The following case was related in illustration:-A man, aged thirty, had been the subject of gonorrhoeal discharge for some months, when he was seized with pain in his right elbow and left wrist; ulceration of the cartilages subsequently took place; in six months he recovered with partial anchylosis of the joints, and was then free from discharge. Here was a case of joint affection, of a severe kind, following a purulent discharge from the urethra; here apparently there was no inflammation of veins; here was no introduction of pus into veins, and yet it bore a strong analogy to cases where one or other was supposed to have been the case. What, then, was to be the explanation of the secondary inflammation in this case? It could not have been merely a coincidence, for gonorrhoeal rheumatism was of no very uncommon occurrence, and this appeared but an aggravated form of it. He (Mr. Bullock) had been told by Mr. Lane that he had often seen an attack of rheumatism follow a collection of matter in a part which the patient had refused to have evacuated; and he had himself often noticed that patients suffering from phagedænic and sloughing sores had suffered severe pain in their joints. He would endeavour to explain the pathology in this way: That there were certain changes going on in the mucous membrane of the urethra, resulting in the secretion of pus. From some cause or other this process of secretion was interfered with; the fibrin, which was about to be formed into pus-globules, underwent a retrograde metamorphosis, and was carried on in the circulation, and consequently caused like actions to go on in the accompanying fluid. This resulted in an effort to get rid of the morbid and contaminating material, which was endeavoured to be done by some secreting organ, which either from its structure or function, or some other cause, was predisposed to take on morbid action. Among secondary affections following operations, and not fatal in their results, might be mentioned ulceration of the cartilages of joints, chorea, serous effusions, syncope, vomiting, and rigors. In illustration the following cases were read: A man aged forty-six, the subject of a severe stricture of twelve years' duration, had No. 2 gum-elastic catheter passed and retained twenty-four hours, which was followed by ulceration of the cartilages of the shoulder-joint, and the formation of abscesses in its neighbourhood. A girl, aged 9, was operated on for the necrosis of the tibia. The operation was followed by phagedæna of the wound and chorea. A man, aged 42, had Holt's dilator used for stricture of the urethras it was followed by shivering and effusion into the sheaths of the tendons on the dorsum of his hand. The first and last of these three were cases of synovial inflammation following the introduction of instruments along the urethra into the bladder. Here, as in the former cases, was inflammation set up in a distant part, of the same character, after injury to the urethra, where there was a secretion of pus; here the same explanation as before might be given, the constitutional symptoms and long continuance of the affection clearly showing that there was a blood-poison operating and keeping up the action. The other was a case of extreme interest-viz., chorea co-existing with phagedænic ulceration of an incised wound; in this case the amount of morbid material was probably small, and exerted its influence on the nervous system, and was finally eliminated by the natural emunctories of the body. Of secondary affections followed by fatal results might be mentioned-puerperal fever, purulent depositions in various parts, pericarditis, pleurisy, peritonitis, &c.; and in all the cases the author had seen, there was a marked rapidity of supervention of fatal symptoms, and from the first but small hope of recovery. How great, then, would be the boon could some conclusion be arrived at as to the modus operandi of the exciting cause of this disease. The following cases were then related:-A man, aged sixty-nine, had the operation of lithotomy performed; the second crushing was followed by purulent deposit in both knee-joints, and death on the fourth day. The post-mortem examination showed coagula in, and a slight thickening of, the prostatic plexus of veins; the iliac veins stained, and the venous system generally gorged with blood; ulceration of the cartilages of both knee-joints, and injection of the synovial membrane of both hips. A man, aged thirty-eight, was operated on for stone by lithotomy. On the seventh day he had secondary hemorrhage from a large vessel which had been wounded and tied during the operation; this was followed by inflammation of the right arm, great constitutional disturbance, and death on the fourth day from the occurrence of the hemorrhage. At the post-mortem examination, the cellular tissue from the wound to behind the rectum was found infiltrated with pus, and a circumscribed abscess in the levator ani muscle; the cellular tissue of the right arm and

