superficial joints the diffuse, fusiform enlargement, which in addition to the other symptoms almost always portends chronicity and ultimate serious impairment of function. No class of surgical cases is as trying to the surgeon's time and patience, you may spell the word both ways. If he is to

be adequately paid for his services the patient's pocket-book must also suffer, but-Ah! How frequently are these cases among the dispensary class, and how rarely among the opu lent. And this circumstance has a direct bearing upon the prognosis, for however altruistic the surgeon there soon comes a limit to his possible accomplishment, unless generous means are at his disposal. In the vast majority of such cases it is absolutely useless to start with any method of treatment without impressing upon the patient, parents or guardian the extremely chronic condition of this disease, the fact that in order to accomplish even a tolerably good result, months and years, rather than weeks, of care will be necessary.

In the Laura Franklin Free Hospital for Children, where we always have a large sprinkling of these cases, we find that a generous proportion of them have been "cured" at one time or another, according to the parents' story, and we must confess that parents, particularly of the poorer classes, can hardly be blamed for failing to see necessity of such prolonged treatment as is often necessary in order to save a joint which has become tubercular.

The surgical treatment of these cases is both mechanical and operative. Considering the mechanical side first we are at once confronted by a score of opinions and theories which are more or less antagonistic in their details, but, at the same time, the general principles underlying all are annually becoming better defined, and perhaps we may be pardoned for confining ourselves to the main features, rather than entering into details which would necessitate intolerable prolixity.

We firmly believe that mobility of the limb, together with the constant increased intra-articular pressure engendered by muscular spasm, are the greatest auxilliary factors in de

struction of the joint and in aggravation of the tubercular process. Both fixation and extension are therefore indicated if we would minimize the damage and place the limb in the best possible condition for recovery. The theory that fixation of a tuberculous joint tends to its ankylosis is quite exploded in our opinion.

The question before the orthopaedist is not "whether to fix and extend," but "how to fix and extend." Unfortunately, perfect fixation and perfect extension are each quite impossible, and we must therefore be content, even in the most favorably located joints, with as good approximation of these two conditions as circumstances will permit. In some joints, notably the ankle and those of the upper extremity, extension is quite out of the question, but here Nature has been kind to us, in that in each instance we are dealing with a joint in which the disease is never as serious as in the knee or hip, and the result of simple fixation and non-use is quite satisfactory.

In tuberculosis of the hip we are in the habit of using the Phelps method, which consists, briefly, in first placing the child in bed, and having fixed the body and well leg in plaster of Paris, extending the leg with the weight and pulley, in the line of the existant deformity.

As soon as complete relaxation of the muscular spasm has been attained (three to eight weeks), we apply the long Phelps' splint, which provides both traction and fixation. When the knee is affected, the Thomas knee brace is preceded by fixation with plaster of Paris, and, in the more aggravated cases by traction.

One of the most important and, unfortunately, frequently neglected points in the use of traction is that, as its object is the diminution of intra-articular pressure, it must be executed in the line of deformity.

Frequently physicians, carrying in mind the fact that their object is to straighten the limb, pull it toward the straight line. In the more pronounced angular deformities.

this result is an increase instead of diminution of intra-articular pressure, for the reason that the long bone to which the traction is applied, having inserted into it the rigidly spastic muscle acting as a fixed point, acts as a lever of the first-class in which the weight moves in a direction opposite to that in which the power is acting.

Another grave error is the omission to fasten the child's body and the well limb when applying extension in hip disease. If we fail to fix the pelvis there is no use in fixing the diseased limb, for motion of the pelvis has the same effect upon the joint that the femur has.

In tuberculosis of the ankle, tarsus, shoulder, elbow, wrist and corpus, immobilization must suffice, since efficient extension is quite impracticable.

