranting the supposition of irradiating in the closest proximity." From the fact that the reflex pain occurs commonly during night and the sleep of the patient, it must be inferred that the trophic or ganglionic province is principally, if not exclusively involved. But a few exceptions have come to my notice to which I shall refer in due course. You are perhaps aware that I was the first observer of these reflex pains ; at all events, I was the first who called attention to them, and explained their % •^ '4 i II Ml If li n : ( ii 24 character and operation. Perhaps they might have escaped my observa- tion as well, had I not for a time shared the same roof with patients of this class, and had not thus an opportunity been afforded me for study- ing this singukr symptom in all its bearings. One night, after having left my patients profoundly asleep with the lights lowered, my attention was suddenly attracted by a peculiar shriek emanating from the sick room. Within half an hour the shriek was twice repeated. Though well acquainted with the different voices of my little patients, I could not discern to whom the cry belonged. It was in so peculiar a note, high, shrieking and short, commencing with a full intonation, and terminating as abruptly. In entering the room, I found everything and everyone as quiet as I had left them shortly before. The only noticeable change was an acceleration in the breathing of one of the patients. Whils^, thus contemplating and watching him, he again uttered the same shriek, rose into a sitting posture, rubbed his eyes, stared around with a terrified expression, and sunk back upon his bed, continuing his scarcely interrupted sleep. In another ten minutes this scone was re- enacted, with almost the same concomitants. During several of these paroxysms I observed a peculiar quiver of both the adductor and flexor muscles of the thigh. The rest of the joint was evidently disturbed by it, and the paiu accompanying the quiver must have been of an agonizing character, for the patient automatically grasped the affected limb, as if to arrest the involuntary movement. His rest for the balance of the night was disturbed by meanings, and repeated attempts to changing h' nosi- tion. I found the aspect of the patient much changed on the following morning ; he looked pallid, haggard,and prostrate ; he was of morose and irritable temper, his pulse excited, and his appetite indifferent. The tenderness of his joint had signally increased. Whilst the abduction was more difficult and painful than before, the entire group of the ad- ductor muscles was as tense as if possessed of tonic spasm. In continuing my observations for successive years, I have seen this very symptom in almost every aggravated case of joint disease in struc- tural affections of the spine, and in acute periostitis in the proximity of joints. In all these cases it is invariably of the same type, though vary- ing in intensity. The greatest violence of reflex pains we observe in morbus coxarius, and in affections of the knee joint. It is rather remarkable that the patients thus afflicted do not remember these nocturnal pains, and that the shrieks of different patients are almost i&variably of the same note and duration. It may well be said these shrieks are as characteristic of joint disease Ill 25 •and as important in its diagnosis, as the peculiar croup tone in diphther- itic laryngitis, and the cries of a parturient woman in the last period of <3onfinement. As already remarked, these reflex pains occur almost exclusively dur- ing the night, and whilst the patient is dormant. In a few exceptional cases, however, I have met the symptom under inverse circumstances. In one case (Schindler) the pains continued for several days and nights, and kept the affected member with but short intermissions, in a constant state of clonic spasms, and until the flexors of the leg had been divided. They may be met with, irrespective of time, when contracted muscles arc put upon the stretch. Whenever the reflex pains prevail, the patient suffers most severely ; loses flesh and appetite ; becomes anaemic, and prostrate, and the disease of the joint progresses with marked rapidity. According to my clinical experience, the reflex pains chiefly accom- pany bono diseases, and in these they arc most severe. In synovitis they are certainly much milder, if at all present. In some instances the reflex pains assume the character of genuine neuralgia, and follow the course of the principal nerves ; in others they discharge their violence upon certain groups of muscles, painfully oscil- lating and cramping them, leaving them in a state of cataleptic tension. With the symptom of reflex pain, two others are very soon ushered in: — 1st, Attenuation of the a^ected member. 2nd. Musculur contraction. The wasting of the affected extremity is as common a symptom of articular diseases as it is conspicuous. The adipose tissue becomes rapidly diminished, and finaiiy extinct; the muscles lose their bulk and normal contour, the bones lose in circumference and length ; the ex- tremity assumes a cylindriform shape ; its growth is arrested ; the animal heat is below the standard of the body, and in cold weather the extremity presents that mottled appearance which is so common in paralysis. The symptom of attenuation is co-ordinate with that of muscular contraction, and never observed without the latter. Among the many hypotheses advanced in explanation of this symptom, that of Barwcll is about the most superficial, ascribing it to the per- manent compression of the capillaries within the muscular structures. At best this theory would apply to the waste of muscles, but leaves the ^ther structures of the extremity out of account. Without entering into a digest of the various opinions, I shall content i :! Ill 26 myself with offering my own. It requires, indeed, no great pathological acumen or diagnostic sagacity to reduce that symptom to its proper source. It consists not only in the diminution of substance, but the arrest of growth is so prominent, that impeded innervation and impeded nutrition must be charged with the mischief, for which pathology furnishes ample analogy. In club-foot, for instance, the very same conditions prevail, the same attenuation — the same arrest of growth and development — the same reduction of temperature, co-existing with muscular contraction and mal- position. The muscular shortening in joint diseases is well known to careful observers, but its pathological character has as yet not been fully appre- ciated by the profession. la carefully analysing the facts in the premises, I shall encounter no difficulty in establishing views fully con sistent with the nature of the symptom in question. 1st. I have already adverted to the influence of the reflex pain upon certain muscles appertaining to the afibcted articulation, setting them into a most agonising quiver. This symptom is, indeed, so con mon, that its peculiarities may be ascertained beyond a shadow of doubt. 2nd. When these muscular spasms subside, they leave its structure in a state of rigor, or stationary retraction and tenderness, which, however, gradually disappear, if no new spasms set in. 3rd. Every attempt at elongating the so retracted muscle, by gradual extension, is very painful, and not rarely it is resisted by returning spasms. 4th. Faradayism renders the state of so retracted muscles still more tender, and not seldom gives rise to greater and painful shortenings of the muscular belly. 5th. During anaesthesia the muscular retraction relaxes and allows full extension, which, in some instances, may be successfully perpetuated by appropriate appliances. In others, the retraction re-appears with the cessation of the anaesthetic effect ; the muscle remains tender and jerking. If, under these circumstances, the extension be persist-ed in, the articular disease becomes au'crravated. 6th. Persistent retraction terminates in structural changes of the muscle, and destroys its expansibility, both physiologically and experi- mentally. Faradayism produces scarcely any excitation whatever, and chloroform anasthaesia exercises no marked influence upon its tension. Thus the muscle, having attained its maximum of contraction, and that contraction being rendered permanent by organic changes of its structure^ the term contracture has been fitly applied to that condition. 27 Dr. Benedict, of Vienna, rrnintains that a constant galvanic current possesses the power not only to reduce the contraction, but to establish the physiological expansibility of muscles so affected. I have, however, not seen a single case at his clinic in the general hospital of that city that could be accepted in proof of his views. Nor (lan the successful hrisement foixe, without myotomy, pass as evidence, since the violence generally employed is quite sufficient to tear asunder all resisting structures — myolemma or muscular fibres — thus virtually accomplishing the same results as would be produced by dividing the contracted muscle. 7th. The subcutaneous division of the contracted muscle overcomes both resistance, spasm, and attending pains. 8th. The division of contracted muscles exercises the most beneficial influence upon the affected extremity, in promoting its nutrition, growth, and development. Even the muscles themselves become more bulky and susceptible to the action of Faradayism. The contractures of muscles, force of course, the affected extremity into a position corresponding to their respective traction, and they become therefore the source of malpositions. In all joint diseases some muscles, or group of muscles are invariably contracted to the exclusion of others. Thus for instance, in morbus coxarius, we find the adductor muscles of the thigh, and some of the flexor muscles materially shortened. Among the adductors, the pectineus ; and among the flexors, the tensor vaginae feraoris, are the most implicated . In consequence of these contractions, the affected extremity is unduly flexed, and adducted and rendered apparently shorter than its fellow, the disparity being increased by the elevation and rotation of the correspond- ing side of the pelvis. In affections of the knee joint the Viceps muscle is commonly the only one contracted, and but exceptionally the remain- ing flexors become involved. Hence the affected member is more or less flexed at the knee joint, and in the higher degree of flexion, the leg is rotated on its longitudinal axis, and the toes everted. This position im- plies an anatomical derangement;of the respective parts of the joint, the external condyle of the tibia receding, and the internal, protruding in front of the joint. In affections of the tibio-tarsal and tarsal articulations, the peroneii muscles are retracted, and ther'jby the foot rotated so as to give it the position of talipes valgus. In affections of the wrist joint we meet with contractions of the flexor radialis and ulnaris, with abnormal flexion of the hand ; sometimes but one of those muscles is shortened, and the hand has a corresponding leaning in its direction. In affections of the elbow joint the biceps muscle and the pronator teres are involved keeping fj f' iii .„ 28 the forearm in a state of pronation and flextion. In affections of the shoul- der joint we notice the contraction of the pectoralis major, with adduc- tion of the arm to the body, &c. It is self evident that the contraction of certain muscles in certain joint diseases is by no means accidental but governed by the supply of co- ordinate nervous fibres. Schwun by his very careful and minute dissec- tions, has fully established the fact, that such a co-ordination of nerves exists, supplying joints and muscles. And Hilton, another reliable ana- tomist, has affirmed that anatomical arrangenient. But even without these anatomical facts, clinical observation would be justified in such an infer- ence. ' In most joint diseases there is more or less immobility. To a certain extent the immobility is of a voluntary character employed by the patient to obviate the paincausedby the exercise of the affected joint. Frequently, and in advanced cases, the immobility may arise from hydraulic pressure upon the articulating surfaces, by effusion into the joint, as may be seen in the second stage of hip disease, and in some affections of the knee joint with unyielding and thickened walls. The deposits of osseous inaterial around the joint, and osteophytes, will produce the same effect. Muscular contractions are a material im- pediment to the mobility of affected joints. I have already referred to malposition of the respective affected articu- lations, as one of the general symptoms attending articular diseases, and adduced its most prominent cause. There are however other causes which occasionally bring about that result. One of them is the gradual disin- tegration of the epiphysis. Next the separation of the epiphysis and its dislodgement from the shaft. Another, the fracture of the epiphysis eventuating in joint disease. The last though not least is effusion within the articular cavity. The experimental injections into joints made by Weber and Bonnet demonstrate that liquids forcibly thrown into the articular cavities through an aperture of a stationary bone will force the movable part of the joint into certain positions denoting the greatest capacity of the articulation. Similar changes in the position of joints are produced in the living body by effusions.* But in order to accomplish this the walls of the articu- lation require to have been rendered unyielding to the process of inflam- mation, in which case the effusion acts like a wedge driven between the .articular surfaces. As long as the walls remain flaccid, or retain their • Collateral with more or less perfect immobility. 29 healthy elasticity ; an immense quantity may be accumulated in the joint without any effect upon its position, as is the case in ordinary hydrathro- fiis. Last, I have to mention fever, as one of the common symptoms of joint diseases. This symptom is merely of temporary duration, and accompa- nies only the higher grades of these affections, their inflammatory periods, or at times when a mighty local irritation exists, be this through foreign bodies, sacculated pus, or the like. It generally subsides with the removal or alleviation ot che local disturbance. In all these instances the fever is strictly symptomatic. Rheumatic affections of joints are however, usher- ed in with marked febrile excitement, which seems to form an essential part of the morbid process. Profuse and continuous suppuration of joints is mostly attended by hectic fever, which presents the usual characteristics. But rarely do we meet with pyaemia, caused by affection of the joints. I do not think that I have seen more than a dozen cases, in all in my practice. The latest refers to a little girl, eleven years old, of very delicate constitution. From causes unknown, she was attacked almost simultaneously with an affec- tion of the left tibio-tarsal joint, and periostitis of the corresponding tibia, both disorders eventuating rapidly in suppuration. A few weeks after the first attack, a large abscess had formed during one night at the left hip, another soon afterwards made its appearance below the right clavicle, soon to be followed by a third in the right hip. It is yet doubtful in my mind whether this case does not come under the head of spontaneous pyaemia, a form which is seriously doubted by some authors, or whether pyasmia resulted from the original affection. The division of joint diseases into acute and chronic forms, is rather inappropriate, because artificial. It is apt to confound the character of the affection, and has no practical value in any respect. Whether the duration of the malady, or the violence of the symptoms is the principle of division we shall find neither to u? tenable. Almost every joint disease assumes a protracted course, and is thus essentially chronic. But few exceptions can be adduced to this rule. Rheumatic synovitis may be of short duration, and characterized by violent symptoms, but joints thus affected will require months to recover their normal status. On the other hand, we observe periods of acuity, , in the most chronic and protracted joint diseases, which may challenge the most acute forms known. I suggest, therefore to drop a clinical dogmatism, worthless to the experienced surgeon, and confusing to the novice. The symptoms by which synovitis is characterized, materially vary, m I (1 i'l I 8;! * '■ 30 l)oth, in duration and intensity. "We need scarcely adduce the general symptoms of this disease, having already alluded to them on a prior occasion. The chief, and pathognomonic phenomenon, is effusion within the arti- cular cavity, and rapid change in the contours of the joint. From the physiological character of the structure, effusion, should, a priori, be expected, as clinical observation substantiates it. To speak of a dry joint in these affections is nn absurdity. The most insignificant irritation of the synovial lining, is attended with copious secretion of a fluid, with the peculiarities of synovia. The higher grades may not exhibit the same quantity of morbid secretion, but enough to give definite fluctuation. The liquid is of a more plastic nature, con- tains blood corpuscles, flakes of fibrin, fat globules and epithelium and becomes early contaminated by the organized elements of pus. To a certain extent the composition