forearm saturated with sero-purulent fluid.-A man, aged thirty-four, had the operation of perineal section performed for stricture of the urethra; it was followed, on the next day, by rigors, and subsequently by pericarditis and pleurisy, and death on the tenth day. Post-mortem examination showed recent pleurisy, adherent pericardium, purulent deposit in the lungs, and deposits under the capsules of the kidneys; sub-arachnoid effusion, small coagula in, and slight thickening of, the prostatic veins, the remainder healthy.-A woman, aged forty-two, was operated on for ruptured perineum. She had sloughing of the wounds, and died of pleurisy and peritonitis. The uterus was found enlarged and inflamed, and pus oozed from the Fallopian tubes; there was recent peritonitis and pleurisy. Large quantities of opium were given in this case after the operation.—A boy, aged sixteen, had chorea following an opening made in the urethra through the perineum, of which he died. The autopsy revealed an abscess between the rectum and bladder, and another behind the pubis, and exposed bone and fibrinous vegetations on the mitral valve.-A boy, aged twelve, was seized, four days after a blow on his left leg, with pericarditis, pleurisy, and pneumonia, and died in less than forty-eight hours. The post-mortem examination showed purulent deposits in the right lung; in the substance of the left ventricle of the heart and in the kidneys recent pleurisy and pericarditis; pus under the periosteum of the tibia and femur.-A woman, aged forty-six, had an abscess in the palm of her right hand, following a wound with a rusty nail. It was opened, but matter subsequently formed at the back of the hand; this was let out by incision, but the patient died of secondary deposits in her knees. No inflamed veins were detected.The last set of cases were interesting from the variety of causes producing the affection, and the number of different parts affected with purulent deposition; their inamenability to any kind of treatment. There was also to be noticed the small amount of pain felt by the patient, even when an important organ was affected. Could it be the extreme rapidity with which the vessels were relieved by secretion, thereby lessening the amount of distension of parts, and consequent pressure on nerves?

Pathology and Treatment.-By nearly all writers on the subject, Mr. Bullock said, the greatest prominence had been given to phlebitis, which had been unhesitatingly given as the primary cause of the affection; more difference of opinion had existed as to the mode in which the purulent depositions in various parts take place. Mr. H. Lee had been the first to throw any doubt on the importance of phlebitis as the primary cause of the disease, but rather considered it (the phlebitis) to be caused by the irritation of morbid material introduced into the veins. It appeared to the author that, taking into consideration that there are cases of undoubted "purulent infection" in which there is little or no evidence of inflamed veins, we must look further for the cause of this disease, though it must be acknowledged that phlebitis was a very frequent accompaniment of it and was caused by it; and moreover he thought there was no doubt that the poisonous matter which lights up the disease circulated in the veins, and consequently might be an exciting cause of inflammation, but that inflammation of the veins might be only a portion of the general inflammation existing in the part first affected, it being propagated along them to a distance by their continuity of structure. He took the same view of this disease as of typhus or cholera, or any other disease of that kind: that as these were the result of a poisonous matter circulating in the blood, so was this. He was supported in this by the fact that puerperal fever acts very often as any other epidemic disease, and that it (purulent infection) was most prevalent in hospitals and places where large collections of people were. He considered that the fibrin which was about to form pus in a wound or other part, from some cause, either atmospheric or local, did not do so, but it was carried on in the circulation and underwent a retrograde metamorphosis; that on reaching some secreting organ there was a tendency to throw off the morbid material; the unhealthy fibrin then took on a progressive metamorphosis, and underwent that degree of development it was about to do criginally, and so formed pus; that in the case of joints it was shown by Dr. Alderson, in his Lumleian Lectures for 1853, that the structure and distribution of the bloodvessels were peculiar, there being a firm and unyielding tissue, in which, when the blood vessels, excited by morbid material circulating in them, became distended, a certain degree of stagnation took place; then was the time for changes to take place, there being already a tendency to form pus; it was done there. In proof of the theory, the small quantity of pus introduced into the veins, and the extent and magnitude of the symptoms produced,

were to be looked at; that there must be some process of development going on in order that the morbid material might be distributed all over the vast area of the circulation. The treatment then must be directed to interrupt and destroy the process of morbid development which was taking place, and to check undue action in those parts in which it had unhappily taken place, and to evacuate pus if possible as soon as formed.-Lancet, May 28, 1853, p. 501.

70.-ON ANCHYLOSIS.

From a Paper headed "Berlin,-Its Medical Institutions, &c." By Dr. WILLIAM HALES HINGSTON. [In true anchylosis there is no motion whatever, the bones having grown together; but in false, the motion is diminished but not destroyed. Cooper remarks, "No attempt should be made to cure, though every possible means should be taken to prevent a true anchylosis." Dr. Hingston observes:]

With such authority before us, and the authority of many more I might quote, it would require no small amount of courage to interfere with what has been designated a favourable termination," "a desirable termination ;" and a surgeon who would undo this wise provision of nature, might be pronounced reckless and bold. I confess that such would have been my own opinion had I read, and not seen, the treatment-the successful treatment-of true, and in many cases long-standing, anchylosis, by breaking up the callus. This mode of practice is not novel. It was tried many years ago in France, but the result of these experiments was such as to discourage others from repeating them. Violent inflammation of the joint, and the most disagreeable consequences, generally followed; and the patient was left in a worse condition than previous to those experiments. But the French erred greatly. Instead of breaking up the callus gradually and cautiously, they restored the perfect flexion and extension of the limb immediately, and then kept up the motion of the joint, in order to free the condyles from their abnormal adhesions. As already remarked, the consequences were frequently very serious. The majority of surgeons would not follow the example, and writers on surgery only mentioned this mode of treatment in order to caution the professiou against adopting it.

