an inflammation of the femoral or the tibial epiphysis. If an acute synovitis ushers in the case, there may be large effusion into the knee-joint and partial flexion. Swelling is usually slight in knee-joint disease. Pulpy degeneration of the synovial membrane occurs; the joint enlarges; the ligaments soften; the skin is oedematous; muscular spasm is marked; the leg is flexed; the bones are displaced backward and outward, the foot being everted ; lameness exists, due chiefly to deformity; pain may be absent, is often slight, and

is rarely severe. When the disease begins in the bone or an epiphysis there are pain, tenderness, lameness, swelling, inability to extend the limb completely, sudden spasmodic muscular contractions, and final involvement of the joint. When an abscess forms, it may destroy the joint very rapidly or it may break externally.

Treatment. In treating

FIG. 64-Sayre's FIG. 65.-Hutchinson's knee-joint disease, employ general antitubercular treat

Knee-splint Applied. Knee-joint Splint.

ment. Apply splints (Figs. 64, 65), extension (Fig. 66), or a plaster-of-Paris bandage, and keep the patient in bed for a few weeks; then permit him to go out with crutches, with a high-heeled shoe upon the sound foot. In cases in which treatment was begun early the disease can often be arrested in from eight to twelve months. If the symptoms do not abate after a number of weeks, or if the condition grows worse and an abscess arises, aspirate and inject iodoform emulsion. If these means fail,

open the joint and perform an excision or an erasion. Some cases demand amputation, which, if the patient's health is much impaired, is to be preferred to excision.

Ankle-joint disease begins usually as a chronic synovitis, but it may arise in the tibial epiphysis. The symptoms are

FIG. 66. Sayre's Double Extension of the Knee-joint (Tiemann).

pain, swelling, lameness, limitation of joint-movements, and atrophy of the calf-muscles. Suppuration often occurs, and sinuses form.

Treatment. The treatment of ankle-joint disease consists in the employment of antitubercular remedies, and of rest by means of splints or plaster. Caution the patient to avoid standing upon the diseased extremity. When suppuration occurs, open, drain, wash out with corrosive-sublimate solution and with iodoform emulsion, and put up the ankle-joint in plaster. When joint-disorganization occurs, perform an excision or an erasion. Some cases demand amputation (Syme's amputation being preferred by some, amputation above the ankle being approved by many). Osteoplastic resection is sometimes advised (Wladimiroff-Mikulicz operation).

Shoulder-joint disease, which is rare in children and is commonest in adults, begins either in the synovial membrane or in the epiphysis. Pain is slight, atrophy of the

deltoid and other muscles is noted, the joint is stiff, and the scapula follows the motions of the humerus. Suppuration is

rare.

Treatment. In treating shoulder-joint disease, employ antitubercular remedies and iodoform ointment. Put on a shoulder-cap, apply the second roller of Desault, and hang the hand in a sling. Maintain rest for at least four months. If an abscess forms, open and drain it. In rare instances dead bone will have to be gouged away. occur. Excision is sometimes required.

Caries sicca may

Elbow-joint disease may begin in the humerus or the ulna. The joint is swollen, its movements are somewhat limited, the skin is usually hot, muscular wasting is pronounced, and pain is generally slight. Pus may form.

Treatment. In treating elbow-joint disease, employ antitubercular foods, drugs, and hygienic measures; iodoform ointment locally; rest by means of an anterior angular splint (Fig. 67) and a triangular sling. If matter forms, open the

FIG. 67.-Stromeyer's Anterior Angular Splint.

joint and drain. Splints are to be worn for from four months to a year. If any considerable area becomes carious, perform an erasion or an excision.

Wrist-joint disease may arise at any age. The joint presents a puffy swelling, loses its normal contour, and becomes spindle-shaped. Hand-movements are impaired, pronation and supination cannot completely or satisfactorily

be performed, the joint is stiff and partly flexed, the grasp is enfeebled, pain may be severe or slight, the skin is usually hot, and muscular atrophy is marked.

Treatment. The essential treatment in wrist-joint disease comprises cod-liver oil, tonics, good food and fresh air, and iodoform ointment locally. Apply a Bond splint and sling or put on a plaster bandage, and maintain rigid rest for from four to six months. Suppuration demands incision and drainage with the maintenance of rest. A moderate amount of caries is treated by drainage and rest. Necrosis demands removal of the sequestra. Extensive caries requires excision.

Septic Arthritis.-This infection is usually due to the staphylococcus pyogenes aureus or to the streptococcus pyogenes which find entrance by means of a wound, by the spontaneous evacuation into a joint of the products of an osteomyelitis, by extension of suppurative inflammation through contiguous structures, or by the blood-stream, as in pyæmia and other conditions.

Symptoms.-The symptoms of septic arthritis are-severe pain, which is aggravated by motion and is worse at night; discoloration, heat, and oedema of the skin; partial flexion of the joint; fluctuation; and marked constitutional symptoms of sepsis. The joint tends to rapid disorganization, and fatal septicemia is very apt to occur. In pyæmic arthritis several joints become infected.

Treatment. The treatment in septic arthritis consists in prompt incision, evacuation, antiseptic irrigation, drainage, antiseptic dressing, and immobilization. Cure is followed, as a rule, by ankylosis, but in cases treated early the joint may be preserved.

Infective arthritis arises in the course of an acute infectious disease (such as erysipelas, typhoid fever, measles, scarlatina, variola), and may be due to pyogenic cocci or to the specific micro-organism of the acute infectious disease.

Joint-inflammation arising in the course, or as a sequel, of an acute infectious disease may or may not suppurate.

Symptoms and Treatment.-If no suppuration takes place, the symptoms of the attack resemble those of rheumatism; if suppuration occurs, the symptoms are identical with those of septic arthritis. The treatment in a non-suppurative case is the same as in ordinary synovitis (p. 395). In a suppurative case, treat as in septic arthritis (p. 411).

Gonorrhoeal Arthritis, or Gonorrhoeal Rheumatism.During the progress of gonorrhoea every rheumatic attack is not gonorrhoeal rheumatism, for ordinary rheumatism may just as likely arise when a man has clap as when he has not this malady. Furthermore, the term is bad, as gonorrhœal rheumatism is not rheumatism at all, but is a septic or an infective disorder of the joints or of the synovial membranes, the infective material being contained primarily in the urethral discharge. This infective arthritis sometimes, though rarely, arises during the height of a gonorrhoea, but is more frequently met with in chronic cases or when the intensity of the inflammation is abating in acute cases. Men suffer from gonorrhoeal rheumatism far more frequently than do women, and the seizure is very apt to recur again and again. In some cases many joints are involved, but in most cases only a few joints suffer. Osler states that the knees and ankles are most apt to be involved in a gonorrhoeal rheumatism, and that this form of arthritis is peculiar in often attacking joints which are apt to be exempt in acute rheumatism ("the sterno-clavicular, the intervertebral, the temporo-maxillary, and the sacro-iliac ").

Changes in and about the Joint.-The inflammation of gonorrhoeal arthritis may be located around rather than in the joint, and especially in the tendon-sheaths. Suppuration is unusual, but it does occur in joints and in tendonsheaths. Cultivation of the exudate may or may not show