of the synovial fluid may still be recognized by the abundance of alkalies and the soapy feel. In the highest grade of synovitis, the synovial lining, is as you are aware, converted into a pyogenic membrane, and presents the structure of granulations, as stated in the preceding section of our discourse. Under all these conditions, there is more or less morbid effusion. The dryness of articulations cannot be denied, but it is noticed in conditions of a different character, and independent of inflammatory affections of the synovial lining. Thus, for instance, it complicates pro- gressive deformative arthritis, which originates in the articular faces of the bones and though the synovial membrane may gradually be com- promised, it is affected in such a manner as to destroy its character as a secreting structure. In white swelling, the synovial membrane sometimes piesents the peculiarity of dryness, but from anatomical changes of a pulpy charac- ter, not the result of direct inflammation. In pure synovitis we never observe consecutive intumescence, infiltra- tion, or hardening of the surrounding tissues, and never to such an extent as we find it in diseases of the periosteum, and the osseous strnc- ture, unless indeed the latter have become involved. In the more active forms, there is intense pain within the whole joint, with consecutive febrile excitement ; but reflex pains are moderate, and the spastic oscillations never very intense In the lower grades of syno- vitis (Hydrarthrosis), these symptoms are entirely wanting, and the patient suffers scarcely any other inconvenience, than the effusion within the joint would naturally occasion. The affections of the periosteum and of the epiphyses, are attended by 31 la In a widely diiForent group of symptoms. Tho beginning of these diseases is very insidious, and their development so slow as to require months to a(psumc u noticeable form. But little pain attends the initiatory period. The whole trouble marks itself os weakness of the limb, dryness and stiffness of the joint, with inability to use the extremity in the morn- ing. For a time the contours of the joint suffer no change ; and if there be any fulness at all, it is more generally diffused, and extends beyond the limits of the articulation. There is no discoloration of the integuments, though there is frequently that u'«a;^ whiteness, the result of oedema; whence the term " white swelling." The latter is often the first symp- tom which attracts attention. Though the patient may have the sensa- tion of heat in the affected parts, it is not ohjective cither to the hand or thermometer. The patient may gradually experience son.-^ difficulty in using the articulation to the fullest extent, feel induced to spare the extremity in locomotion, and thus favor certain positions as a source of greater comfort ; malposition is superadded only at a later period. The advance of the disease is marked by progressive swelling of the periarticular structures : the contours of the joint disappear, not from effusion within the articular cavity, but from infiltration of the surround- ings and therefore no fluctuation can be discerned. Contemporaneous with the enlargement of the articulation, the original feeling of soreness, increases to aching pain, being augmented by pressure and locomotion ; the rest becomes disturbed by reflex pains, and the limb forced into a position over which the patient loses all con- trol. Every attempt to alter the same is attended with aggravated iSuffering. When the swelling and firmness of the soft parts still more increr.se, then the pain assumes a torturing character. The limb attenuates and becomes cooler, whilst the swelling shows but a moderate addition of \ jmperature. In viewing the affected extremity, the contrast between the waste of the limb, and the general enlargement of the articulation, with its nume- rous distended veins, is strongly marked, and it is this form of articular disease, which in times past was designated as fungus articulorum, tumor alius, and ivhite swelling. It was thought to be of malignant growth, and amputation its only remedy. Thanks to the progress of pathological anatomy and tho material aid of the microscope, this error of our ancestors has been effectually dis- pelled. Now-a-days, white swelling has been recognised as an affection of the articular ends of bones, and their respective periosteum ; with subsequeni M I m ■t : I p^r 32 )'. periarticular infiltrations of seroplastic material, with its attending orga- nization into fibroplastic cells, fibrous structure, fat, &c. And surgery oflFers tha means of relief as long as the pathological changes axe suscep- tible Of reduction. The knee joint is most frequently visited with this disease, and it is there one can best study its different phases. On a former occasion I have assigned the reasons why this malady attacks the knee joint more frequently than any other, and likewise why the disease is more frequently observed in childhood than in adult age: and therefore need not recur to that subject. I shall now confine my remarks to the discussion of some features that characterize the process under consideration. One of these points is the extraordinary slow advance of the disease. Some authors think that a low grade of nutrition of the structures pri- marily involved, offers an acceptable explanation. On close reflection we shall find this view inadmissable, and contradictory to analogy. Nu. trition in childhood is more exuberant than at any later period. In the former, maintenance is not the only object of the nutritive process ; it is enhanced by growth and developement, demanding more ready supply, and meeting with the most elastic condition of the vascular carriers of that supply. In these advantages the infantile skeleton participates ta a higher degree than the other systems of the organism. Hence from a physiological point of view, we have to reject the ad- vanced theory. In questioning analogy, we notice facts which demonstrate beyond a shadow of doubt, the prolific character of nutrition in the osseous system of children. Fractures consolidate more rapidly with them than with adults ; artificial joints are scarcely ever observed during the period of evolution ; if periostitis has laid bare the bone of a child, exfoliation rapid- ly ensues, and sequestra form much more quickly than at a later period. Tliesc facts coincide with the exporiments of Flourent and Wagner, and dispose effectually of the before mentioned hypothesis. In all those cases of white swelling, that I have had the opportunity of anatomically investigating, and they have been numerous, I have observ- ed that there is always, in one or the other condyle, an insular disinte- gration of the cancellated structure, in which sometimes a small seques- trum is imbedded. Under the microscope scarcely any trace of the van- quished structure can be discerned. The chief clement is fat. But in the neighbourhood of this pathological focus, hyperacmia, traces of fun- goid granulations, and osteoporosis are noticed. This condition explains satisfactorily, the proximate cause of the pathological changes inconsis- i tent with the active process of ostitis. In some rare instances, however, the healthy portion of the bone surrounds tlic disintegrated isle with a sclerotic capsule, by which the afFccted portion becomes, as it were, isola- ted and rendered innocuous, in a similar manner as foreign bodies en- capsule. This pathological condition may not cover all cases which pass under the name of tumor albus, but certainly this is the most preva- lent. There is a specimen in my collection, of the lower third of a femur of a young girl not exceeding fifteen years of age. She was admitted to the Brooklyn Medical and Surgical Institute, with all the symptoms of white swelling, comprising the articulation and peri-articular structures ; the swelling however likewise involved a portion of the femur. The local disturbances were as intense as were the nocturnal pains, and the spasms of the flexor muscles. The knee was of course drawn to a right angle. From the history of the case, and the clinical character of the disease, circumscribed osteomi/dlfis, with its termination in abscess was diagnosed, and in view of her reduced constitution, and the copious discharge of matter from the neiglibourhood of 'ic joint, amputation was deemed expedient. The condition of the specimen fully confirmed the diagnosis. There is a large pyogenic cavity at the lower end of the femur, which opens at the posterior aspect of the bone, by an irregular aperture not less than an inch and a half in diameter ; in thecircuniforeiice of which, the periosteum is raised up, and its internal surface covered with new bone. The epiphysis is somewhat loosened from its attachment, and in time would have become separated. The original focus of the dicsease had been obviously limited to the cancellated structure, and rather remote from the joint, but its consecu- tive effects had extended over the joint, and involved its soft surround- ings. There may be still other exceptions from the anatomical prototype, but their numerical proportions scarcely affect the statistics. The adherents of the tubercular theory, may rejoice at this patliological admission of mine, of those insular and circumscribed pathological foci, which they may claini as bona fide evidence of tubercular deposit. I hold however, that pathological detritus, limited to an isolated place, cannot in the eyes of competent judges, pass as tubercle. If the disease is permitted to spread, it eventuates in perforation of the articular cavity ; the formation of external abscesses and fistulous tracts, and the more obstacles the discharge has, the more periosteum will bo destroyed, and the bone corroded on its surface. The protracted development of these phases extends over many months. ii! .;i \'\ A 1 Ilv-J 34 and often additional injuries are required to accomplLsh so extensive disintegration. A lull of all symptoms, is often observed in the like cases, to be follow- ed by new exacerbations. A goodly number recover spontaneously, or by appropriate treatment. These recoveries happen not rarely at the period of puberty, at which time the mode of nutrition of the epiphyses becomes perfected. In analysing tTie gradual development of this disease, its preceding cause, (traumatic injuries) ; the comparative moderate c /ccts upon the integrity of the adjacent osseous structure ; we find a more passive path- ological condition, a direct necrobiosis of the affected structure, more from want of proper maintenance, than from active and progressive disease. When active symptoms subsequently set in, they are the eflforts of the vi& medicatrix naturcv to eliminate the detritus foreign to the integrity of the bone. Frequently the detritus becomes absorbed, or pe vaded with cal- careous elements, and thus recovery is attained. This gradual change of the osseous structure and annihilation of its nervous and vascular endowments, though limited in extent, renders it intelligible why so little pain is experienced by the patient, during the first disintegrating period of the disease. The intense pain that is at a later period superinduced, is evidently connected with toe peripheral and active process of osteitis arising in the circumference of the focus. The original disease has nothing to do with it. The appearance oJ nocturnal pain constitutes a serious complication and indicates the commencement of suppuration. The contraction of the biceps muscle is quite common, and the result of reflected spasm. The leg is thus held in an angular position to the thigh, and most usually rotated on its longitudinal axis, with eversion of the toes. T^liis position goon pari ^jass?*, with an anatomical derange- ment of the joint itself The patella rides upon the external condyle of the femur, and is generally adherent ; the internal condyle of the tibia projects in front, whilst the external one recedes. The contraction of the biceps is exclusively accountable for this mal- position, for at a certain angle it acts as a rotator, when not counteracted by the simultaneous contraction of the internal hamstrings. I have but lately exhibited to the New York Pathological Society a specimen of this kind, and the action of the biceps is so undeniably de- monstrated, that there is no more room for further speculation to ac- count for the symptoms. For a long time the mobility of the affected joint remains, if not im- peded by the contraction, but when synovitis is superinduced to the 35 original affection, the joint may become obliterated by fibrous adhesions between the articular faces, which may still more impede the mobility, but rarefy are there osteophytes passing from one bono to the other, depriving the joint of all vestige of motion. True bony anchylosis is of very rare occurrence, and much more the consequence of penetrating wounds of the joint, and high graded synovitis, than of this form of disease. Whether the disease originates in the synovial membrane, in the crucial ligaments, in the periosteum, or the epiphysis of the joint, the symptoms apertaining to each of them respectively, will be so blended in their advanced course, as to render diagnostic discrimination almost im- possible, leaving the previous history as the only guide. The pathological conditions of joint disease^, vary but little, when suppuration, burrowing of pus, has been going on, and the bones have been disintegrated for any length of time ; the symptoms attending those conditions are almost uniform in all such cases. The competent and experienced surgeon may yet recognize the patho -genesis of the original disease, but novices rarely realize differences so indistinct and sub- tle. Thus, in caries of the joint emanating from synovitis, the articular surfaces arc more generally denuded of their respective cartilaginous coverings, but the osteo-porosis does not much exceed the surface ; the crucial ligaments are but partially destroyed ; the semilunar cartilages partly disintegrated, discolored, and mostly detached. On moving the articulation, crepitus is discernible. If, however, the bone has been the starting point of the disease, the caries of the articular surface is gener- ally restricted to the originally affected locality ; and the cartilage is there and thereabout disintegrated. The crucial ligaments are mostly destroyed in toto, and crepitus is less distinct. The clinical character of hip disease will now demand attention, on account of some peculiarities in its manifestations. Morbus coxarius is about as good a term as could be chosen and certainly more appropriate than " coxalgia " which applies solely to the pain of the affection. The Jirst stage of tins lesion materially conforms with the same stage of the affections of other joints. The only symptom requiring special mention, is limping. It is most noticeable in the morning, less during the day, and least towards evening ; most conspicuous after great exer- tion, and sometimes absent after a day of complete rest. The duration of this period is variable ; repeated accidents and the continuous use of the affected extremity may sliorten, and constant rest prolong it. The so characteristic pain at the knee, may already muko its appear- ance at this stage, but if so, there will be likewise indications ol' retracted :l! i ! hi wm^mm ill ■I . I lii muscles, with which this symptom appears conjointly. This pain has often confounded the diagnosis of the less experienced, without any need; for you may press and squeeze the knee joint as you please, witli- out the slightest increase of that pain, whereas the pressure upon, and movement of the hip joint will aggravate it. The progress of the malady may, at this ju'icture be arrested, and the patient relieved from further trouble. The second Stage is characterized by elongation, abduction, eversion and slight flexion of the aft'ected limb at the hip, with lowering of the pelvis, flattening of the gluteal region, sinking of the gluteal fold, and an inclination of the internatal fissure, at, and towards the aft'ected side. The mobility of the joint may either be impeded, or entirely suspended. Adduction is generally impossible. For the purpose of locomotion, the patient brings the lumbar portion of the spine and the other hip joint into play ; thereby easily deceiving the inexperienced observer. In the erect posture the spine exhibits a single curve, of which the convexity corresponds with the seat of trouble. The superior spinous process of the ilium, is depressed when compared with that of the other side, and the healthy member is adducted in pro- portion to the malposition of its afflicted fellow. In walking, the patient places the latter forward and outward, and drags the other limb after it in a rather diagonal direction. All these symptoms more or less complete, can be ascertained by undressing the patient ; dropping a plummet line from the occipital protuberance, walking, and by careful examination in the horizontal posture. If the patient sit^^ down in such a manner as to accommodate the aft'ected member, both pelvis and spine assume normal re- lations, thus proving that the elongation of the limb does not depend on the lateral declivity of the pelvis, as ^'Gross asserts. The chief or proximate cause of the entire group of symptoms rests with the immobility of the joint and the fixed adducted position of the extremity. In