In all serious cases of tubercular joint disease there is opportunity for difference of opinion as to when mechanical treatment must be supplemented by some of the more radical operative measures. It is exceedingly difficult to express an opinion which will apply to all classes of cases. A small socalled cold abscess, when in relation with the deeper joints like the hip and shoulder, is in our judgment best handled by simple aspiration. The injection of various solutions and emulsions of iodoform have given us poor satisfaction, indeed. The procedure is painful and not without danger, and does not in our experience present any advantage whatever over simple aspiration. If the fluid re-collects once or twice it is usually bound to come to the surface, and we take this or a large collection of fluid as an indication for operation. By operation we, of course, do not refer to mere incision. If these fluid collections-the result of caseation-are to be interfered with at all beyond simple aseptic aspiration, the operation must be as complete and radical as possible. In operating these cases it must be borne in mind that the fluid and the cavity are, so far as the ordinary pyogenic germs are concerned, aseptic but capable of infection.

The abscess cavity invariably connects directly or indirect

ly with the joint cavity or with the epiphyseal focus, and if we would avoid a mixed infection, which is always serious and frequently fatal, the operation must be conducted upon the same lines of asepsis as we would employ in opening a healthy joint, or the abdominal cavity itself. The short incision is a delusion; if we cut at all it is far better to incise the cavity from one extremity to the other. It is our custom to make-barring anatomical barriers-an incision which equals or exceeds the longest limits of the cavity, to retract widely, and, having evacuated the fluid, to expose every nook and corner, using the Volkmann's spoon to remove the tubercular membrane, with the most painstaking precision. From some portion of this cavity will be found the tortuous sinus leading to the joint and the original bone focus. This sinus may be small, but the spoon will easily make it large enough to admit the finger with which the joint is explored; diseased bone is then freely scraped away, or the joint resected if nec essary.

A large rubber drain pipe, as large as the finger and with stiff walls, is then introduced, entering the joint by the most direct route from the surface. The rest of the wound is closed, and we, as a rule, get aseptic healing of all except the drainage tract.

We

Arthrectomy and excisions must be looked upon as major operations, and the greatest discretion is necessary in their election; the advisability, methods and results of a single class of excisions is an ample subject for a long article. can, therefore, only consider one or two important points. In children any amount of temporizing which does not endanger the limb or life is justifiable rather than the performance of a resection, which removes epiphyseal lines before the bone has nearly or quite completed its growth. Resection of the knee under twelve years of age is followed by disastrous shortening of the limb. Each bone has its peculiarities in this respect, and he who disregards them brings upon the patient serious results and upon himself the patient's just.

condemnation. In conclusion it may be said that this subject might better be handled in a volume than in a paper of respectable length,-that it tries the surgeon more sorely than does the delectable vermiform appendix and the serpiginous pus tube put together, that our mistakes in these cases are far more hideous than the ill-adjusted fractures which haunt us in our dreams, and send us to the Fidelity and Casualty for a mal-practice policy,—and our triumphs are often more beautiful when described than when seen with the naked eye.

MODERN AIDS TO ACCURATE DIAGNOSIS.

BY J. P. RAND, M. D., MONSON, MASS.

(Read at the annual meeting of the Mass. Hom. Med. Society, April 10, 1901.)

Ladies and Gentlemen:

The subject assigned to me is too large for anybody to comprehend within the limits of a single paper, since all that has proved valuable in the past we still retain to form with discoveries of later date the modern aids to accurate diagnosis. I will therefore make no attempt to cover the whole ground but state as concisely as possible some of the methods by which medicine has been taken out of the mysticism and developed into an actual science.

Disease was formerly supposed to be the result of some offence to Deity, and even yet the superstition is implied in our formal expressions of condolence. We still hold the Deity responsible for our personal bereavements when we say, "Whereas it has seemed best to an all wise Providence to take our dear brother or sister, etc."

But the golden thread of truth runs through all ages and superstitions alike Our deities change with the measure of our comprehension, and while the religion of the savage and scientist has but little in common, in this they both agree: Disease is still an offence to the Deity-the Deity of natural law by which our material bodies are governed.