It occasionally occurs that no treatment will check the spread of the suppuration, or the case may only present itself to our notice when the malady is already advanced, and the patient's health broken; when abscesses have formed among the deep muscles in the neighbourhood. In such unfavourable circumstances the surgeon's thoughts at once revert to his knife and his saw, and very frequently these are the only means of saving life. The operations to be chosen and the reason of their choice are the subject of a special chapter; at present we are only occupied in considering how the surgeon shall save a joint, and not how the patient shall lose it. The experience which I have had of the fungous form of strumous disease, and the efficacy of well adapted treatment, convinces me that extensive suppuration and utter loss of health are the only reasons which should cause us to remove the part. The mere presence of sluggish granulations, evidenced by intractable and long persistent tumefaction, is no valid cause for such an operation. All such tissue may be made to consolidate or to be absorbed by the adoption of fitting means.

CASES OF THIS DISEASE.

CASE XXVIII.-George Caverner or Kavanagh, aged 5, a thin, pale child, with reddish hair, a tumid upper lip, and red-bordered eyelids, came to me at the Charing-Cross Hospital 6th October, 1859, with a swelling at the ankle-joint. The boy was in no pain and could walk well, but the mother observed the swelling six days ago; the boy knew nothing about it. He had also a slight strumous ophthalmia of the left eye.

The ankle is swollen; the tumefaction is chiefly visible behind and in front of each malleolus; it extends also, in a smaller degree, as an illdefined band across the front of the joint. It is slightly tender, chiefly in front of internal malleolus.

A splint on the inside of the ankle; two bandages to be used in fastening it, that the limb just above the joint be left uncovered; to this part, i. e., lower end of tibia, a narrow blister to extend from one malleolus to the other five grains of calomel and rhubarb to-night in treacle.

11th.-The blister rose pretty well; the boy's eye looks better. Ordered the following draught three times a day after food:

13th. The boy's eye better, but the ankle much the same; the blister is healed; splint to be fastened on with strapping-plaister; blister across instep just below the joint.

20th. He does not get on as quickly as I should like. The eye is more inflamed again. Repeat the calomel and jalap as before, and after its due action let the following be taken in the form of pill night and morning:

27th.-The eye nearly well; ankle not tender: the joint to be tightly strapped after Scott's method, with Empl. Resina; to discontinue the pill; repeat the iodide of potass and of iron as before.

From this time he progressed continuously to recovery: was discharged from attendance at the end of November.

CASE XXIX.-Jane Shearman, aged 6, a pale strumous child, has been suffering for twenty months from pain and swelling of the left knee, and was admitted into the Charing-Cross Hospital, under my care (through the kindness of Mr. Hancock), December 9th, 1859. The knee is flexed at about a right angle; the joint a good deal swollen, round, and shapeless; the child cries when it is touched and when any attempt is made to move it; the flexors, of course, act against any attempt at straightening; the joint is white, not hot; the thigh and leg are shrivelled.

I drew four lines of linear cauterization, one on each side of the patella, and one an inch behind each of these, and got the limb into a straight position without dividing the tendons; for under the action of chloroform the contraction of the flexors was found to be voluntary or emotional, as was suspected. On recovering from the chloroform and the sleep that came on afterwards, the child expressed no sense of pain, but sat up and began to play with other children in the ward and with toys.

On the 3rd day the skin between the cauterized lines looked red and inflamed; on the 5th some separation at the edge of the charred slough had occurred. The horny portion gradually separated, and on the

1st January, 1860, the marks left were simply clear lines of ulceration with small conical granulations; they were dressed with zinc ointment and gradually contracted.

30th. The knee was much diminished in size; all the scars of the ulceration are healed, except the one next the patella on the inner side; for some reason that I cannot fathom, this ulcer opened out wider than the others; it is, however, contracting, and discharges very little. I strapped the joint pretty tightly, bandaging the limb upwards from the foot.

Feb. 15th. The line of cauterization healed a week ago; the knee is much smaller; it is kept tightly strapped. The child is allowed to be up, and to move about by means of a stool and the sides of her bed.

March 6th. The child was nearly well, and her mother insisted on taking her out, though I should have wished to have kept her another week; passive motion had been used, and the joint promised to be nearly as useful as ever.

CASE XXX.-Marianne Taylor, aged 12, a dark-haired girl with coarse features, came to me at the Charing Cross Hospital 23rd November, 1858,

with a diseased elbow which, she says, has troubled her more or less since she was three years old. At that time she fell down and hurt her arm: her mother took her to St. George's Hospital. After about three weeks she seemed well; but, four months afterwards, the elbow began again to swell, and she was taken back to St. George's Hospital; then to some other places: matter came away, and a sore continued discharging till she thinks she was about five years old, and it was much longer before she could use the arm. She has had the present relapse for nearly two years; she is a boot-closer, and could do her work till six weeks ago; now she wears her arm in a sling.