imitating tliem wc produce the very same efi'ect. There can be no doubt tliat the elongation is but apparent, and not real, as the late professor Rust of Berlin, claims. Nor is there any en- largement of the head of the femur, from cither tuberculosis or other causes, to which he ascribes the actual elongation. The sole source of the symptom is hydraulic pressure from existing intra-articular effusions. I was led to this view from the analogous position of the femur and the immobility of the joint produced by experimental injection. Acting on this supposition, 1 have succeeded in substantiating the correctness of ♦Uroas' " I'rucliciil Ubscrvalious " I'liiladt'l^liia 1859, nn ■*^1 a7 ts le jn- of of my opinion, by paracenteses of the articular cavity. The removal of the intra-articular fluid was followed immediately by returning mobility and the correction of the malposition. This point is consequently settled by demonstrable evidence. With the apparent elongation of the limb, the structural pain gradual- ly increaseSj and the reflex symptoms rapidly rise to an intense degree. The nocturnal pains, in this period are more violent and torturing than at any later, and for obvious reasons. Whilst the extremity is immova- bly fixed by hydraulic pressure, the adductor muscles are nightly agita- ted by reflected spasms, and kept on the stretch. The limb becomes attenuated and exhibits marked disproportion with its fellow, the con- stitution, rest, appetite, suffer gravely, and reduce the patient in weight and appearance. The eff'usion may still be of a plastic and organizable character ; sero-purulent, or exclusively pus : may be free from, or con- taminated with structural detritus, benign or destructive. Its composi- tion will naturally determine the issue of the case. If the eff'usion be mild, plastic, benign, free from deleterious admixture, its partial absorption and final organization into fibrous structure may take place, and thus ter- minate the malady. Or its quantity may lead to a disruption of the cap- sular ligament, and the escape of the intra-articular effusion into the sur- roundings of the joint, and there become organised and innocuous. Through similar changes the sero-purulent effusion may pass with the same result. But if the articular contents are of a destructive character, they may, by macerating and corroding the acetabulum pass into the pelvic cavity through the cotyloid notch, or through the capsular ligament, and will invariably give rise to the formation of abscess, corresponding in lo cality with the place of perforation. Ill the moment the perforation is effected a new scries of symptoms appears, and with which the third stage of the disease is ushered in. The third stage is distinguished by diametrically opposite symptoms. The contrast of the two stages can best be realized by placing them in juxtaposition. Second stage. Affected limb. Apparently elongated. Abducted. Flexed at hip and knee. Toes everted. Foot fully on the ground Healthy limb adducted Pelvis lowered. Third stage. Allt'cted limb. Apparently sshortened. Adducted. Flexed at hip. Toes inverted. Uall of toes only. Abducted. Tilted up. i f Iff ' i l! W F3-T I ! >! ! [ i ■ t i .1 ' 'I I i ill; !l 38 Pelvis projects forward. Pelvis angle of inclination acute. Nates flattened. Gluteal fold lowered. Interaatal fissure inclined to affected side. Spine curved on the affected side Nocturnal pain very intense. Backward. Almost rectangular. Full and convex. Elevated. Inclined towards the op- posite side. Curved towards the other side. Greatly diminished. It will be seen that the third stage is characterised by unmistakeablc clinical manifestations, and by so peculiar a gait of the patient, as to be recognised at a distance. The shortening, adduction, and inversion of the limb, conjointly with the rotundity of the gluteal space, strongly convey the impression of posterior superior dislocation of the femur. This similarity of the two mav have led Rust to presume their identity, and ascribe to the action of the contracted muscles the cause of spontaneous dislocation. The morbid enlargement of the caput femoris, said to exist (at the second stage) lent a plausible argument to this hypothesis. What was more simple and transparent, than that the head of the femur partially expel- led frorr?, the acetabulum by its disproportionate size, should leave it entirely, and follow the undue traction of the muscles. This hypothesis of the renowned German surgeon prevailed among the profession ; spon- taneous dislocation was henceforth a settled fact, against which but heterodoxy could raise its voice. Buehring, of Berlin, if I do not mistake, was the first who took issue with Rust's theory, and attempted to reduce the acknowledged similarity of symptoms to causes widely different from those propounded. In this effort, he derived material assistance from the advancement of pathological anatomy. The ques- tion once opened has received a rational solution. At this present mo- ment there are few well informed surgeons who recognize spontaneous dislocation. Nelaton has informed us of a good method to decide the relative position of the femur to the pcetubulum. In drawing a line from the anterior superior spinous process of the ilium, to the tuberosity of the ischium, it passes on its way, from one point to the other, the apex of thvi large trochanter, in the normal position of the femur. It crosses the trochanter more or less below the apex in dislocation. In applying this test in the third stage of morbus coxarius, you will mostly find the normal relations, or so insignificant difference as to preclude all possibility of dislocation. Irrespective to this clinical fact the morbid condition of these points contradict the assertion of Rust*m toto. It might rather be said that the acetabulum becomes dislocated, 39 since we often find it extending up, and backward in which direction the femur fellows, but true dislocations belong to the rarest occurrences, I have searched in this respect the anatomical museums, on this, and the other side of the Atlantic, without having found more than about a dozen specimens, exhibiting the conjoined evidences of hip disease and dislocation. In this statement I am borne out by other enquirers. It follows therefore, that dislocation is but a rare incident in hip disease, indeed much more so, than might be rationally expected, considering the actual state of the joint in many instances. If dislocation is practicable in a healthy articulation, how much more predisposed must the latter bo, when the acetabulum is denuded and enlarged, the round ligament totally destroyed, ihe head of the femur dimininhed in size, the cotyloid cartilage more or less disintegrated, the capsular ligament broken through &c. ; which all tend to facilitate the displacement of the femur. It is thus evident, that the slightest appreciable injury should suffice to bring about a dislocation, but its spontaneity cannot be conceived, and must therefore be denied. On the other hand, it must be borne in mind that the joint being more or less tender, is well taken care of by the patient and protected against incidectul injuries. One of these means is the play of all muscles by voluntary effort to keep the joint at rest, and thus dislocations are prevented, which other- wise might seem inevitable. Wherever dislocations take place, there can be no doubt as to their being the result of some injury or other, however trifling. That much I can at least assure, that I never myself have had the opportunity of observing a single case of indisputable dis- location consequent upon morbus coxarius, and I have had my finger in the hip joint too often to be deceived. If you examine a patient so afflicted, with the aid of ana3Sthetics, extending the affected limb, whilst at the same time exercising counter extension by placing your foot against the pelvis, you will notice a certain amount of mobility of ihe joint, but the absolute impossibility of abducting it. In searching for the cause, a firm and unyielding contraction of the adductor musch s will be found, over which the anaesthetics seem to have no influence whatsoever. It is thus in the third as in the second stage, the malposi- tion of the l-.xiO is produced by a single cause, and the rest of the symp- toms follow as physical necessities. Now, for instance, let us presume the femur held in undue position of adduction and flexion, and the patient attempt to walk, he would yield the pelvis as much as possible for th<3 purpose of relieving the tension of the contracted muscles. The first thing he does is to rotate the pelvis in its transverse diameter, thus approximating the anterior superior spinous process of the ilium, to the ' i ! 1 ■n ■J I d 40 ' M^ Mi I' ! I*'' IP 15.; I insertion of the tensor vaginae fcmoris. This accounts for the enhanced unfile of inclination witli the horizon. By turning the pelvis on its axis at the lumbar articulations, the patient favors the former object. If the pelvis remained (juite horizontal and ths e5:tremity of the healthy side rec- tangular to the former, the aiTectcd limb would necessarily cross its fellow, and locomotion would thus be rendered impracticable. Hence the affected side of the pelvis is tilted up in proportion to the adduction of the affect- ed extremity, the healthy member is thrown out, (abducted) and paral- lelism is thus achieved. If tlie pelvis is thus out of position, the spine and shoulders have to adapt themselves to the static changes. In compounding the effects of these changes in the position of pelvis and femur, we can almost to a nicety, ascertain the amount of apparent shortening, without regard to the so called spontaneous dislocation. The longitudinal rotation of the pelvis will raise the extremity as much as an inch, the flexion of the femur upon the pelvis, another inch, and the obliquity of the pelvis from one to three inches. Thus the limb may be shortened in the aggregate, from three to five inches, an amount never to be produced by traumatic dislocation oP the femur upon the ilium. Most cases of morbus coxarius terminate with the third stage ; but comparatively a few advance to the fourth and last stage of the disease, ■which is a combination of the symptoms of the third, with those of caries, abscesses, fistulous openings and tracts, in the neighbourhood of the joint, local pain, arising from such sources, and hectic fever. Thus it will be seen that hip diseiise is characterized more than any other, by a certain immutable regularity and chronological succession of symptoms, which, in themselves, furnish the strongest ground for differ- ential diagnosis. Though the first stage may escape the vigilance of the professional attendant, the second will inevitably decide his appreciation of the growing trouble. The third stage is invariably preceded by the second, and the fourth by the former stages. This, at least, has been my observation in a large number of oases, and I entertain no doubt that it is substantially the same with other accurate observers. The excep- tions that may be adduced apertain. to cases partly not hip disease at all, partly hip disease of a consecuti\'e nature, and consequently blended with other pathological conditions; Periostitis in the neighbourhood of the hip joint often produces simi- larities of hip disease of a most striking character. We may find in connection with it all the symptoms enumerated under the third stage of morbus coxarius, but this difference will always bo manifest : that the symptoms of the second stage never preceded that condition. If the joint is not secondarily implicated in those cases there will be a freer mobility m 41 of the same, and no crepitus ; whilst on the other hand, the femur is enhirged and tender. Sometimes we meet with malposition of the femur in consequence of Potts' disease, and periostitis of the spine, which may give rise to an erroneous diagnosis. The history of morbus coxarius and affections of the spine is so diftorentially marked that the mistake may be easily cor- rected. Eventually, the application of chloroform will suffice to overcome the muscular retractions of the latter, and prove the hip joint to be in- tact. ^V'e owe to Erichscn's careful investigations, our knowledge of the suppurative affection of the sacro-iliac junction, but the symptoms ad- duced by that author are so widely different from those of hip disease, that they hardly can be confounded. Eventually the careful examina- tion of the corresponding hip joint must necessarily settle all doubts. IV. PROGiNOSlS ON JOINT DISEASES. From the preceding remarks of the discourse we may sum up the fol- lowing prognostic axioms. From the collective character of joint affections, we must come to the conclusion that they constitute formidable diseases. In their respective courses, they ax*e slow aud protracted, often of year.'; duration. In their commencement and development they are insidious, and may nave proceeded to considerable disintegration of normal tissue before the patient becomes aware of the impending difficulty. The restitutive powers of some of the articular structures are of an indifferent character, owintr to the imperfections of their nutrition. In as far as the osseous aructure is concerned, recovery depends on the gradual destruction of the affected parts, which of course is necessa- rily tedious. In most joint diseases the affected structures undergo changes more or less disqualifying them for the performance of their respective physiolo- gical offices, thus cither impeding or annihilating the usefulness of the articulation. • . -, The suppuration of articular cavities leads to their perforation, to ex- tensive subfascial burrowing of pus, and not only involves the extremity, but the constitution at large. Reflex pains and spasms accompanying joint diseases are of the most -11 lii •* ]n 11 I'* '^ I V. ; ; ; I it. In fine the patient should be placed on a suitable table, so as to be accessible from all sides, and be put under the full influence of an anaes- thetic, that volition may he suspended and the rest of the examination be painless. These preparations I regard as essential, to obtain a full know- ledge of the character and extent of the disease, T do not deem it necessary to enter into the full details of the examin- ation with which you are already acquainted. But a few points deserve special attention. In the first place, we hav to ascertain the condition of the bones constituting the affected joints, and find out whether the disease has originated remote from the joint, in the periosteum or in the bone itself. In either case, we shall find by comparison, that the circum- ference cf the bone is incrcised and the adjacent tissues more or less infiltrated, its surface be uneven, pressure upon it be tender, and by bending the bone, we occasionally find that it has lost its elasti- city and hardness. We have next to direct oit attention upon the con- dyles, compare their size, elasticity and sensitiveness with the correspond- ing condyles of thf other limb. Frequent practice will enable us to dis- cern changes which are easily overlooked and ignored by the novice^ There is a certain degree of elasticity in the condyles, which is lost by the morbid alterations, even the increased tenderness of the bony struc- ture becomes manifest, though the patient be in anaesthesia. On moving the joint carefully, we ascertain the degree of mobility and the changes that may have taken place in the articular surfaces. Polypiform growths of the synovial membrane may thus be discovered, when they are too small for the touch of the finger. Crepitus would be the evidence of destruction of cartilage ; its absence proves nothing to the contrary, as we have learned on a former occasion; [f the joint allows an undue lateral or rotatory movement, we may infer that the lateral or interme- diate ligaments have become destroyed^ and if combined with crepitus, it may indicate that the articular faces have been materially flattened and changed in form. If the periarticular tissues of a joint arc largely infiltrated, and the joint itself is either dry or contains but little fluid, we have the more reason to suspect bone disease, and centre our attention upon the condition of the osseous structure, A distension of the articu- lar cavity without induration of the periarticular structures, indicates synovitis. Durin< ic anaesthesia, we can but ascertain whether the malposition ispuduced by interartic\^lai adhesion or muscular contractions, or both, and, moreover, whether the contracted muscles still retain tlieir expansi- bility, or have more or less lost it. If there are sinuses about the joint we must try to discover their course and termination, though they may 45 be very circuitous. I have found pewter and elastic probes more availa- ble for this purpose than silver ones ; and large probes I etter than the finer oras. In this way, gentlemen, we shall arrive at a clear under- standing of our case, and establish a reliable diagnosis as a basis of therapeutic action. The first stage is the disease but virtually. The aflfected structures are but in a state of congestion and hyperaemia with incident tenderness, there are no substantial changes as yet, and by at once taking prompt measures, wc may succeed in obviating future mischief. The earlier this is done the surer we may count on success. Nay more, I should consider myself justified in treating every injury to the joint as a virtual afiFection of the same. A few weeks' restraint is notiiing in comparisvin with those terrible maladies that may eventuate from apparently insigni- ficant causes. But with all the precautions imaginable, and with the most appropriate and prompt treatment, we are not always able to pre- vent the C(msc(]uenccs, more particularly il' they refer to injuries of the periosteum and the bony structure. The vertj first ihemjmttic axiom in the treatment of joint discuses is rest, ahsolutc and unconditional, and the next, proper position of the affected articulation. The efficacy of these two is greater and more reliable than the entire antiphlogistic appai'atus, and they generally suffice to meet the exigencies of the first stai>'e. The affected joint is to be rendered immovable by appr.