Chapter XXI: Diseases of Joints (2)

The changes in the joints involve almost exclusively the synovial membrane and the ligaments; they consist in cellular infiltration and exudation, resulting in the formation of new connective tissue which encroaches on the cavity of the joint and gives rise to adhesions, and by contracting causes stiffness and deformity. The articular cartilages may subsequently be transformed into connective tissue, with consequent fibrous ankylosis and obliteration of the joint. The bones are affected only in so far as they undergo fatty atrophy from disuse of the limb, or alteration in their configuration as a result of partial dislocation. Osseous ankylosis may occur, especially in the small joints of the hand and foot.

The disease is generally poly-articular and may be met with in childhood and youth as well as in adult life. In some cases pain is so severe that the patient resists the least attempt at movement. In others, the joints, although stiff, can be moved but exhibit pronounced crackings. When there is much connective tissue formed in relation to the synovial membrane, the joint is swollen, and as the muscles waste above and below, the swelling is spindle-shaped. Subacute exacerbations occur from time to time, with fever and aggravation of the local symptoms and implication of other joints. After repeated recurrences, there is ankylosis with deformity, the patient becoming a helpless cripple. On account of the tendency to visceral complications, the tenure of life is uncertain.

From the nature of the disease, _treatment_ is for the most part palliative. Salicylates are only of service during the exacerbations attended with pyrexia. The application of soda fomentations, turpentine cloths, or electric or hot-air baths may be useful. Improvement may result from the general and local therapeutics available at such places as Bath, Buxton, Harrogate, Strathpeffer, Wiesbaden, or Aix. In selected cases, a certain measure of success has followed operative interference, which consists in a modified excision. The deformities resulting from chronic rheumatism are but little amenable to surgical treatment, and forcible attempts to remedy stiffness or deformity are to be avoided.

#Arthritis Deformans# (_Osteo-arthritis, Rheumatoid Arthritis, Rheumatic Gout, Malum Senile, Traumatic or Mechanical Arthritis_).--Under the term arthritis deformans, which was first employed by Virchow, it is convenient to include a number of joint affections which have many anatomical and clinical features in common.

The disease is widely distributed in the animal kingdom, both in domestic species and in wild animals in the natural state such as the larger carnivora and the gorilla; evidence of it has also been found in the bones of animals buried with prehistoric man.

The morbid changes in the joints present a remarkable combination of atrophy and degeneration on the one hand and overgrowth on the other, indicating a profound disturbance of nutrition in the joint structures. The nature of this disturbance and its etiology are imperfectly known. By many writers it is believed to depend upon some form of auto-intoxication, the toxins being absorbed from the gastro-intestinal tract, and those who suffer are supposed to possess what has been called an "arthritic diathesis."

The localisation of the disease in a particular joint may be determined by several factors, of which trauma appears to be the most important. The condition is frequently observed to follow, either directly or after an interval, upon a lesion which involves gross injury of the joint or of one of the neighbouring bones. It occurs with greater frequency after repeated minor injuries affecting the joint and its vicinity, such as sprains and contusions, and particularly those sustained in laborious occupations. This connection between trauma and arthritis deformans led Arbuthnot Lane to apply to it the term _traumatic_ or _trade arthritis_.

The traumatic or strain factor in the production of the disease may be manifested in a less obvious fashion. In the lower extremity, for example, _any condition which disturbs the static equilibrium of the limb as a whole_ would appear to predispose to the disease in one or other of the joints. The static equilibrium may be disturbed by such deformities as flat-foot or knock-knee, and badly united fractures of the lower extremity. In hallux valgus, the metatarso-phalangeal joint of the great toe undergoes changes characteristic of arthritis deformans.

A number of cases have been recorded in which arthritis deformans has followed upon antecedent disease of the joint, such as pyogenic or gonorrhœal synovitis, upon repeated hæmorrhages into the knee-joint in bleeders, and in unreduced dislocations in which a new joint has been established.

(Anatomical Museum, University of Edinburgh.)]

Lastly, Poncet and other members of the Lyons school regard arthritis deformans as due to an attenuated form of tuberculous infection, and draw attention to the fact that a tuberculous family history is often met with in the subjects of the disease.

(Anatomical Museum, University of Edinburgh.)]

_Morbid Anatomy._--The commonest type is that in which the articular surfaces undergo degenerative changes. The primary change involves the articular cartilage, which becomes softened and fibrillated and is worn away until the subjacent bone is exposed. If the bone is rarefied, the enlarged cancellous spaces are opened into and an eroded and worm-eaten appearance is brought about; with further use of the joint, the bone is worn away, so that in a ball-and-socket joint like the hip, the head of the femur and the acetabulum are markedly altered in size and shape. More commonly, the bone exposed as a result of disappearance of the cartilage is denser than normal, and under the influence of the movements of the joint, becomes smooth and polished--a change described as _eburnation_ of the articular surfaces (Fig. 158). In hinge-joints such as the knee and elbow, the influence of movement is shown by a series of parallel grooves corresponding to the lines of friction (Fig. 158).

(Museum of Royal College of Surgeons, Edinburgh.)]