The elbow is much swollen; the whole being a shapeless, conical mass, concealing all the shape of the bones, and without distinct boundary between the swelling and the rest of the limb; both upper and forearm are much wasted. The tumour is white, soft, pseudo-fluctuating, perhaps a little hot the scars of old sinuses are to be seen below the situation of the outer and inner condyles; there is a very soft place near the latter which is likely to suppurate. She has no starting pains, no tenderness of the joint-surfaces; the arm may be flexed a little way producing slight pain and no grating.

:

STRUMOUS SYNOVITIS OF ELBOW.

Ordered splint of gutta-percha to be fitted to the outer side, and a little in front of the arm, so as to leave the outer condyle bare; it was to be cut in a rectangular form, to extend from the axilla to the hand, allowing this to be in a position between supination and pronation; to take two tablespoonfuls of the Mistura Potassii iodidi composita three times a day.

27th.—Mr. Short was good enough to administer chloroform, and I made two long lines of cauterization from two or three inches above the bend of the elbow to the same distance below, one a little behind the outer, one a little in front of the inner condyle, taking care to draw this latter over the softened portion of tissue above referred to. The iron, quite white-hot, was passed twice through each line.

30th. The girl had gone home when she recovered from the chloroform and was in no pain; to-day the elbow smarts a good deal: cold lotion.

5th Dec.-Lines of ulceration begin to separate the eschar from the rest of the tissue; the skin has a bright rosy blush, but she says the pain is not much.

12th. The sloughs have disappeared. On the afternoon of the day she came to me, about a teaspoonful of pus flowed out of the middle of the inner eschar; it was in order to lay open this suppurating point that I drew the line over it, for by such means I hoped to procure the rapid filling up of the cavity; this has perfectly succeeded, the tissues in that part are as sound as elsewhere: the tumefaction has very much decreased. Dress the sores with strips of lint and nitric oxide ointment.

19th. The wounds begin to contract and the swelling is still decreasing ; the compression from skin contraction is evident; the ointment continued, and before putting on the splint a bandage was applied tightly and smoothly.

26th. The wounds healing; there is now little enough discharge to allow the application of strapping.

Jan. 10th, 1860.-The strapping has been kept applied and the arm is much diminished. Continue.

24th. The elbow about the same size, on measurement, as the other, though it looks bigger on account of wasting of the limb; no pain on pressure anywhere; more particularly no tenderness between outer condyle and head of radius. Passive motion carefully employed for about ten minutes, and the arm replaced on the splint; the biceps somewhat contracted.

30th. The arm was subjected to passive motion every other day, and the splint retained for ten days after the above date; since the 20th a bandage simply has been applied and the arm kept in a sling. She has now very tolerable movement of the arm. Bandage to be discontinued; the elbow to be held under the stream of a tap every morning; throat a little sore. Since she has been attending the complexion is much improved; to discontinue the compound iodide mixture, and to take instead an equal quantity of Quinine Mixture three times a day.

This patient went on very well; she came backward and forward occasionally, rather to procure a repetition of her medicine than for the sake of anything being done to the arm. She had, in March, no other appearance of disease than the scars of the cautery in thin red lines, a little

thickening, detectable by touch, about the joint, and inability to get the arm perfectly straight.

CASE XXXI.-Catherine Dogget, aged 18, strong, stout, came to me at the Charing-Cross Hospital 9th May, 1858, with diseased knee.

The swelling first came on, with some slight pain, eight months ago; she was in the country at the time and was able to rest; she did not put the foot to the ground for a month; the pain went off, but the swelling did not altogether disappear. She attributed the disease to a slight sprain.

The knee was, when I saw it, a good deal swollen; the swelling is soft and gelatinous, with false sense of fluctuation, round, concealing the shape of bone, &c.: she has some pain in it, and a spot on the inner side of the patella is painful and tender. A gutta-percha splint to the outside of knee; a blister to the inner side and above it; to be followed in three days by another below the joint.

23rd. The knee is not better: the pain at the inner condyle is, if anything, increased. Chloroform administered; actual cautery applied in two lines on each side of the joint.

23rd June. The cautery lines all but healed; for the last week the bandage has been very tightly applied and she finds relief: the joint was strapped.

30th July. The joint is still strapped: it is now very nearly the same size as the other, though most anatomical points, as the ligamentum patella, and the depressions on both sides, are not marked as they should normally be. Ordered rubbing night and morning with flour or other inert powder.

August. This patient perfectly recovered.

CASE XXXII.-I was asked by Mrs. T. to see her daughter, aged 17, 30th September, 1859, with a diseased knee of four years standing. She has dark long hair; a white transparent skin; very white conjunctivæ, long dark lashes. Her health is a good deal broken by long confinement.

At school, rather more than four years ago, her knee became painful; she may have hurt it, as she was very fond of running and other exercise, but does not remember it. When the knee became painful it swelled.