^ iate band- ages, materials, or special appliances ; and if the affection concern, the lower extremity it would bo additionally advisable that the patient takes to his bed and thus get riJ of the superincumbent weight upon the affected joint. The ordinary way of rendering a joint immovable, is by hardening bandages, by leather, gutta-percha, wooden, wire or light metallic splints, that are adapted to the form of the extremity. If the morbid condition of the joint is not far advanced, so that we maj'^ not require to inspect the articulation often, and thus disturb the dressing, stiflF bandages are certainly preferable, othcrwi.se) splints should be chosen. The stiff bandages are made by impregnating the outer portion of the dressing with flour, etarcii, or dextrine-paste, plaster of Paris or the liquid glass. Inasmuch as these bandages are more or less impermeable to the perspiration, it is necessary to first surround the extremity with a well applied flannel bandage, under which the unevcnness of the surface should be filled with cottonwool. How the rest is done, is indeed very indilfurent, as long as it fulfills its object. Until the bai dage is perfectly dry, it would be advistible to fasten a splint to the member. In some instances it maybe advisable previous to ■I i II i|: ■•;l > m si il V i 1 ' !**■ fi > i' i- iffli ' tr' -' i ■ I I! 46 the application of the bandage, to apply an appropriate nun)ber of leeches^ so as to reduce the hyperaeraia and stasis, the effects of which are, how- ever, but transitory. The fixture of the joint should immediately follow. Except in recent injuries, the application of cold is rarely demanded, but if resorted to, it should be efficiently applied in the form of ice bags, for which purpose one part of the joint may be relieved from the bandage and exposed to the action of that remedy. The position of the aifected joint should be such in which the patient is most comfortable and at rest. It is chiefly governed, however, by the tendency of certain muscles to contract, and therefore, should at once be placed in an antagonistic position. If you remember that portion of our discourse in which I referred to muscular contraction, you will know to choose the position which is most appropriate. In adopting the same, muscular contractions and ma positions will thus be obviated. Some surgeons advise to give the extremity such an angle as will be most con- ducive to its usefulness. We have nothing to do with that object at this juncture ; our object is to relieve the disease and thus preserve the entire usefulness of the joint; their advice is in place when the joint is about anchylosing. Tiie straight position of the elbow joint gives more relief than the flexed one, irrespective to the fact that the latter favours the contraction of the biceps and brachialis. And a straight limb bears more vertical weight than a bent one, and may be used to greater advantage in locomotion. The same treatment holds good in perforating wounds of the joints* with the additional rule that the wound be carefully cleaned, its margins properly approximated and united. In this way I have seen many an in- cised and punctured wound close by first intention, without any inconve- nience whatsoever. Different is it with torn and contused wounds, where the first intention is but exceptional, and suppuration the rule. Immobi- lity and proper position of the joint, fire likewise U chief indications here, and should be scrupulously observed, but the dressing should cir- cumvent the wound and leave it accessible to local treatment. In using dextrin., starch and plaster of Paris bandages, that part in the neighbourhood of the wound would be protected by a coating of var- nish so as to render it unimpregnable to the discharge. I rather prefer to secure the immobility of the joint by wire and me- tallic splints (tin or sheet iron) inasmuch as they will permit the use of permanent bath, wliich I consider invaluable in the treatment of such wounds. We owe the introduction of this remedy to B. Langenbeck, to whom surgery is indebted for many and valuable improvements. If suppuration of the joint ensues, you will do the most for tlie recovery of f '■"■'■, 47 your patient by giving free vent to the discharge, and by keeping the suppurating surface in a very clean condition. By these means, and eventually by free incisions into the articular cavity, I have saved many a patient. There is hardly any necessity for medication, unless incidental derange- ments demand therapeutic interference. The local treatment suffices to check and ameliorate the articular disease ; time and patience accom- plish the rest. Beyond those local remedies I have mentioned, notiiing else is required at this juncture. From painting the articulation with tincture of iodine, I have seen no benefit ; and fly blisters interfere with the fixture of the joint, cause a needless irritation to the patient, and sometimes give rise to reflexed muscular contraction, as I have seen. In the second stage the indications of treatment become more diversi- fied. The pathological character of this period is expressed by structural invasions of a more decided nature ; by more copious infiltrations and effu- sion within the joint ; by reflexed pain, muscular spasm and consequent malposition; and, in fine, reactive disturbances of the constitution. If the patient has been properly attended to at the first stage, the dis- ease will but rarely advance to the second, and if the local affection was of a nature that could not be checked in its advance by due precautioi), the second stage will be at least materially mitigated by the previous treatment. Assuming, however, that the patient comes under your charge with the full pathological and clinical force of the second stage, the same remedies and appliances commend themselves, for rest and position are the im- perative axioms whilst the disease is in active progress. In this stage the antiphlogistic treatment is resorted to in vain, as long as rest and position of the joint are disregarded, and the limb permitted to bend, rotate, or assume any prejudicial posture. Nay more, the antiphlogistic remedies even fail to give the slightest relief or to alleviate one single symptom ; my own personal observation has decided this fact conclusively, and I do not entertain the slightest doubt that other surgeons have met with the same negative results. But in securing rest and position to the af- fected articulation, we almost instantaneously give relief to our patient, and initiate progressive improvements. Having done this it rests with you whether you deem local depletion and the application of ice or nar- cotic fomentation additionally necessary. I have but rarely and I may say but exceptionally needed them, although I mean not to deny the fact that the distended capillaries may temporarily and usefully be depleted by leeches, wet cups and scarifications ; the effect of which you have, however, to render permanent, by means of which I shall soon speak. • 1 i ■ til lt 1 ; ! 111 ! ; ! i ■Ml 48 '' Si If the aflfected member has already been placed in malposition, you have promptly to reduce the same to insure articular rest. This should be done under the full influence of ansestheties. I consider chloroform better than ether, and equally safe. If I stated the number of chloroform applications that I have made with complete safety, it might be considered as grandiloquy, and as a slur upon professional brethren who have had the misfortune of meeting with fatal accidents. My )nind is free from any such intention ; I simply state the facts. Yet I cannot divest myself of the impression that many accident cases might liave been obviated by the use of a proper and reliable article^ by descrimination of patients, and due care by the administrator. Of all the chli)roform offered for sale in tlie maiket, I deem that of Dr. Sijuihb of Brooklyn tlie best ; it is always of the same purity and specific gravity, of the same physical quality and physiological action, and I use it with perfect confidence. The mode in which I administer chloroform is very simple, although, perhaps, not economical. I form a coarse towel into a short and wide funnel, with an inch opening at the apex for the free access of air; and look more upon the action of the lungs as indicative, than upon that of the heart. At the very moment that the thoracic res{)iration ceases, and the diaphragmatic suction prevails, I suspend '/lilorolbrm iidialation, whether the patient be under its full influence or not. This seems to be the margin of its legitimate use, beyond which the danger commences. Patients addicted to the copious use of alcoholic liquor, and those that present a leuco-phlegmatic, bloated and hydraemic appearance, are not fit recipients of chloroform ; nor would I deem it safe to administer it to pa- tienls with a weak and flat pulse, in whom the propelling power of the heart is more or le^s impeded by the fatty degeneration of that organ. It has been my ibrtune almost always to be assisted by reliable and experienced men who watched the effects of the chloroform, and did not divide their attention by looking after the operative proceeding. In a few instances I came near losing my patient by chloroform, and averted the fatal catastrophy only by noticing the impending danger in time. But these mishaps were clearly traceable to that carelessness which arises from the divided attention of the assistant. The patient being under the full effect of chloroform, we now proceed to reduce the malposition, and bend the limb either in the opposite or intermediate position from that in which we found it. If we meet with resistance we liave to overcome the same by a legitimate effort of physical power. 1 would not hesitate to break up inter-articular adhesions if they off"ered opposition. If intra-articular cflFusion opposes the reduction of 49 i ■ ^ the malposition, I would certainty perform paracentesis of the joint. If muscular cantractions are in the ^vay, I would resort to myotomy or tenotomy. ^/ There are authors who oppose every and all interference with the position of injiaimd joints, as downright meddlesoiucuess, and as re- prehensible surgical practice, and advise the redaction of the inflam- mation as the preliminary step. I apprehend that their advice is actuated much more by traditional fears, in interfering with inflamed articu a- tions, than by experience. Unless I were permitted to adopt that plan, T would decline all res- ponsibility attached to the treatment of any joint disease. I have already stated that antiphlogistic remedies have very little effect upon the inflamed structure of a joint, and none whatever if the articulation is permitted to be disturbed in its needful rest, by the jerks of the patient, or the spastic oscillation of irritated muscles. If under such circumstances, and under the purely antiphlogistic treatment, the disease becomes arrested, it is in spite of, and not by virtue of such treatment, and probably has been protracted thereby. I could prove this by uncountable cases, and produce the individual pa- tients to prove the facts by their own stories. JJut such evidence is scarcely needed to gentlemen whose own ore of experience will furnish them with sutticient aifirmative facts. No one will deny the beneficial results of relieving an inflamed ar- ticulation of its morbid product, provided that the process of removing the same does not entail additional danger. Mr. Barwcll docs me tlie honor of eulogising the operation which lias benefitted so many of his patients. That the operation, if properly performed, is harmless, I shall prove to you on a future occasion. The division of muscles for therapeutic and orthopoedic purposes in joint diseases lias met with an unfair adjudication. Barwell, Davis, Prince and other writers on the subject, arc in toto against this operation ; they hold that extension is quite suftieient to control the spastic affection of muscles agitated by the reflexed cifects of joint diseases. My ex- perience in extension in the aft'eotions of joints is certainly not inferior to any one of these; gentlemen , and perhaps not inferior to them collective- ly. I say so with due respect to the literary merits of these authors. And I can bring forth, if required, the very proofs of Dr. D.ivis's error by cases which he ha 1 treated by extension for months in suoccssiou and in his very establishment, without subjugating the muscular resistance. Need I state to you that I hive availed myself with avidity of all r i i Ml! lis 50 suggestions and means promising aid and comfort to this class of my patients ? And it would surely be a source of gratification to me if I could consistently and truthfully acknowledge my professional indebtedness for information, valuable or practically useful. As it is, I am impelled to state, that I have derived little or no benefit from extension j^er se in the treatment of progressive joint diseases. Whatever benefit I have derived from it at all, is unquestionably due to its collateral effect upon jixing the affected articulation. The collective experience on this question I can sura up in the follow- ing aphorisms. Ist. Extension cannot part the inflamed articular surfaces, for which it has been erroneously designed by its author. 2nd. Powerful extension is perhaps the promptest remedy against an ephemeral muscular spasm, as every one has experienced with himself if he has happened to be suddenly attacked by spasms of the muscles of the calf, but it cannot be relied on in persistent spastic agitations of the muscles. 3rd. In many instances, extension will not only fail to relieve th^ spasms, but will re-act unfavorably upon the violence of the existing joint disease, if persisted in. 4th. The division of the contracted muscle is the surest and unfailin^r remedy. — The most violent periods in the course of joint diseases I have ob- served, in consequence of keeping a retracted muscle on the stretch, and nothing short of division would give relief, though many things ami the most stringent antiphlogosis were vainly tried before. It is indeed a most egregious error to assume that the division of con- tracted muscles is merely of mechanical importance ; in some, as yet physiologically unexplained, manner do the contracted muscles relate to the existing joint disease. The retractions never appear before the disease has advanced to a certain degree of violence and structural in- vasion, and unless overcome in an effective manner, they increase to ac- tual contracture. In all these cases the disease is necessarily protracted, and when at last it subsides, the contracture remains tliough its original cause has disappeared. On the other hand, the original joint disease may be reproduced after years of extinction, if the contracted muscles are unduly and persistently extended. Some cases of this description are but too lively in my remembrance, and my experience on this sub- ject is too dearly bouglit to be ever forgotten. From all this it follows that certain muscular groups stand in vital re- lation with certain joints, one actuating and irritating the other through '■:i \ cl t( n: e: al ni T m Wi pc g« di I fif m 51 the same source of nervous supply. Hence the division of so contracted muscles has a vital bearing on the status of the joint, aside from the mc- Fig. 1. chanical relation. In this view we have to judge the therapeutical charac- ter of the operation. Dieffenbach already suggested the antispostic effect of myotomy and tenotomy ; I not only accept his view as correct, but from experience, I am justified in enhancing the same, that in joint diseases at least, it is the most reliable, prompt and unfailing antiphlogistic. Having suggested and practised myotomy as an antiphlogistic, it is but natural that I should spread before you the grounds on which it stands. The way in which I came to the knowledge and appreciation of this re- medy, was simply this; acting on the conviction that rest and position were the two great axioms in the treatment of joint diseases, I had to dis- pose of muscular resistance as best I could ; and often not being able to get rid of it by any other means, I resorted to division. The eflFects of the division upon the arrest of the joint disease being strikingly beneficial, I gradually included the same as a remedial agent. A practice of fifteen years duration of this operation entitles me to a vote on its merits. in m ■n ' 1 Hi '. «! 1- ! » 'I rwmmm ' t ;i l!'i I ! 