When this last condition is subdued, friction with motion (at first passive and then active) should be resorted to in order to promote absorption of the new growths. The former of these is very valuable for superficial joints, and often restores flexibility and perfect shape to the part more rapidly than any other means with which I am acquainted. It should be applied with the bare hand, but a little flour, starch, or oxide of zinc, may be used to protect the skin. Active motion should not be allowed as long as the points above mentioned remain tender. If the disease be in a joint of the lower extremity its use must be still further postponed, and even when first given up to the patient's management should be protected by tight strapping.

I have deferred making mention of a treatment that has been much recommended when the effusion is large in quantity, namely, subcutaneous incision of the synovial membrane; for it has not fallen to my lot to be driven to such a resource. It is founded on the idea that the tension of the sac prolongs inflammation, and there is no doubt that such may be the case when the fluid greatly distends the membrane. A tenotomy knife passed under the skin may be easily made to incise the sac to a considerable extent, the fluid then flows out into the areolar tissue, whence it will be absorbed. If care be taken to exclude air, no suppuration will follow this little operation, and it is quite credible that the inflammation would be more manageable when all tension had ceased. In a case whose symptoms warranted this treatment, I should not hesitate to put it in practice.

Acute suppurative synovitis, whether or not resulting from a wound, requires a few words. It is certain that an opening freely admitting air into the joint cavity will produce suppurative synovitis; but the same disease will follow an injury without wound, and even idiopathic synovitis; while on the other hand all surgeons must have seen cases of wounds into joints, which were not followed by any evil symptom. This partly depends upon the form and size of the wound, upon its rapid closure, and very much upon the state of the person's health at the time. A wide gaping wound into the joint, allowed to remain open, will generally cause the disease; but sometimes a little wound will produce it, however well treated, while often a larger wound will not do so-for sometimes the health is in such a state that

a suppurative inflammation will commence on the slightest provocation-while at other times wounds will heal, and injuries be recovered with marvellous rapidity.

CASE VII. On the 14th March, 1859, I saw H. L., a young woman upon whose knee a boil had that morning been so incautiously incised, that it was feared the joint was opened; the circumstance leading to this suspicion was an escape of synovia. The boil was close to the ligamentum patellæ, close to and running parallel with which was an incised wound, a little more than an inch long, from which synovia oozed, and when the leg was bent flowed pretty freely. This flux proved nothing, since, although rather plentiful, it might be produced by the bursa in this situation. I therefore warmed, oiled, and carefully introduced a thin probe, when it sank at once to a depth clearly showing it to have entered the knee. The instrument was withdrawn, a gutta percha splint placed on the limb, and the wound closed by painting its surface with collodion, and covering it with a piece of soap plaister; the object being not merely to prevent the entrance of air, but also the exit of synovia, which would tend to keep it open. The wound healed without a sign of synovial inflammation.

CASE VIII.—The following case was kindly sent me by my colleague, Mr. Canton.

Henry Short, sailor, ætat 32, was sent to me on the 25th April, 1859.

He came for ulcers about the right elbow, of which he gave the following account:-Three years ago, while at sea between Madras and Calcutta, there broke out on board ship a complaint which he calls scurvy-boils; several of the crew were affected. He had several boils on different parts of his body, the worst being about his elbow, and nearly a fortnight after they had opened into an ulcer, the bone began to get bare. On his arrival at Calcutta he went into hospital, where the sore healed: he says that no bone came away; but in this he must be mistaken.

There is now a large scar, with uneven edges at the back of the elbow, upon which four small ulcerations have again appeared-one in the centre being deep and fistulous. Around this spot the elbow is deformed by a depression which, judging by eyesight, merely appears to result from absence of bone. On examining the part more closely by touch, it is evident that a portion of the olecranon is absent; the part still remaining is attached like a sesamoid bone to the triceps extensor tendon; between that detached piece and the rest of the ulna is an interval which corresponds to the depression above mentioned, and which varies from three-quarters of an inch, when the arm is straight, to one inch and a quarter when it is bent, and even to nearly two inches when the cubit is strongly flexed. In the centre of this space is the fistulous ulcer already described, out of which synovia flows freely. When he alternately bends and straightens the arm, rather quickly, air is sucked into, then driven out of this opening, with an evident impulse; and at the same time the synovial sac is first separated from, afterwards propelled against, the bones of the joint, making a flapping noise like the dry valve of a pump before the water has risen. When he had continued this action some time the joint looked a little swollen, and on pressing it

with the hands air could be expelled from the synovial sac. The man experienced no pain nor any stiffness of the joint, and seemed surprised when told to keep it at rest.

The treatment was simply rest, closure of this opening by adhesive plaister, and the internal use of iodine. The ulcers gradually healed; that leading into the joint hardly slower than the others, because all flow of synovia was prevented. On the 30th May he was well, and about to start on another Indian voyage.

August, 1860. This man has returned: the ulcer into the joint is again open, but no inflammatory symptom has shown itself.

When a wound has been made into a joint, the chances of escaping suppuration are, ceteris paribus, proportioned to the time it remains open; it should therefore be instantly closed against all entrance of air, and kept at rest; the patient must be watched that the first signs of inflammation may be combated. It may be well, particularly if the bowels have been sluggish, to give some mild form of aperient at once, that in case inflammation begin one may have a day's start of it. The opium treatment comes again into consideration, and if now a patient were to come under my care with a wound of an important joint as yet uninflamed, he should probably be kept opiated for several days. I have known the most terrifying looking injuries-the prow of an outrigger run four and a half inches into a man's loins; a knife plunged into the abdomen, so that a wound of the stomach seemed a necessity; area railings run through a thigh-all treated by narcotising-all get well without a bad symptom.* Locally, ice, or at least very cold water constantly renewed, is the very best application.