The practice so successful under Langenbeck, and which has given rise to these remarks, consists in breaking up the callus certainly, but in a manner very different to that employed by Louvrier. The patient is placed upon his back, and chloroform administered until complete anesthesia is induced; until, in fact, the muscles cease to offer any resistance. If the anchylosis be of the knee (the most favourable joint for the operation), an assistant, or assistants, fix the pelvis, and the surgeon commences gradual flexion, if the joint be in an extended state, or extension if in a flexed state. The force to be employed must be regulated by the surgeon himself. In cases of many years' standing, the force required, as might be supposed, is considerable; sometimes the whole weight of the body is necessary, but it must always be applied with care. When the callus yields to the external force, the amount of flexion is preserved until the next trial, the limb being exercised, passively, during the interval. A great degree of flexion is not to be desired at once; and the more cautiously and patiently the limb is managed, the less danger of violent reaction, and the greater probability of success.

Indeed, this constitutes the great difference between the treatment of Louvrier and that of Langenbeck, or between failure and success. When managed with due care, the inflammation set up is very trifling, indeed seldom sufficient to retard the cure. Frequently no reaction is perceptible. Every two or three days the patient is again subjected to the same treatment. Sometimes a couple of months are necessary to restore the functions of the joint perfectly, but three or four weeks are frequently sufficient. Although many years have elapsed between the occurrence of the anchylosis and the attempt at restoration, yet in most cases the callus may be broken up, and the integrity of the joint restored. It is absolutely requisite, however, that the patient should exhibit no tendency to scrofula, and this the more especially if the anchylosis be the result of scrofulous inflammation or ulceration.

From the want of exercise of the joint, the limb is usually much smaller than the sound one. Sometimes almost total atrophy of the muscles is the consequence, but a

short time suffices to restore them to their original volume. In concluding these remarks, I feel perfectly justified in supporting the claims this mode of treatment has to be admitted among the regular operations of surgery. And as anchylosis, as a result of disease of, or injury to the joint, is unfortunately of frequent occurrence, any mode of alleviating the subjects of it should obtain a fair trial, especially when supported by experiments. -Glasgow Medical Journal, July, 1853, p. 178.

71.-ON THE TREATMENT OF CONTRACTIONS AND ANCHYLOSIS OF THE KNEE AND HIP JOINTS, BY FORCED RUPTURE.

By DR. PHILIP FRANK, Manchester.

[After making some general remarks, Dr. Frank describes the method practised by Mr. Langenbeck, since 1847, the knee-joint being the one supposed to be affected]

The patient is placed on his back, and put under the full influence of chloroform; as soon as the muscles become entirely relaxed, the patient is turned round on his belly; an assistant holds the head in a raised position, to prevent respiration being impeded, and to facilitate the further inhalation of chloroform, if necessary. The patient must be so placed, that the patella of the bent knee rests on the anterior margin of the operating table. The pelvis is fixed by the hands of assistants. The operator then clasps with one hand the femur just above the popliteal fossa; with the other, the leg, just above the ankle, and by alternate flexion and extension, practised with more or less power, according to the nature of the case, restores the mobility and the normal position of the joint. A loud crepitus attends the rupture of the adhesions. Should the strength of one hand of the operator prove insufficient, the femur is held down by an assistant. The operator clasps the leg with both hands, and produces, either by strong gradual pressure, or by sudden jerking movements, the rupture of the more powerful impediment. Even firm osseous bridges are thus made to yield with a loud snapping sound. This was once, in a case of undoubted osseous anchylosis, so loud as to cause the mother of the patient, who was sitting in an adjoining room, to swoon. If, in course of the operation, the tibia threatens to luxate backwards, and particularly, as is often the case, a consecutive subluxation is already present, especial care must be taken to support the joint by pressure on the posterior surface of the upper end of the tibia. Still, luxation is often unavoidable, its mechanism depending on pathological conditions of the part, which art is unable to change. We refer to those cases where, in consequence of large defects of the inferior and posterior surfaces of the condyles of the femur, consecutive subluxation has supervened during the course of the inflammatory disease. A perfect luxation is in these cases more probable during the violent forced extension, if the patella is so firmly anchylosed with the femur as to present an invincible impediment to the pressure of the anterior surface of the tibia against its inferior margin. The tibia is often compelled to describe a circular motion backwards, the centre of which is situated there, where tibia and patella come into mutual contact.