52 More than in the first stage, rest and position of the affected joint are requisite in the second ; and it is in this where special apparatuses are profitably resorted to, to accomplish so important an object. In hip disease, my wire apparatus has not yet been exceeded by any later inven- tion, I place it before you for inspection [fig. 1], You will see that it consists of a heavy wire frame, which is so covered with wire webbing as to fit the posterior half of the body, from the axillary cavity to the sole of the foot. There is an opening for the anus ; the foot boards move by a screw and bolts. To protect it against the corroding influence of urine and faeces, that part of the apparatus most exposed, should be thickly covered with varnish. The average price of the same for chil- dren is fifteen dollars currency. In using the apparatus, (fig 2) you have to line it wi^h cotton or other wool or tow, and whilst the patient is under chloroform, you place him in it, and fasten by means of flannel bandages, body and limbs, so securely as to insure his position. If you should desire likewfse to apply cxten.sion, for greater security of rest and position, you may f;pply longitudinal and circular strips of stout adhesive plaster, and fasten the former to the foot board. Some writers, among thorn Mr. Barwell, have challenged the originality of this invention, and boldly pronounced it a copy of Bonnet's wire appa- ratus. I apprehend that Mr. Barwell has seen neither, otherwise he could not have come to so inapplicable a conclusion. I have never claimed 53 the introduction of wire into surgery; that point is conceded. Bon net's apparatus is a clumsy and unwieldly contrivance, produced for no other purpoL ban ,o raise the patient by means of pulleys, in such a manner as to obviate painful jarring ; my apparatus is an improved Dzondi-Hagedorn where dirsct extension can be exercised, whilst the coun- ter extension rests with the healthy extremity on the same pricciple whicli we employ in having our boot pulled off. I leave it for you to decide, whether the mode of extension com- monly employed in hip dise.ise, offers the same advantages as my apparatus. In this, position and rest are insured ; the patient can pass his focces with perfect ease, by raising the lower end of the apparatus, and placing a bed pan under it. You can carry the patient from one place to the other, put him in a carriage, draw or drive him into the open air, and thus meet all the objections that have been raised to confinement. In the other mode, the extension is a fixture of the bed, but what is still worse, it allows the patient to accommodate him.self to the position, so as to render extension nugotory. I have seen the patient turn right around, with the perineal band, and accomodate himself so ingeniously that the malposition became as bad as if there had been no restraint whatever. Davis, Veddcr and Barwell, -have successively suggested portative ex- tension apparatus to obviate the confiucment of the patient. The ho- nor of the original suggestion is entirely due to Davis, and the merits of the same ought to be liberally accorded to him, for it certainly has bro- ken the ice of the scrofulous heresy, and paved the way to the rational ideas of therapeutics, which had hccn pre viousUj advanced, but disregard- ed up to that time. Sayre, though strictly speaking, but an exponent of Davis, nevertheless deserves some credit for the adroitness with which he has propagated and popularized the instrument, which seemed - ' ~ve been an elephant in the hands of the inventor. Davis's instrument as improved by Sayre is here shown (fig. 3.) But all the before named apparatus arc at fault in one essential point : they neither fix the affected joint, nor do they prevent the adduction of the extremity. The an»ount of extension exercised by them is, moreover, very insignificant, and if it was fifty times as much, it could not separate the articular sur- faces of the hip joint, as is erroneously claimed by their respective authors. Besides they depend on adhesive Fig. 3. strips for their fastenings, which do not stick well in Hi. H- It' 54 •cold weather, and easily slip in warm. Sayre's modification to circum- vent the affected extremity with a semicircular addition at the lower end of the instrument, so as to gain two purchases and two fastenings, was an acceptable improvement^ in the adjustment, but no more.* These deficiencies in the mechanical construction of portative apparatus, have obviously induced An- drews of Chicago to fasten a straight steel crutch to the boot, allowing shortening and elongation. In appropriating thus the foot for extension, the tuber ischii for counter extension, and the screw as the moving power, he happily supplied a desideratum and got rid of the annoyance aad insufficiency of the adhesive strips. 1 had seen nothing of Andrews' very acceptable improvement when I constructed the apparatus which is now before you (figs. 4 and 5). From this to that which I now use, was but one step (figiv 6 and 7), it needs no description or explanation, its construc- tion speaks for itself. Not knowing the chronolo- gical priority of either Andrews' or my appliance, I will concede with pleasure this honour, if such it be, to my diligent co-hbourer on this field of surgical culture. My instrument affords both efficient extension in a vertical line and complete fixture to the joint, wherein lies its chief usefulness. For two years I have had it in use, and it has given me the fullest satisfaction, in promptly responding to all the indications that can possibly be realized by such a contrivance, and above all it has guarded against the re-short- ening of the adductor muscles once divided, which so often happened in my practice, wheti I used Davis's, Sayers's, and Vedders's apparatus. That of Harwell, I know but from its illustration ; I have never seen nor used it, and forego an opinion on its merits. With all advantages that may possibly accrue from my instrument, I must warn against its premature use at the second stage, unless the disease has substantially subsided, and 'you intend only to follow up the results of your treatment by its application ; the superincumbent weight is too much for an inflamed hip joint, even when supported. Fig. 4. '. I ^ i ■ * The latest contrivance of this kind is that of Dr. Taylor, of New York. He needed not to have gone to the expense of a patent (!) because it offers no superior iniucemeiits and is not likely to be employed by any one else. a 6ft To secure the rest and position of the knee joi I 'generally prefer iiietallic splints to stiff bandages. Vou can handle ti.eni better without jurring the joint; you can leave a part, or the entire joint free, for ob- servation and local appliances, an(' lose nothing in the mechanical effect- you can take them off" and re-apply them with the greatest ease : you Can combine extension with them, give it inclined plane, &c., and thus secure all the advantages for your patient that could be desired. I generally keep a set of these splints on hand, so as to be prepared for emergencies. The price is but trifling. .'I; One is a simple gutter splint (fig. 8) for simple cases. The other ha.s a semicircular deficiency at the knee joint to expose one or the other side (fig 9). The third con.sists of two .splints joined by intermediate iron braces designed to leave the knee joint entirely free. (fig. 10) By drawing bandages from one side to the other across the knee, a moderate degree of anterior pressure may be exercised. If the patient has so far recovered as to resume locomotion with safety, a portative apparatus of an approximate efficacy, should be subatitucd for the metal- ■m H' 56 11. I I' lie splint. For this purpose, stiif bandages, leather or gutta /^ -%jjj^ percha splints, or a special contrivance (figs. 11 et 12) 1* 1)/ would Cijually answer. The last consists of two braces Vs^^__^i/ along the limb, three or four bands, with a knee cap made of buckskin. If the patieut's limb is much attenu- ated and cylindriform, it would be an improvement to connect the apparatus with the boot, so as to prevent slipping. Sayre has introduced, for the purpose just mentioned, a portative extension apparatus for both knee and ankle joint, with a view of parting the aflFected articular sur- faces, and thus alleviate pressure upon one another. JMy belief is that such an object is unattainable by any me- chanical contrivance, and moreover superfluous. In placing an affected joint in such a position as to have the largest possible contact of the articular surfices, we at any rate diffuse the pressure, if it actually does exist. Sayre's knee apparatus can only be used when ^^' ' the limb is fully extended. In order to perform paracentesis of an articular cavity, the rule ought to be observed, to place the joint in such a position as to drive the liquid to the most accessible spot. At the hip joint this is at the posterior circumference of the acetabulum. The glutei mu.scles being attenuated, we generally succeed in discovering fluctuation a^ that particular place. Whilst the surgeon is about inserting the trochar, an assistant takes hold of the affected extremity, and rotates it inwards, which gives the greatest distension to the posterior wall of the capsule. This manoeuvre not only facilitates the entrance of the instrument, but likewise the exit of fluid, and prevents the entrance of air. At the knee joint we have to procure first a straight position, which drives the entire liquid into the anterior portion of the joint, By means of a tightly applied flannel bandage, commencing at the toes, we obviate oedema ; the joint is then surrounded with stout adhesive straps, from the tuberosity of the tibia, to beyond the patella; the unevenness of the joint being previously filled pj ,^ 57 with graduated compresses ^r witli cotton. Tlius tlie licjuid is driven to the cul de sac, where it is easy of access. — That place in the cul de sac between the duplicature of the vagina fenioris and the tendon of the biceps, is most avaihible, there being no muscular structure interposed. Having thus well prepared the articulation, you will easily enter with the instrument, and the liquid will rush out through the canula with great velocity : by moving the finger across the distended portion, you still more facilitate its exit, and with the same finger close the wound, while the other hand withdraws the canula. I have thus in numerous instances entered the articular cavity,' and repeatedly the same articulation, without having caused in a single in- stance reactive trouble, scarcely ever failed to give instantaneous relief to the joints, although in many cades bv.^ temporarily. This is the same proceedure which I invariably adopt, in the treatment of hydrarthrosis, and which has proved in ray practico a r^ry reliable method. Puncture of the joint, in these cases, has been unjustly abandoned by the best surgical authorities, (among others, Nelaton) who considers it dangerous, inasmuch as there is not sufficient centrifugal pressure of the Fig. 10. liquid, to prevent the entrance of air, for he states most emphatically that the inter-articular fluid runs out slowly and never entirely. ^. By the ■ill' i .iiii 63 II plan just advanced we overcome all difiiculties and dangers, thus ori*e of the objectiors may be considered disposed of. The other concerns its efficiency ; in this respect, I. can but state, that with the exception of one single case, I have radically relieved twenty-seven cases ; one by three, two by two, and the balance by one puncture. Of course I have continued compression of the articulation for some weeks after the operation. All the cases operated on were protracted ones of not less than three months, and the majority of more than a year's standing. This plan, then, compares very favourably in point of dispatch and efficacy, with any other I IcuonV of, and certainly is not as hazardous as the injections suggested and practised by Bonnet and Nelaton. Compresnon of affi^cted joints is one of the most estimable auxiliaries in their treatment, and should be resorted to wherever it is practicable ; but when Fig. 11. resorted to, it should be thorough and decided. Whether the substance employed for compression has any additional virtue, and whether, therefore, \ porous or impermeable substances should be used, | I am not as yet decided ; my experience is almost 1^^ entirely confined to the use of adhesive plaster spread on Canton flannel, on account of its plia- bility and durability; and I have been satisfied with the usefulness '^/f these substances. When, in spite of this treatment, the disease should advance, the articular cavities become more and more distended, and the tendency to disruption is manifest, then the question of free incision arises. Gentlemen, I am most^anxious to put my views on this question so definitely on record, as to leave no doubt as to their bearing and meaning : there- fore, I wish to be understood. First. That I do not advise nor practice any meddlesomeness with joints at all, unless the strongest indications prevail. Second. A moderate quantity of liquid within the pjg 12. articular cf.vity, whether this liquid be essentially synovia, or plastic or 59 =^i purulent effusion, is no indication per se^ to puncture a joint, for the two former liquids may readily be absorbed and got rid of, and so may pus by previously undergoing a fatty degeneration. I have met with such cases, and but lately the joint of one of my patients opened in the middle of the thigh, from which I could squeeze a large quantity of pus, fragments of cartilage and other detritus, which had for months painlessly occupied the joint, and had completely under- gone fatty degeneration. Tklrdh/. I puncture the articular cavity if the effusion is progressive, the distension of the joint very painful ; and for the purpose of red icing an existing malposition, provided the latter depends in part or m toto on the presence of intra-articular effusion. Fourthly. I open affected joints by free incisions, when progressive sup- puration of the internal articular surface exists, and threatens disruption of the capsular apparatus. If I am not mistaken, my esteemed friend, John Gay, Esq., of the Oreat Northern Free Hospital of London, has first claimed the legitimacy of this operation, and received a goodly share of abuse for it. I have to offer but a few remarks on the usefulness of free incisions. The very essence of surgical wisdom is to imitate nature, and to avail ourselves of similar means for certain purposes. In suppuration the joint is first dis- tended to its utmost capacity by pus, and then spontaneously opened, and the matter forced into the adjacent tissues. The ordinary place of perforations is near the bone, sometimes in part below the periosteum, mostly under the respective taseiae of the extremities, into the interstices of the muscles, and along the bone ; additional destruction is thus caused. If a joint disease has acquired this character, the joint, as such, ceases to exist : al) the structures constituting the internal suiftice undergo patho- logical changes, which mostly admit of no reconstruction ; the articular cavity is simply an abscess, and should be treated as such. The old sur- gical axiom " ubi pus ibi evacua," has received its qualification by modern surgery, but its full sway must be recognized, whenever the abscess manifests its tendency to spontaneous opening. For if we have to choose between the alternative of spontaneous perforation, and its uiulesirable sequelae, and free incisions, — no surgeon can hesitate in his prcf jronco. Sometimes it might be advisable to puncture the joint, and even repeat- edly, with a view of obviating the danger of spontaneous disruption ; but if the latter present ^i itself in unmistakeable signs, we should not hasitate in changing the artu .-tr cavity into an open abscess, and give free vent to its contents. Hancock, of London, claims exsection of the joint as preferabk to free incisions, being more efficacious and less dangerous. There is some conditional truth in this proposition, well deserving con. 1 ■iil I' l!!^ bui^uiaBSB 60 sideration. If you freely open a joint and find pathological changes, beyond those of simple suppuration, as for instance, extensive caries ; the sequestration of a bone ; the partial or total destruction of intra-articular ligaments and cartilages ; in fact, changes that would require many months to overcome, exsection of the joint would be infinitely preferable, in such case the free incision would be the initiatory step towards it. On the other hand, if the joint is in a condition of simple suppuration, so that the closing up of the articular cavity by granulation might be safely relied on, the free incision will suffice. In fact, both are distinctly dif- ferent remedies for distinctly diflforent purposes, and one cannot be sub- stituted for the other. Having laid down the general principles for the second stage of joint diseases, we may now refer to a few special points. One of ihcm is the treatment of subperiosteal extravasation or effusion ; another, the special treatment of those nccrobiotic disintegrations of one or the other condyle, to which I have adverted in another part of our discourse. The management of the former is very plain : a subcutaneous division may give all the needful relief, and stop the impending trouble, at any rate prevent its increase. The other is of a more subtle character, re- quiring a clearly established diagnosis, settled therapeutical principles, and consistent action. How to arrive at the Hrst I have already indi- cated, and to render the diagnosis still more conclusive the use of an explorative trochar would bo advisable. If we have become thus satisfied of the nature of the complaint, trephining by a small instrument, and the subsequent scooping out of the disintegrated tissue, is the most direct and le^;itimate remedy. I must, however, confess that I have, but in a few cases, resorted to this operative proceedurc, though with marked success ; my personal experience is therefore limited, but it would seem the most appropriate and direct remedy when a clear diagnosis can be obtained. In summing up the treatment of the second stage of joint diseases, you will perceive that I rely exclusively on local appliances with a view of obtaining Jlrst, rest and position of the aifccted articulation. In procuring these I have occasionally to divide resisting muscles and to puncture joints. Second. — Compression of the inflamed structures. 