If inflammation set in, antiphlogistics may be used, but with the greatest caution; we are to expect suppuration, and we must husband our patient's strength to the utmost. I prefer as soon as this action has commenced, to give only salines to calm the fever; to put on poultices; use hot fomentations-do all that is possible to bring on the purulent stage, and its characteristic or suppurative type of fever, then to commence a stimulant and tonic treatment-wine, ammonia, quinine, the mineral acids, æthers, and a strong diet. Now whether or not narcotism have been used, opium will be indispensable on account of the pain,

*The first of these was under the care of my friend Dr. Julius, of Richmond; the second under that of my

excellent colleague Mr. Hancock, to whom I owe many obligations; and the third under my own.

which is atrocious. This stage of traumatic synovitis corresponds sufficiently with a non-traumatic attack which has become suppurative, and the following point in treatment becomes important. If the wound in the joint be small, or if there be no wound, shall the synovial sac be incised to let out the pus; or shall it be evacuated by a trocar; or shall it be let alone?

In a paper read by Mr. Gay before the Medical Society of London (Medical Times and Gazette,' vol. xxiv., 1851, p. 546), that able surgeon recommends free incisions into the joint, on the plea that they allow shreds of cartilage, which may be shed into the cavity, to escape. It is for other reasons that I cordially commend the value of such treatment. Some French authorities, Petit, Boyer, and others, might also be quoted in favour of this plan. A joint once suppurated has lost that sensitiveness to the contact of air which it normally possesses: it is an abscess, and one cause of the great constitutional disturbance produced by the disease, is confinement of matter deep among bones and tough fibrous structures. Therefore, if a depending part of the joint can be in any way reached, it should be widely incised; but the part must be depending. Pus must not be allowed to stagnate and putrify in the recesses of the cavity, or pycemia will be pretty certain. The difficulty of getting at the hip, except by a very deep cut, would render such means inapplicable to that joint. The trocar would be a better method of emptying the cavity; but the greatest caution must be used that no air be permitted to enter.

CASE IX.-Henry Short, ætat 31, came into Charing-Cross Hospital December 20th, 1859, having slipped down on the ice and hurt his knee. By the kindness of Mr. Hancock he is put under my care.

There is synovitis and much inflammatory fever; the swelling fills out the subcrureal bursa very considerably, forces the patella away from the femur, and causes the popliteal space to be much less hollow. There is a tremulousness about this man, and an appearance generally which leads me to consider him a drunkard.

Bed; a straight splint with foot-board, duly padded, at the back of the limb. Bowels constipated: a purge of blue pill and black draught: cold lotion. 21st.-Evidently the accident has affected him: he is over tremulous; slept little last night.

Ordered to take the following pill night and morning:

Cal. gr. ij., Opii gr. ss.

The drops every night :

Træ. Opii mxx.

Four ounces of Gin.

24th.-Better; but little pain in the knee; the tremulousness is gone: asked for more gin: refused. Let him go on.

28th.-Blister above the joint to be dressed with simple ointment. 3rd Jan., 1860.-The joint to be strapped.

10th.-Discharged cured.

We have seen by Cases VII. and VIII. that wounds in joints are not always followed by synovitis; the next shows that traumatic synovitis need not always be suppurative.

CASE X.-Charles Costrell, ætat 22, strong and robust, shoemaker, ran an awl into his knee, 2nd July, 1860; and on the 4th, feeling pain in the joint, came to Charing-Cross Hospital. Mr. Canton, under whose care he came, took the man in and kindly gave over the case to me.

There is considerable synovitis of the knee-joint: the shape of the swelling, the buoyancy of the patella, the heat of the part, and the inflammatory fever, sufficiently attest the fact. Ordered-Bed; wooden splint with a foot-board to the back of the limb; 8 leeches above the joint, a poultice afterwards. Five grains of blue pill to-night and an ounce and a half of compound senna mixture to-morrow morning.

6th. The fever continues; pulse hard, 92; he has not so much pain over the joint, but complains greatly of pain at the back of it; this, he says, was severe in the night and kept him awake. On examining the splint I found that the pads, which I had directed to be put under the popliteal region, had been neglected. I placed two thick pads, one longer than the other, under this part; the smaller one being in the middle, immediately behind the joint; this relieved the pain at once. Ordered to take the following draught every six hours:

7th. He is less feverish and perspires freely; has very little pain in the joint, except at night on a point of the inner condyle, just internal to the patella, and this is sometimes very painful; there is much fluid in the knee-joint. Ordered a blister above the knee, in front, going across the whole lower and fore part of the thigh; to be dressed with simple ointment.

12th. The blister has nearly healed, though it rose well; the pain and amount of fluid both diminished; a blister to be applied below the kneejoint, that is to say, across the head of the tibia, to be treated in the same

way.

16th.--Better: the fluid has much diminished. Cold lotion. 21st. The limb was tightly strapped. Leave off the draught.

23rd. The joint so much diminished that the strapping has to be renewed.

31st. He was allowed to walk with a crutch on the 26th, and two days afterwards a stick sufficed. He now begs to be discharged.