only one bone is broken displacement is slight, there is severe pain on motion and pressure, and crepitus can generally be obtained. A simple fracture of a metatarsal bone is dressed in an immovable dressing for four weeks.

Fractures of the phalanges of the toes are due to direct force and are often compound. They may require immediate amputation.

Treatment. In a compound fracture where amputation is unnecessary, drain with strands of catgut for forty-eight hours and dress antiseptically; at the end of this time apply over the bichlorid gauze a gutta-percha or a pasteboard splint extending from beyond the end of the toe to well up upon the sole of the foot, and fix the splint in place with a spiral bandage of the toe and instep. The splint is to be worn for four weeks. In a simple fracture fasten the injured toe to an adjacent toe or toes by a plaster bandage to be worn for three weeks.

3. DISEASES OF THE JOINTS.

Synovitis is a primary inflammation of the synovial membrane alone. If other structures besides the synovial membrane are involved, the condition is known as "arthritis." Two forms of simple synovitis exist-namely, acute and chronic. Some surgeons speak also of subacute cases.

Acute Simple Synovitis.-The causes of acute simple synovitis are contusions, sprains, twists, and overuse. The causative influence of exposure to cold or damp has been much debated. It seems probable that in some cases cold produces vasomotor paresis of the vessels of the synovial membrane, a condition which may eventuate in inflammation. The membrane is red and swollen and the joint contains an excess of turbid fibrinous fluid. If the inflammation advances, arthritis arises and sometimes blood is effused.

Symptoms.-The symptoms of acute synovitis are—pain, which is increased by motion of the joint, by pressure upon the articulation, and by a dependent position of the limb, and which is worse at night. Pressure upon the cartilage does not cause pain, but friction of the synovial membrane at once develops it. The patient places the limb in the position which gives the greatest ease, and in this position the part becomes more or less fixed. A fluctuating swelling is noted, most marked between the ligaments, which swelling bulges out the synovial area and hides or obscures the articular heads of the bones. The swelling is due early to

extensive secretion of synovia, and later to effusion of liquor sanguinis. Bulging takes place at points where the capsule is thin, and at such points fluctuation may be detected. Fluctuation in the elbow is sought for posteriorly. Fluctuation in the knee is sought for on either side in front. A large effusion in the knee floats the patella up from the condyles. A small effusion in the knee can be detected by Fiske's plan; that is, cause the patient to bend forward at the hips, resting each hand on the front of the corresponding thigh. The anterior structures of the joint are relaxed, and, by tapping the patella, even a small effusion can be discovered. The skin over the joint is rarely reddened, but feels hot to the hand of the observer (over more superficial joints, but not over shoulder and hip); the joint is partly flexed; fever exists, varying in degree with the size of the joint, the acuteness of the attack, and the nature of the cause. Suppuration rarely follows simple synovitis, but if it does, rigors occur, there is a septic temperature, and the joint soon gives evidence of containing pus (periarticular edema). Traumatic synovitis without infection tends toward cure without suppuration if the patient is healthy, and after it ankylosis is rare.

Treatment. In treating acute synovitis immobilize the joint. In severe cases place it in such a position that the limb will still be useful even if ankylosis occurs. In mild cases we can immobilize in the position of rest (semiflexion), apply leeches, use the ice-bag or the Leiter coil, and follow the cold by lead-water and laudanum. After a day or two apply gentle pressure, intermittent heat, and iodin and ichthyol. If the effusion is very great and persistent, and pressure, astringents, and sorbefacients fail, aspirate with antiseptic care. If effusion recurs, apply a plaster-of-Paris dressing or use flying blisters and massage. A rubber bandage is often useful toward the termination of a case.

Chronic Synovitis.-Chronic synovitis follows acute synovitis or it may be chronic from the start. The synovial membrane looks nearly natural, but is edematous, and the joint contains an excess of fluid. If the quantity of fluid is large, the patella floats up and the disease is called "hydrops articuli" or "dropsy." In prolonged cases the synovial membrane is thickened in some places, softened in others, and is often adherent, and the villous processes of the synovial membrane are hypertrophied. If the membrane becomes extensively softened (pulpy degeneration), the softened areas bulge and suppuration eventually occurs. In the

knee-joint a traumatic synovitis is sometimes linked with inflammation of the semilunar cartilages. Roux tells us that this inflammation may be produced by a squeeze, a twist, or a direct force, but a squeeze is the common cause. Hyperextension of the knee may squeeze the cartilage, and so may attempting to rise from a stooping posture. If this injury has taken place, the condition of disability will be prolonged. Symptoms. In chronic synovitis pain is absent or is only present during exercise or from pressure, and is slight even then; there is some limitation of movement; passive motion may develop creaking or crepitus; fluctuation is apparent; there is atrophy in the muscles about the joint; and the hypodermatic needle will draw out a viscid, straw-colored or bloody fluid.

Treatment. For hydrops use rest and pressure (a Martin rubber bandage or, better, a plaster dressing), massage, douches, frictions, passive movements, and flying blisters. Painting the joint with iodin and spreading over it blue ointment, and inunctions with ichthyol, may do good. The actual cautery is a valuable expedient. Aspiration and the subsequent use of a plaster-of-Paris bandage may be tried in some cases. Some surgeons advise aspiration, washing out with salt solution, injecting a 5 per cent. solution of carbolic acid, and immobilizing. Incision and drainage constitute a radical but proper plan. If pulpy degeneration exists, perform an excision or an erasion. If pus forms, incise at once and drain. Internally, treat any existing diathesis and give good food, tonics, and stimulants. Chronic synovitis is often greatly benefited by the use of a hot-air apparatus. The affected part is placed in the apparatus every day, and is subjected to a temperature of from 250° to 300°.