2hird. — Paracentesis and free incisions in joints when suppuration prevails. ■ Fourth. — In dividing periosteum,and in removing disintegrated bony structure by trephine and scoop.* • Kirkpatrick, Medical Press and Circular, Dublin, Aug. 21st, 1867, recom- mends the use of cscharotics, especially potassa c. calce, for the same therapeutic object, and relates most beneficial results. ■ 61 In the second stage of this class of diseases, we have often to deal "with violent constitutional disturbances, which are more readily overcome by proper local treatment than by any other devised medication, never- theless the utmost attention should be given to proper diet and hygiene, which is the more necessary as all the-;e cases are more or less protracted, and therefore more or less bear upon the constitutional vigor. Now, gentlemen, let us contrast the treatment just described with the measures of the old school. Ours is mild when compared with the barbarous derivatory appliances. Moreover, ours is effective ; the other is worthless. By our treatment the joint is placed in a condition of spon- taneous recovery. The other proposes to subjugate, by direct means, a disease over which it never had nor could exorcise any positive influence. Nor is this all ; by applying the actual or potential ciiutjry, nesv troubles are superadded and new t;ixition is imposed upon an already overtaxed constitution. But derivation is not only barbirous, useless, and obnoxious, it is even inconsistent with tlie very pretensions for which it is used. Supposing tubercular depositions are at the bottom of a joint disease, these deposi- tions are either latent and innocuous, or they act like any other foreign substance in creatinu; circumferential inflammation with a view of eventual elimination. In the former proposition, we know nothing what- ever of the presence of those depositions ; simply because they give no trouble. If we could possibly anticipate the time when such tubercular depositions would be likely to take place, then derivation might be relied upon as a preventive of the impending danger. But since we have quietJy to wait until the so called tubercular depo- sitions are formed, and until they are undergoing the process of soften- ing and compromising the surrounding structures, there is not even a pretence of reason to employ derivation, just as little as if any other foreign substance was lodged within the precinct of the organism. It is claimed that tubercle is not only without organization, but even, not susceptible of it : derivation can therefore exercise no action upon the tubercle itself ; that much must be logically admitted. Can it prevent the disintegration of the adjacent structures, and re-establish their former type ? of course not ; then what is to be expected from derivation at all ? The progress of pathology has been most fruitful in recognising the existing physiological laws which govern alike health and disease. The most reliable observers tell us that inflammations once set up, will run their course to their termination, whether medication be imposed/or not. The idea of bringing a recent pneumouia, bronchitis, pleuritis or a oatarrh of the air passages to an abortive end has been so tlioroughly •.f^' i i t I I 62 u ^■- ffl exploded that no wise practitioner follows any other than the expectant method of treatment, and Hughes Bennett has earned for himself a lasting distinction in proving that fact by clinical statistics. If you concede the fact you have to accept the inferences, that is to say, if you cannot cut off or shorten the course of a recent disease by any means ; what can you hope to do in cases of long standing, in structural disin- tegrations, and more particularly then, when the cause (tuberculosis) is persistently at work. It will be equally easy to demonstrate the utter uselessness of deriva- tion in the primary affections of the synovia! lining. In the mildest form of them (hydrarthrosis) there is a degeneration of the synoYial membrane which Johannes Muller describes as lipoma arborescens, which is fully compatible with the increase of the natural secretion, but in which, however, the absorbent powers seem to be entirely lost. Next you have the so called catarrh of the synovial lining in which, according to Volkman, the epithelium is partly thrown off, partly converted into pyogenic source : there you have morbid secretion and loss of absorption. And if you have to deal with a more parenchymatous suppuration of the membrane, you have no longer synovial membrane, but a luxuriantly granulating and secreting surface, with very doubtful absorbing endow- ments. The restitutio ad integrum is absolutely conditional to the re-establish- ment of absorption, and this is a question of time. Can you reach or overcome such a difficulty, by blistering or any other derivant applied to the external surface of a joint ? Certainly not ; like in pleuritic or pericarditic effusions you have either to tap or patiently wait. I do not want to enter more deeply into the discussion of the thera- peutic value of derivation, heretofore unduly praised and over estimated. All I propose is to make a few hints and suggestions, and leave the rest to your mature deliberations. In the third stage of joint diseases we have still more to deal with both extensive and continued changes in which mostly all the component parts of the articulation are compromised. In whatever tissue the malady might have started, in its progress it has comprised the rest. Thus in synovitis,the articular cartilages have been exposed to constant maceration of pus, and have suffered those elementary metamorphoses to which I invited your attention on a prior occasion. And when at last they drop off in rags and fragments, the osseous surfaces of the epiphyses are iu turn subjected to the same obnoxious actions. With the progress of their disintegration, the periarticular structures become more or less invaded and gradually manifest conditions very si- es niilar to those of white swelling. If, on the other hand, the primary af- fections of the periosteum and epiphysis proceed to the perforation of the articular cavity, it is self-evident that its lining must suffer appropriate alterations. The third stage is consequently a disease of the entire arti- culation, and its treatment a formidable object of the healing art. Notwithstanding the undeniable difficulties of these affections, quite a large proportion of the patients recover with or without aid, and some- times under domestic surroundings of the humblest kind ; whereas others run their course to destruction in spite of therapeutic efibrts and hygienic advantages. The reason of this difference is not always apparent. Oc- casionally the abscess determines where the joint gives way to the centri- fugal action of the pus. If, for instance, the pus escapes through the floor of the acetabulum, it spreads over the internal surface of the pelvic bones, by detaching the periosteum, and may eventually make its appearance below Poupart's ligament, or through the ischiatic notch, or between the gluteal muscles. Irrespective to the lesion of the hip joint itself, this condition alone would constitute a frightful disease, sure to terminate disastrously. Similar complications may occur with other joints and ag- gravate their respective diseases. The indications of treatment diversify with the complications present- ing. Generally speaking the same therapeutic rules come into play at this juncture which have been already detailed. Rest and position, ex- eroisi, even in these aggravated cases of joint disease, their beneficial in- fluence, but the appliances should be portative so as to allow the patient the conditional enjoyment of open air perambulations. Of these the pa- tient is greatly in need to sustain his constitutional standard. The ap- pliances should, moreover, be such as would not be easily saturated and soiled by the discharges. James Startin's suggestion to impregnate the bandages and splints of felt, with an equal mixture of melted paraffine and stearine, for the double purpose of stiffening and rendering them watertight, is certainly deserving of attention. I have not as yet employed this material, but it seems to me preferable to varnish coating heretofore used. It is self-evident that the fixture of the joint is an essential disideratum to prevent the corroded surfaces of the epiphyses from grinding upon one another, and thereby give rise to pain and renewed irritation. The fistulous openings should be maintained and their drainage kept free. This is, however, no easy task, because their sinuses are very cir- cuitous, and dilatation by laminaria or compressed sponge, impracticable. The laying open of the tracts by the knife is mostly of but temporary assistance, incurring loss of blood which patients can scarcely bear. The fif H I !i: employment of potassa ^- calce (Kirkpatrick) to open direct communica- tion between the articular cavity and the surface, deserves surgical con- sideration. Abscesses freciuently form in the circumference of joints. Those which are attended witli great swelling, pain and fevei', and indicate the efforts of nature to eliminate structural detritus, should be promptly and fully opened ; those which appear more or less remote from the articulation and cause no local or general inconvenience (cold and consecutive abscess : abscessus congCKtionis) may be ignored as long as they do not raise alarm by their si/e and pressure upon important parts. Their contents readily undergo iatty degeneration, followed by gradual resorption. But if they require opening it should be done by trochar with the exclusion of air. The knife should only then be employed when air has entered the pyoge- nic cavity, and decomposed its contents. In this way septicaemia with its fatal consequences can be averted. With a view of bringing about a more decided detachment and dimi- nution of the structural detritus, various means have been recommended. John Gay insists upon free incisions into the affected joint , others allege they have successfully employed the seton,and Kirkpatrick favours an open- ing with his escharotic into the joint and uses it freely upon the osteopo- rotic ubstancc; and finally exscction. The two former apply only to superficial and accessible joints, and all four are necessarily followed by copious suppuration. They are therefore but available in well preserved constitutions, and in superficial caries of the articular fiices. It is obvious that no debilitated patient can pass unharmed through .-^o consuming an ordeal. As to exscction I beg to submit : I. That if a thick slice is removed from the epiphyses, we approxi- mate the cartilaginous disks fastening them to the shaft, which may thus become involved, protract and even prevent the reunion. II. That if we comprise the cartilaginous disks in the operation, the extremities become so much shortened as to render the result nugatory, and the artificial leg preferable. III. That the exscction of single tarsal and carpal bones is but very exceptionally attended with good results on account of the existing inter- communication of the tarsal and carpal joints. The arrest in the growth of extremities operated upon by exscction, as observed by Koenig of Hanau,* is probably founded on error and should not prevent us from resorting to so legitimate an operation in its proper place. The growth is impeded by the previous disease, a fact most pro- bably ignored by that author. * Arcliive of Clinical Surgery, Berlin, 18G7. 05 From these remarks it appears that exsection, as well as amputation, has its defined therapeutic value, and one cannot well be substituted for the other without risk and injury to the patient. 1 have nothing t. do Avith the technicalities of either operation at this juncture. Permit me, however, to tender my advice in reference to two points in exsection. I. Before proceeding with the operation, overcome, if possible, the ex- isting malposition by dividing the contracted muscles. I have mostly taken these preparatory steps and thereby secured perfect control of the subsequent position of the extremity. I owe, perhaps, to the observance of this preliminary measure, the happy results that have attended my operations, more particularly at the knee joint. Whereas some of my surgical friends who neglected it, had great trouble to maintain position, and lost their patients. The supposition that the shortening of the limb is sufficient to relax the contracted muscles, proved, in their respective cases, to be erroneous. II. I remove with great care and accuracy as much of the synovial membrane, serous slides and bursjc (Bilroth) as are extant and exposed to air, for they will suppurate and materially retard union. At this juncture the debilitated state of the constitution deserves the closest attention. No medication will, however, be of service as long as the local troubles are not mitigated by a proper course of local treat- ' ment. The amelioration of the articular disease is the most direct way of relieving constitutional reaction. Nevertheless, quinine, iron, co'.5 liver oil and sedatives may be needed to control fever, pro note luBmatosia, supply an easily digested nutriment, and secure repose and immunity from pain. In morbus coxariiis the principles of division of the morbid periods rest on a diflferent foundation, and accordingly the third st;ige of that disease is determined by the spontaneous disruption of the articulation and a peculiar malposition of the affected member. It is of course necessary to ascertain the anatomical and clinica' character of the existing malady, to determine the plan for therapeutic action. If the inflammatory character of the disease still prevails, the appro- priate means will readily suggest themselves from preceding remarks ; and as readily if caries has ensued. The contracted muscles reqi ire division to allow the reduction of the existing malposition. Next, the articulation should be kept at rest by means and appliances with which we have already become acquainted ; irrespective to the prevailing state m i li i1 4 of the joint ; being equally beneficial in arresting articular inflammation a>; preventive to the irritative grating of carious surfaces upon one another. If anchylosis should thus ensue, it will take place in the most desirable and useful position of the extremity. Locomotion of the patient renders the use of crutches indispensible, the weight of the body will aggravate the local trouble. Only when the caput femoris shows disposition to slide up and backwards, does extension become imperative. My portative apparatus (fig. 6)answcrs the indications. When, however, no improvements in the pathological condition of the joint follow this treatment, when caries and suppuration continue, and threaten the patient with hectic, then the exsection of the head of the femur is justifiable and appropriate. Fortunately the rational and successful treatment of morbus coxarius, lessens the exigency of that operation, and to this fact we may ascribe the present rarity of its preformance. Notwithstanding the avowed aversion of French surgeons to this oper- ation, it cannot be denied that it h:i'< furnished a fair statistic of success, and that it has saved the life of many a patient, which otherwise would have been lost. Of the seventeen partial exsections of the hip joint which I have per- formed in the course of my surgical career, nine were attended by re- covery and two are still under treatment. The limbs have been shortened from one to three inches. f With the exception of one case, the sclerotic tissue formed between the acetabulum and the shaft of the femur, permitted a moderate mobility, and is strong enough to bear the superincumbent weight of the body. That case concerns a young lady upon whom T operated in the year 1S56 when she was nine years of age. Owing to monstrous obesity, the inter- mediate substance has never become firm. I have seen this patient but lately, she has grown to be a handsome and healthy woman ; and I have again had an opportunity of examining into her condition. When she stands on her right limb, the mere weight of her left suffices to bring it to its full length. But if she rests upon the latter, the intermediate sub. stance bends outwards and allows the shaft of the femur to come in con- tact with the acetabulum, by which the limb is three inches shortened. In this positon she can bear the entire weight of the body upon the af- fected side. My apparatus gives her the desired support for locomotion, and with it her gait is easy and graceful. I apprehend that some of the exsections which I have performed, have been under rather unfavourable circumstances, and yet withal the conjoint result is anything but discouraging ; some of my patients died of other G7 diseases (two of laryngeal diphtheria, and one of cerebral meningitis) evidently connected with the impoverished state of their respective nutrition. Though I am not a great admirer of exsection of the hip joint, never- theless I honestly believe that its performance when warranted by the anatomical changes of the joint, bids as fair a chance of success as the exsection of any other joint. It is scarcely necessary to remove carious portions of the acetabulum unless very accessible, for the nutrition of that portion of the pelvis is unimpaired, and inasmuch as it remains ac- cessible to local appliances, it becomes soon repaired. In those patients who died after the operation, I invariably found the acetabulum restored to its integrity. 