These luxations of the tibia backwards form complications the more unpleasant, because the conditions under which they originated are the same that form serious impediments to the re-position; and if the re-position were to succeed, to maintain it. It is not possible to lay down any rule whether the joint is to be extended at the first atteinpt, or whether this is to be effected by repeated operations. Alarming tension of the skin, which, after long suppurating disease of the joint, is often firmly attached by cicatrices to the parts beneath, renders it judicious, at the first attempt, to effect only a certain degree of extension. If we have reason to believe that the osseous epiphyses are diseased, and if the resistance during the extension is of any magnitude, considerable caution is called for, as fractures are to be apprehended. Here, also, it would be more judicious to effect perfect extension by repeated operations. According to the practice of Mr. Langenbeck, carious and necrotic processes in the epiphysis need not deter from practising forced extension in a cautious manner. In young individuals this is a matter of the highest importance; for, during the long space of time too often necessary to the cure of these processes, atrophy of the XXVIII.-11.

extremity can ensue, thus causing disproportion of the limbs. Add to this, the contraction can increase, and that the longer the abormal position of the joint is maintained, the more serious and considerable alterations of the parts may supervene. Nor does the alteration of the abnormal position of the joint appear to be devoid of influence in effecting a more rapid cure of these processes. This favourable influence can, with some certainty, be expected, where ulcerative processes supervene on those parts of the epiphysis which, by the abnormal position of the joint, are exposed to an undue degree of pressure. The tibia, in cases of contractions of the knee-joint, being generally more or less in a state of abduction, the external condyles of the tibia and femur are thus exposed to a strong mutual pressure, carious processes in either one or the other are frequently the result, and in these cases the beneficial results of meliorating the false position are most obvious. A short time since we saw a case in the private practice of Mr. Langenbeck, where, in addition to a contraction and spurious anchylosis of the knee-joint, there was a large abscess in the external condyle of the tibia. This disease of the bone had persisted a long space of time, in spite of every treatment; but the joint having been stretched without any evil consequences, a remarkable melioration took place.

But extreme caution is necessary in cases of central necrosis, so often found to extend from the inferior part of the diaphysis to the epiphysis of the tibia or femur, and often communicating with the cavity of the joint itself. The only case among 150 of anchylosis treated by Mr. Langenbeck by forced rupture which terminated fatally, was a case of this kind. We shall afterwards speak of this case at large.

In our dissertation on contractions and anchylosis, we have expressed our full approbation of the opinion first promulgated by Bonnet,—viz., that it is not only justifiable, but even strictly indicated, to stretch a contracted joint, although inflammatory symptoms may still exist. The theoretical presumptions by which this practice is vindicated are too well known to the profession to need any further discussion. It is a practice which has been crowned with the most eminent success, as all those conversant with the works of Bonnet are aware of. A most brilliant case of this kind, which occurred in the practice of Mr. Langenbeck, is subsequently related, which will testify more forcibly in favour of the proposition we advance than the most eloquent arguments. This practice is, of course, contra-indicated if the organism of the patient is in an advanced state of debility, where a dangerous and local re-action might be apprehended. According to the experience of Mr. Langenbeck, a still existing chronic-arthritic process can alone be regarded as an absolute contra-indication. If this process has terminated, contractions of the joint can be successfully treated by forced extension. The deep alterations known to be produced on the articular surfaces by the chronic-arthritic processes do not permit us to expect the restoration of the normal functions of the joint.

It will be no matter of surprise, that forced extension being practised under the precautions enumerated, we have no account to give of serious accidents having supervened during the operation. The skin was never ruptured. Only in one case superficial excoriations were observed in the popliteal fossa. We never saw the popliteal artery ruptured as it was by the machine of Louvrier, nor was ever one of the large nerves lacerated. Only once after forced extension of an anchylosis at an acute angle, anaesthesia supervened in that part of the skin supplied by the saphenus major nerve. In a short time, however, the normal sensibility returned. Nothing more serious than a distension of the nerve can therefore be surmised. Where a subluxation of tibia backwards existed before the operation, it of course became more evident after extension had been performed. Only in two cases, one of which occurred in the Royal Surgical Clinic, the other in the private practice of Mr. Langenbeck, the luxation was rendered perfect. In both of these cases, it was impossible to detach the anchylosed patella from the external condyle of the femur. All the injuries produced by the operation being subcutaneous, the re-action after a proceeding apparently so dangerous never attained a serious character. Of constitutional symptoms nothing but a slight febrile irritation is on record.

As far as local action is concerned, in most cases nothing but a superficial reddening was observed. In some cases a slight inflammatory infiltration of the parts surrounding the joint took place; in others, small sugillations were noticed. A suppurative phlegmon was never remarked. These symptoms quickly yielded, in all cases, to the employment of cold applications. Violent pains in the distended