Arthritis. By this term is meant not only inflammation of a synovial membrane, but also of other structures composing and surrounding a joint. It may follow a traumatic synovitis; it may be due to pus organisms, to tubercle bacilli, to infectious diseases (gonorrhea and typhoid fever), to rheumatism, to gout, to syphilis, and to lesions of the spinal cord. Arthritis may be either acute or chronic.

Tubercular Arthritis (White Swelling; Strumous Joint; Pulpy Degeneration).—Pathology and Symptoms.-The exciting causes of tubercular arthritis may be strains, blows, twists, or cold. The primary infection with tubercle bacilli is usually in the bone, though it may be in the synovial membrane, the joint-capsule, or the structures about the

1 Gaz. des Hộp., No. 125, 1895.

joint. If the primary infective focus is in the bone, a portion of the cartilage is destroyed and the joint is opened, or a sinus forms and perforates the synovial membrane. When tubercular inflammation attacks the synovial membrane granulation-tissue is formed, and the capsule and periarticular structures soon become involved in the process; the parts thicken and soften from caseation, and they may be covered with tubercles, though but little fluid is usually effused into the joint. Some few cases present large jointeffusions. In the ordinary form of arthritis there occurs what is known as "gelatiniform degeneration;" the embryonic tissue is formed in large amount as fungous growths; the structures are markedly edematous and softened; the relaxed ligaments yield under pressure; the natural contour of the joint is lost, and it becomes spindle-shaped; all the structures, articular and periarticular, are glued into one mass; the skin about the joint is white, thick, and adherent, and in it one or more large veins are seen; fluctuation or pseudo-fluctuation is noted when caseation has occurred; pain is not often severe, but it can usually be elicited by certain motions or by firm pressure (but the pain will always be severe when the epiphysis is involved); the temperature of the part is somewhat elevated; deformity results from destruction of bone, cartilage, and ligament, from muscular spasms, and from the habitual assumption of certain attitudes to secure relief from pain; there is soon impairment of jointmotions. When the products of a tubercular arthritis cascate, the thick liquid seeks exit by forming sinuses from which caseous pus runs. If a sinus becomes infected with pyogenic cocci, and the joint itself becomes their prey, acute suppuration arises in the joint, and constitutional involvement is pronounced and perilous to life.

In pannous synovitis a large effusion is formed, there is but little granulation-tissue, though the tubercles are present in large numbers, and the ligaments and structures about the joint are slightly or not at all implicated. The diagnosis early in a case is difficult, often impossible, and the prognosis is grave. In only a very few cases, even when recognized early, is a cure obtained without impairment of joint-function. The best that can usually be accomplished is a cure with more or less ankylosis, fibrous or bony; but often ankylosis is complete. Long after the disease is apparently cured, it may break forth anew. Tubercular lesions may arise in a distant organ, or general tuberculosis may occur. Cascation is apt to produce severe constitutional disorder.

Infection by pus organisms gives rise to grave danger of septicemia. Death is not unusual from exhaustion, from septicemia, from disseminated tuberculosis, from tubercle in an important organ, or from amyloid disease.

Treatment.-Constitutionally, the treatment is directed against the tubercular diathesis. Locally, rest is of the first importance, and it is maintained for many weeks, it being obtained by splints, by a plaster-of-Paris bandage, or by extension appliances. Bier's plan of inducing congestive hyperemia may do good (page 156). Aspiration can be used for fluid accumulations. Caseous masses are often let alone, or an aspirator is used and the joint drained, washed out with boiled water, and injected with an emulsion of iodoform and glycerin (10 per cent.). Injections of balsam of Peru or of iodoform emulsion about the joint once a week are efficient in some cases. If these means fail, if the patient gets worse, or if the condition of the sufferer renders dangerous the prolonged conservative course, then operate, removing the entire diseased area by erasion, by excision, or by amputation. Always remember that an incomplete operation, a partial removal, is worse than no operation, as it opens the portals to systemic infection, and may be responsible for a general tuberculosis, septicemia, or pyemia.

Tuberculosis of Special Joints.-Tuberculosis of the Sacro-iliac Joint (Sacro-iliac Disease).—This is an uncommon affection, and is especially rare before the age of fifteen. The disease may begin in the joint, may arise in adjacent bones, or may result from a cold abscess burrowing into the joint. In some cases it is associated with extensive disease of the pelvic bones. The disease, if undetected, may lead to dissemination of tubercle, to abscess, even to death.

The

Symptoms. Are often obscure. The disease is usually confounded with vertebral caries or hip-joint disease. patient limps on walking, but can stand on either leg; there is pain in the sacro-iliac joint, about the hip, and down the thigh; tenderness is manifest on pressure over the joint and on pushing the ilia together; there is fulness over the sacroiliac joint; but no flexion of hip unless iliac abscess exists.'

Treatment-Rest in bed for months, using also a felt case for pelvis. Counter-irritation by blisters and actual cautery. In some cases injection of iodoform; in others incision and curetting.

1 See A. G. Miller, Edinburgh Med. Jour., May, 1895.