1 VI. TREATMENT OF THE SEQUELAE OF JOINT DISEASES. The most judicious and diligent treatment sacceeds but rarely in re- storing the affected articulations to a perfectly normal status. There re- mains generally some tenderness of the articulation, which shows itself after a liberal use, and on changes of the weather. Besides a certain stiffness and dryness may continue a long time after the disease has be- come completely extinct. The treatment of this symptom may be fulfilled with aromatic lubri- cations, cold and warm douche, flannel bandaging, the longer use of " sole baths," which in Germany have acquired great reputation in these troubles. More than all, passive and active exercises are best cal- culated to give permanent relief. Even slight malpositions may be gradually overcome in this way. There are quacks in every country who acquire reputation and lucre from the treatment of these articular im- pediments, and surgeons may learn from them the undeniable benefit of the use of apparently so insignificant remedies as lubricating frictions and passive exercises. I have myself to acknowledge some practical in- formation from this rather turbid source. Having straightened the con- tracted knee of a lady patient, and repeatedly moved the same under chloroform without succeeding, I at last gave it up. After some months I again met her, with a perfectly flexible and useful jc'nt, and learned that a female quack had restored her extremity to usefulness by persis- 68 M ■=?! tent and daily lubrications and passive motions. In the beginning, the treatment had been very painful and almost unendurable ; but gradually the pain had subsided. I need not to assure you, gentlemen, that this lesson was never forgotten by me ; and I am anxious to impart its bene- fit to you. If you have no time yourself, I would advise you to employ menial hands, but do not give quackery a pretence to superior skill and practical efficiency. The passive motions are best commenced with the assistance of chloroform, which will enable us to overcome impediments, without any hazard whatever to the patient. Tenderness of the joint may follow, bit will subside with a day or two of rest. The passive motions should then be renewed with or without chloroform, as the case demands, and should be carried on until the desired results are achieved. The patient may greatly assist our efforts by appropriate movements. If, however, the previous treatment has been inefficient and regardless of conse'juences, the patient will present more aggravated conditions. The very best treatment is no sure protection against an obliteration of the articular cavltij ; hnt m'llposition of the joint, mnif and should al- ■ways he 2»'evented. Anchylosis forms, then, another object of after treatment. Surgery dis- criminates two forms ; the false or fibrous, and the true or bony, to which might be added a third, by bony bands or osteophytes. The first consists of partial or total connection of the articular faces by sclerotic tissue, the second in tlie bony interposition, and the third forms a partial osseous involucrum of the joint. The false anchylosis results from synovitis, both primary and consecutive ; the true from penetrating wounds and caries of the articular faces ; and the last from suppurative periostitis. There is always more or less mobility in false anchylosis, but there is no vestige when osseous material forms the connecting link. When mus- cular contractions existed previous to the agglutination of the articular faces, the mutual anatomical relations of the latter are invariably changed. The treatment of anchylosis has always been a cherished object of surgery froa; Hippocrates down to the present time. Success is, however, but of recent date. Gradual extension for the purpose of overcoming fibrous anchylosis is an old surgical proceeding and has from time to time found advocates in the professional ranks. Mechanical ingenuity has found a fruitful field for display in the construction of all sorts of instruments ; the latest method imtroduced is that by pulley and weight. The usefulness of gradual extension in the treatment of fibrous anchy- M losis, is foi' obvious reasons but limited and condidcmaJ. and the attempt to substitute the same for hrisemcnt force is a failure. The anatomical conditions resultinsi; from joint disoasts are hut ex- ceptionally amenable to that method : it is tedious at best, and frequently so painful as not to be borne by many patients. It's claimed superiority is, moreover, anytliing but conclusive. Nevertheless we meet with cases in which the elastic resistance of intra-articular adhesions and of the capsu- lar ligament can be but overcome by gradual and persistent extension, and in these it seems to be the only remedy. These conditions we recog- nize only after unsuccessful attempts at hrinament forci, and the latter has therefore to precede. Such cases maybe rare and constitute but a small fraction in statistics, but they do exist, notwithstanding their denial. I possess two specimens of this very character, in my collection, both derived by amputation of the thigh. One belongs to a lady who had contracted fibrous anchylosis of the knee from rheumatit; synovitis, aggra- vated by contraction of the hamstring muscles. Before coming under my charge, she had sufiered hriscment force without previous division of the contracted flexor muscles. Violent reactive inflammation of the joint followed the forcible extension, and the latter was too painful to be maintained. The integuments .sloughed at the internal circumfer- ence of the articulation, and her constitution was so violently shaken tliat her recovery was placed in jeopardy ; and when, after many months of severe suffering, she had regained her strength, she was to all intents and purposes in 7i '/ ^' 6^ 34 I '' I' I the affected extremity, and with a firra, steady, but gentle traction, extends and abducts the limb. Gentle motions and rotations may be combined with the traction, but they should never be made so powerful or free as to destroy the existing adhesions. We ought to be contented with a good position of the extremity, and not to risk the lives of our patient for the sake of more or less free motion. In adults there is less danger of recurring disease, and their limbs bear a freer handling. The fixing of the pelvis is obviously very important to the ulterior results, and the hands of an assistant fail particularly then to fix the pelvis when the thigh is considerably flexed upon the former, for this and the purposes of after treatment, a special apparatus is needed. Buehring, and subsequently B. Langenbeck, have constructed such apparatus, but they are costly, complicated, cumbersome and inefficient. After various changes and improvements I have succeeded in construct- ing an apparatus which meets all the requirements, besides being cheap and simple, and may be attached to a plain camp bedstead. The appara- tus which I submit to your inspection is much more costly than is neces- sary (Fig. 16). The essential part of the contrivance is a wooden block ac- curately adapted to the posterior half of the pelvis, inclusive of the tuber ischii. Any wood carver can make it if you furnish him a plaster of Paris cast. This block is simply ^pj j(. N lined with chamois, and, if well adapted, the patient can lie in the same for months with the same convenience and ease with which a gum plate with artificial teeth may bo worn. When the patient is placed in this block he is fastened down by stout leatherstraps and buckles, in front and across the pelvis. This block is fixed to a plate of sheet iron by means of screws from below ; and the iron plate, by means of four bolts, to the frame of the bedstead. Thus you have a simple and complete fixture of the pelvis which lies closely upon the mattress. (Fig. 17.) All that remains is an iron frame at the foot of the bedstead, and two pulleys to shift upon the frame. This apparatus should be in readiness when proceeding with brisement forc4, and if need bo, may at once be used in place of the table and in preference to the manual fixing of the pelvis. If you should not succeed in completely extending and abducting the extremity, you may defer the completion and in the meantime keep the limb in the same position in whioh your first attempt left it, by pulley 85 and weight, or if you hav3 completely succeeded, the after-treatment may at once he fairly commenced. In these cases extension comes in for its profitahle employment. Without myotomy and hrisement forc6 it is more than worthless because dangerous ; in combination with those pre- (Fig. 17.) liminaries it is a most useful auxiliary. Extension with the aid of my apparatus is certainly most efficient and powerful, since the pelvis is completely fixed, and the patient totally prevented from assuming an accomodating position. I have used it with great benefit in a large number of cases, and know no better substitute. . Two or three months will suffice to render the newly acquired position stable ; then you may allow locomotion with the assistance of my porta- tive hip apparatus, with or without crutches as required. The true bony anchylosis of the hip joint finds its relief in Rhea Bar- ton's opu'ation. I have never had occasion to perform it, and can there- fore ofier no suggestions drawn from personal experience, but it would seem to me that the attempt at establishing an artificial joint at the line of division is unwarrantable for two reasons : 1st. An artificial joint could never give a sufficient support to the superstructure of the body. 2nd. It inevitably protracts the suppuration with its impending ..anger of pyae- mia. Sayre, a few years ago, performed this operation, as he alleged with success, but his patient nevertheless died a few months after from pyaemia. wsm 86 The specimen derived from the case, did not sustain the assertion of that gentleman, no cartilaginous covering, synovial lining or a new cap- sular ligament having been formed. Now, gentlemen, I have arrived at the end of our discourse and will finish with relating a few interesting cases. Some of them present peculiar and exceptional clinical features, others may serve as types of their class. Your attention has been most gratifying to me and I feel sincerely thank- ful for your magnanimous indulgence. ., Case I. '.-.', Hygroma hursale traumaticiiniy of eight years standing, Jihrous anchy- hsis of left knee joint with flexed and inverted malposition. (Vide fig. 18 and fig. 12.) A young man (Packner) twenty two years old, solitjited my professional services in the following case : When at the age of 11 years he sustained an injury to the left knee, which gave him trouble for three years, not materially impeding, however, his locomotion. His general health hav- ing materially suffered, his father, a sea- captain, was advised to take the patient on a voyage and give him the benefit of sea- air. On ship board he repeatedly met with falls and slight accidents without being ag- gravated. One day whilst driving a naiJ into a plank, the hammer struck him heavily just above the left knee-joint and caused a painful bruise, soon followed by intense agony and swelling. From that time to the period when I took charge of his case, the patient had .pj„ jg X never been free from pain and uneasiness, and his haggard, anxious, and desponding appearance bore the unmis- takable evidence of severe and continuous suffering. The affected arti- culation was so tender as to be utterly useless for locomotion; in fact he would not even stand upon the extremity with a mere fraction of tho bodily weight put upon it. Hence crutches were requisite, between which the extremity was suspended, The wealthy father had of course successively consulted the best sur- 87 geoDS he could find, both in Europe and on this continent. They had all agreed in their counsel that amputation was the only remedy. On examining the affected extremity the following clinical points were elicited : 1. An ovally shaped, smooth and throughout, hard tumor, " 9 x 4," inches located immediately above the knee-joint. Its base was broad, abrupt and immovable. There was no tenderness or discoloration about the tumor ; 2. The joint was anchyiosed but allowed a trifle of motion, which was, however, very painful at its inner circumference ; 3. The quadriceps muscle of the thigh was displaced to the outside of the tumor ; the patella lodged upon and adhered to the external condyle of the femur; 4. The tibia occupied an angle of 150° with the femur, and was so turned on its axis as to evert the toes ; 5. Besides there was a slight inflexion at the knee between the two bones which gave it a knock-kneed appearance ; 6. The biceps muscle was considerably shortened and therefore very tense; 7. The temperature of the kaee-joint, more particularly at its inner aspect, was not much raised ; 8. In fine the affected extremity was moderately attenuated. The tumor was obviously accountable for the existing articular trouble and malposition. It had raised up and gradually displaced the extensor muscles of the leg. The latter derived additional physical power from acting, as it were, around a pulley, being converted into a flexor, rota- tor and adductor muscle of the knee. The tibia had yielded to the ab- normal traction. The torsion of the joint had set up inflammation of the synovial lining, eventuating in fibrous interarticular adhesion of the articular faces. Reflex contraction of the biceps muscie had ensued. Thus, by the succession of mechanical effects, a most complicated morbid condition had been brought about in course of time, traceable to no other cause than the tumor. The still existiug inflammatory action at the in- ner circumference of the knee-joint, may be ascribed to the abnormal posi- tion of the extremity, being diagonal through the femur and bearing the weight of the body upon the internal ligaments. But the all important diagnostic question centered itself upon the nature of the tumor ! The apparently very hard texture suggested bony structure. For ostoid, the tumor was too hard and smooth, and had existed far too long a time to sustain the suspicion of a malig* nant growth. Periostitis would have circumvented the femur, and not 88 ■ exhibit a broad and flat base. Bone abscess vrould have distended the femoral tube in all directions and at that size would have become softened. The hardness and smoothness of its surface precluded the idea of an osteo- sarcoma. The evidently traumatic cause, the gradual increase, the regular form of the tumor, and the anatomical region, pointed directly and conjointly to the distension of the subcrural bursa. Yet there was no fluctuation, and that ominous hardness was left unaccounted for. Nothwithstanding the discrepancy, I commenced most carefully to explore my ground with the hope of detecting fluctuation ; for the rather indefinite supposition suggested itself, that the resistance of the vagina femoris might ren- der the tumor both hard and obscure its fluctuation. At the inner and lower aspect of the growth, a branch of the saphena magna perforated the aponeurosis and dipped into the depth. There I felt some elasticity and very indistinct fluctuation, sufficient evidence of fluid, at any rate, to warrant explorative puncture. The patient, a very intelligent young man, having realized the probable character of his case, and deriving new nope from the proposed proceeding, readily consented to the exploration. After having made the necessary preparation, I proceeded next day, with some professional friends, to the patient's dwelling. I met with but little encouragement for the operation, either on the part of colleagues or the relatives of the patient. The former dissented ir, toto from the sug- gestive diagnosis, and the latter presented the authority of the best sur- geons of the country as objection to any other proceeding short of amputa- tion of the thigh. The trocar bein^, inserted, about § xiv of a straw-coloured and alkaline fluid was withdrawn, whereupon the tumor collapsed. On careful exam- ination, the empty sac and its contours could still be discerned ; but, of course, the previous hardness had entirely vanished. Having thus verified the diagnosis, I proceeded with the second part of the programme, in dividing the outer hamstring, breaking up all ar- ticular adhesions, and in fully extending the extremity. A few minutes served to change the condition of the patient, and infuse him and his friends with new hopes for the future. It could hardly be anticipated that pressure alone would suffice to prevent the re-accumulation of the bursal fluid. In order to close up the old depot, I was induced to inject tincture of iodine. That operation was followed with violent inflamraatidn and suppuration of the bursa. When, at last, the cavity had closed, tho quadriceps mus- cle was so firmly aglutinated to the thigh-bone, that it seemed indifferent ■■ vi> 89 whether the articulation of the knee-joint was re-established or not. The patient, desirous for active life, declared himself quite contented with a straight, useful, and painless, though inflexible extremity, with which he is now able, according to a recent letter to a friend, to walk his fortv miles a day, by peddling in California. The presented photograph fig. 12 is the appearance]of the patient at his discharge. At that time I supported his extremity with a straight ap- paratus, with which the patient now dispenses. That the hardness of the tumor was simply caused by the constraint and resistance of the vagina femoris, will be admitted without further dispute. And we noticed the same symptom in the case of Mr. A., one of the great hotel proprietors of New York. We need h?rdly say that the correct treatment of Mr. A.'s case depended likewise on corr«^ct dis- cernment of the tumor, about whose character and structure conflicting opinions and apprehensions had been advanced. ^ V^ ^^'^^ ^^' '■--'■' Traumatic diastasis of the lower epiphysis of left femur. Remarkable deformity and malposition of the knee-joints. Abnormal lateral mobility. Total resection. Recovery. Francis Shaw, a lad of fourteen years, of Irish descent, and endowed with robust health, presented himself in October 1860, at the clinic of the Brooklyn Medical and Surgical Institute. He came at the instigation of a surgical instrument maker to get my advice with reference to the feasibility of a mechanical apparatus to steady and support his limb, and to render it useful for locomotion. He stated that he had acquired the deformity when but seven years old, and that ever since the trouble had increased, and that then he was unable to use his extremity to any pur- pose. To the best of his memory he received a blow at the knee-joint with an iron rod, which gave him pain and disabled him for a short time. A physician had been called in soon after the injury, but finding no undue mobility or deformity he pronounced it a simple contusion, and advised rest and cold fomentations. These directions were followed for three weeks, when the patient resumed his walk. Since that time dates the impediment. In the erect posture, the patient throws his whole weight upon the sound member, when balanced between two chairs a three inch block is required to equalise the length of both extremities, as may be seen in the adjoining diagram (Fig. 19). The left limb is peculiarly knock-kneed, the thigh being adducted, the leg abducted and everted, and laterally both forming an angle of 120°. This position alone would have been quite sufficient to render locomotion infirm G Hi 90 and defective, but us it was, the limb became totally useless by the relax- ation of the knee joint. At the moment the patient rested upon the affected extremity, the leg became still more abducted and everted, and the angle with the thigh could easily be reduced to 80° and less. Both (Fig. 19. See page 299.) articular faces moved with undue freedom over each other, and the tibia could be freely rotated upon the femur, the scope of eversion being, however, greater. This abnormal condition was due to some re- markable anatomical changes in the configuration of the joint. The articular surface of the femur had an oblique direction, from below and inward to up and outward, the two condyles were absent, and the bone terminated below us a segment of a sphere, of which but a part was appropriated for articulating purposes, the patella and the quadriceps muscle were drawn out of position to- wards the outer aspect of the extremity. The tendon of the biceps muscle occupied the popliteal space. In every other respect the limb presented the ordinary condition, except being slightly attenuated. 91 a I) n c >- e d isefore the patient had applied to our institution he had presented himself before the surgical staflF of the New- York City Hospital, who had come to the conclusion to advise mechanical support, which was, however, entirely out of the question. On the other hand Francis Shaw had ar- rived at an age which made him desirous of entering upon some business, and therefore insisted upon some means to render his limb serviceable. There was nothing left but the exsection of the knee joint or amputation of the thigh ; for no orthopaedic ireatment could be relied upon to ma- terially alter the anatomical status. I could not hesitate to decide in favour of exsection, since both the con- stitution of the lad as well as the bony structure concerned, were in a most auspicious condition. The operation was performed on the 9th of October. I had to remove quite a large piece from the femur so as to obtain a rectangular surface ; but a very thin slice was taken from the tibia, the patella was likewise removed. The bones were then brought in close proximity and kept in position by softened iron wire, and the wound united by silver wire in fine, the limb was secured in one of the iron splints (vide fig. 10) which left the knee-joint itself free of access. Recovery followed rapidly, partly by first intention. The bone wire was removed on the twenty sixth day after the oijeration, and at the end of the second month the patient was up and about, .and accompanied me on crutches to a [neighbouring gallery to ha\o his photo- graph taken. Represented in (Fig. 20.) On the 28th Feb. 1861, -I exhibited Francis Shaw at the New-HTork Pathologi- cal society, when his conditions were as follows : integuments, completely cicatrized ; firm union of the bones by short fibrous tissues admitting but of scanty motion ; moderate enlargement of the circumfe- rence ; circulation and temperature normal ; deficiency in length two inches ; correct position of the foot. With a heel of two and a quarter inches, pelvis and shoulders stand square. His locomotion was, aside from the stiffness of his knee, unimpeded. You may imagine that the diagnosis of the case must have been per- 92 plexing, when the most distinguished surgeons of New- York signally failed to realize it, nor could I lay any claim to :i clear understanding of the proximate cause in the premises before the operation, yet I have the gratification to say that the views I V.id first formed and expressed to my class, did not fall short of the ■ lality. That the injury to Francis Shaw nad produced no fracture was self- evident from the previous history so clearly related. Nevertheless the continuity of the femur must have suffered in such a manner as not to disturb the form of the limb, nor give rise to any undue mobility. With diastasis of the lower femoral epiphysis these conditions are com- patible. Had the patient quietly remained in bed for six or eight weeks, there is no doubt that the subsequent trouble would have been averted. But in rising prematurely, the soft agglutination of the epiphysis with the shaft gave way and allowed the former to turn gradually round, and with it dislodge the entire joint. In the newly acquired position the undue pressure upon the external condyle of the femur had gradually diminished its size until no trace was left. And the internal condyle became the terminating end of the femur. The fragments of bone removed by the operation (fig. 21 and 22*), render this reasoning at least plausible if not conclusive. a (Fig. 22.) Case III. Morbus Coxarius in its third stage. Consecutive Abscess connecting with the joint. — Complete prevention of malposition. George D., ten years old, of good constitutior. and general health, de- scending from healthy parents, and one of nine children who are enjoying perfect health, came twenty months ago under my treatment. His • a. Epiphyseal line. 0. Internal condyle of femur. e. Slice of tibia. Fig. 22, represents the posterior view. 93 left hip-joint was then very tender and, immovable, the extremity was slightly bent upon the pelvis, abducted and rotated with cvorsion of the toes. The pelvis was lowered at the affected side, and the spine conse- quently inclined the sunie way. On examination under chloroform, it was found that the hip-joint was almost immovable, allowing but slight flexion and extension, but no adduction and rotation whatsoever. The tensor vaginre femoria and the pectinaeus muscle contracted. There was but a moderate fluctuation at the joint. In addition to this I was informed that the patient complained of pain at the knee and violent nocturnal paroxysms. The limb was moderately attenuated. Although the boy had manifested the symptoms of morbus coxarius but a very short time, he gave evidence of constitutional sufifjring, looked pale and thin. A full diirectly upon the left hip, was assigned as the osten- sible cause of this disease. Those symptoms strictly coincided with the second stage of morbus coxarius. The treatment was initiated with leeches to the affected articulation. The contracted muscles were thereupon divided and the patient was placed in the wire apparatus, and thus rest and position of the extre- mity insured. The immediate effect of this treatment manifested itself in complete repose and immunity from pain, both structural and reflected. This treatment was continued for six months, when again a thorough examina- tion was instituted. There was almost complete mobility, without cre- pitus ; no fluctuation about the joint ; the limb occupies a rectangular position to the pelvis. There was no pain on pressure or motion. The constitutional appearance of the patient was notably improved, appetite and rest were perfect. Presuming that the disease had been effectually arrested, I allowed the patient one hour's locomotion per day, with the hip splint and crutches, and this time to be gradually prolonged provided no active symptoms should recur. During the balance of the day and the night, in the re- cumbent posture, and the limb again secured as before. There was no reason to alter the plan, and at the end of another six months he enjoyed his full freedom and went regularly to school, crutches and portative appan?- tus, as well as the wire apparatus during the night, being continued. About four months ago, an abscess formed over the place where the tensor vaginaD femoris had been divided, and was attended with the or- dinary signs. It was punctured, evacuated, and its walls kept compressed by flannel bandage ; since then it has three times refilled and again been punctured. Each time the wound closed. The matter drawn from the mmmi 94 abscess was rather thin and somewhat soapy, oontairiing, however, no structural detritus of any account, and particularly no elements of bone. I am rather undecided as to the nature and meaning of the abscess, and have no means of ascertaining whether it connects with the joint or is the consequence of suppurative bursitis. There is indeed not a single symptom indicative of the joint being implicated, although the possibility cannot be denied. But the fact that the punctures close and form no sinuses, is rather against articular suppuration. It is at best therefore an open question. On the other hand I have seen these abscesses often form at the same location, and subsequent to the division of the tensor vaginae femoris. Not unlikely these abscesses grow out of an injury to the bursa of that muscle, and would have no great pathological import. If this version should prove true, the diagnosis of this case should be modified accord- ingly. From the general aspect of the case, I expect perfect recovery at no distant time. The diagrams (figs. 23 — 24) represent the present (Fig. 23.) (Pig. 24.) status of my patient in as far as the position of the afieoted limb is con- cerned, and it will be observed that form, position, and length are normal, not even the circumference of the limb differs materially with its fellow. 95 Case iv. Malposition of the right limb with more than four inches shortening, the result of now extinct Hip Disease. Harry M., ele\ i years of age, came under my charge in the following condition. The right extremity considerably attenuated ; the thigh without its proper contours \ extreme adduction and inversion ; pelvis tilted up and rotated backward ; corresponding deflection of the spine ; gait very awkward and limping, in spite of a four inch heeled boot ; trochanter major protrudes considerably, and exceeds by three quarters of an inch a line drawn between the anterior superior spinous process of the ilium and the tuber ischii ; insignificant mobility of the articu' '■ , without a trace of abduction and rotation. These impediments were the consequences of morbus coxarius, since eighteen months entirely extinct. / Ithough of slender build, he had enjoyed perfect health, and been a very active boy up to the very time when he was suddenly struck down with that disease. There is no morbid diathesis in the family ; the father of the patient is even a very robust, muscular and astive man, the very picture of health and manliness. In addition to this the patient has been, and is still, sur- rounded with the attributes of opulence and rational hygiene. The pre- monitory symptoms were but few, insignificant and of short duration. When at a boarding school in the country the patient was suddenly at- tacked with the most violent symptoms of morbus coxarius, which con- tinued with unabated intensity for five months ; then they almost as abruptly abated, leaving the patient in that deformed state which I have briefly sketched. But the shortening had steadily increased so as to re- quire from time to time a higher heel to his hoot. Even during the 6 months preceding the operation, the increasing shortening of the limb had been observed. He had, however, completely regained his standard of excellent constitutional health, and was as active as before. There were no local symptoms indicative of continued joint disease. I have not been able to ascertain the cause of the original attack. There is certainly ) pretence of constitutional causation, although the patient does not remember having met with any accident worth speaking of. I, nevertheless, consider myself justified in assuming the same, for the very activity of the patient seems to warrant such a supposition, still more so the violent character of the disease and its rapid course without suppuration. The patient came under my treatment in the spring of this year, and ,jremained four months with me. During this time I have divided sue- 96 cessively most of the abductor muscles ; and at four different occasions, mth the assistance of chloroform, broken down most fibrous adhesions, and by steady extension in the recumbent posture and repeated passive motions, I have succeeded in placing the affected extremity in a rectaogu- lar position to the pelvis, and extended and loosened the still existing fibrous impediments to such a degree as to allow moderate mobility of the articulation. From the high position and pro^iinence of the larger trochanter, it is evident, that the neck of the femur rides upon and is fastened to a new articular facet at the superior and posterior portion of the acetabular mar- gin, where it still remains, and from which position I do not intend to displace it. At the end of the second month I allowed locomotion to the patient, supported by crutches and my first hip apparatus. It was at that time that the photograph (figs, 24 and 5) were taken. You may judge for yourselves of the material changes to- wards improvement which had been effected up to this time. Previous to his discharge, another photograph with the second hip instrument applied, was obtained, (vide fig. 7). In that position the pelvis has resumed its proper level, the extremity stands rect-angularly, within five eighths of an inch off the fioor. The passive motioDS are still continued with due care, and daily lubrications are being made with phosphorated oil, to promote healthful innervation and nutri- tion. The patient is directed to wear the hip instrument night and day until the changes of form and position become per- (Fig. 25.) ° marent, when a heel ^ of an inch higher than that of the other boot, will sufiice to ensure easy gait and locomotion. These changes have been wrought within the shorv period of four months in a deformity and malposition which in former times were con- sidered beyond surgical aid, and this case famishes, therefore, an illustra- tion of the grand progress in orthopaedic surgery. Brooklyn, N.Y., Clinton, corner of Warren steeet. staf oet noi rent occasions, rous adhesions, speated passive • in a rectanga. le still existing mobility of the rochanter, it is bened to a new icetabular mar- not intend to 3omotion to the It was at that I may judge for al changes to. Ich had been , Previous to lotograph with it applied, was n that position iS proper level, rect-angularly, ch off the floor, still continued iibrications are lorated oil, to ion and uutri- i to wear the . day until the on become per- the other boot, period of four mes were con- are, an illustra-