While these degenerative changes are gradually causing destruction of the articular surfaces, reparative and hypertrophic changes are taking place at the periphery. Along the line of the junction between the cartilage and synovial membrane, the proliferation of tissue leads to the formation of nodules or masses of cartilage--_ecchondroses_--which are subsequently converted into bone (Fig. 157). Gross alterations in the ends of the bone are thus brought about which can be recognised clinically and in skiagrams, and which tend to restrict the normal range of movement. The extension of the ossification into the synovial reflection and capsular ligament adds a collar or "lip" of new bone, known as "lipping" of the articular margins, and also into other ligaments, insertions of tendons and intermuscular septa giving rise to bony outgrowths or osteophytes not unlike those met with in the neuro-arthropathies.

Proliferative changes in the synovial membrane are attended with increased vascularity and thickening of the membrane and an enlargement of its villi and fringes. When the fatty fringes are developed to an exaggerated degree, the condition is described as an _arborescent lipoma_ (Fig. 159). Individual fringes may attain the size of a hazel nut, and the fibro-fatty tissue of which they are composed may be converted into cartilage and bone; such a body may remain attached by a narrow pedicle or stalk, or this may be torn across and the body becomes loose and, unless confined in a recess of the joint, it wanders about and may become impacted between the articular surfaces. These changes in the synovial membrane are often associated with an abundant exudate or hydrops. These degenerative and hypertrophic changes, while usually attended with marked restriction of movement and sometimes by "locking" of the joint, practically never result in ankylosis.

The _ankylosing type_ of chronic arthritis is fortunately much rarer than those described above, and is chiefly met with in the joints of the fingers and toes and in those of the vertebral column. The synovial membrane proliferates, grows over the cartilage, and replaces it, and when two such articular surfaces are in contact they tend to adhere, thus obliterating the joint, cavity, and resulting in fibrous or bony ankylosis. The changes progress slowly and, before they result in ankylosis, various sub-luxations and dislocations may occur with distortion and deformity which, in the case of the fingers, is extremely disabling and unsightly (Fig. 160).

_Clinical Features._--It is usually observed that in patients who are still young the tendency is for the disease to advance with considerable rapidity, so that in the course of months it may cause crippling of several joints. The course of the disease as met with in persons past middle life is more chronic; it begins insidiously, and many years may pass before there is pronounced disability. The earliest symptom is stiffness, especially in the morning after rest, which passes off temporarily with use of the limb. As time goes on, the range of movement becomes restricted, and crackings occur. This stage of the disease may be prolonged indefinitely; if it progresses, stiffness becomes more pronounced, certain movements are lost, others develop in abnormal directions, and deformed attitudes add to the disablement. The disease is compatible with long life, but not with any active occupation, hence those of the hospital class who suffer from it tend to accumulate in workhouse infirmaries.

_Hydrops_ is most marked in the knee, and may affect also the adjacent bursæ. As the joint becomes distended with fluid, the ligaments are stretched, the limb becomes weak and unstable, and the patient complains of a feeling of weight, of insecurity, and of tiredness. Pain is occasional and evanescent, and is usually the result of some extra exertion, or exposure to cold and wet. This form of the disease is extremely chronic, and may last for an indefinite number of years. It is to be diagnosed from the other forms of hydrops already considered--the purely traumatic, the pyogenic, gonorrhœal, tuberculous, and syphilitic--and from that associated with Charcot's disease.

_Hypertrophied fringes and pedunculated or loose bodies_ often co-exist with hydrops, and give rise to characteristic clinical features, particularly in the knee. The fringes, especially when they assume the type of the arborescent lipoma, project into the cavity of the joint, filling up its recesses and distending its capsule so that the joint is swollen and slightly flexed. Pain is not a prominent feature, and the patient may walk fairly well. On grasping the joint while it is being actively flexed and extended, the fringes may be felt moving under the fingers. Symptoms from impaction of a loose body are exceptional.

_The dry form of arthritis deformans_, although specially common in the knee, is met with in other joints, either as a mon-articular or poly-articular disease; and it is also met with in the joints of the spine and of the fingers as well as in the temporo-mandibular joint. In the joints of the fingers the disease is remarkably symmetrical, and tends to assume a nodular type (Heberden's nodes) (Fig. 160); in younger subjects it assumes a more painful and progressive fusiform type (Fig. 161). In the larger joints the subjective symptoms usually precede any palpable evidence of disease, the patient complaining of stiffness, crackings, and aching, aggravated by changes in the weather. The roughness due to fibrillation of the articular cartilages causes coarse friction on moving the joint, or, in the knee, on moving the patella on the condyles of the femur. It may be months or even years before the lipping and other hypertrophic changes in the ends of the bones are recognisable, and before the joint assumes the deformed features which the name of the disease suggests.

The capsular ligament, except in hydrops, is the seat of connective-tissue overgrowth, and tends to become contracted and rigid. Intra-articular ligaments, such as the ligamentum teres in the hip, are usually worn away and disappear. The surrounding muscles undergo atrophy, tendons become adherent to their sheaths and may be ossified, and the sheaths of nerves may be involved by the cicatricial changes in the surrounding tissues.

_The X-ray appearances of arthritis deformans_ necessarily vary with the type of the disease and the joint affected; in the joints of the fingers there is a narrowing of the spaces between the articular ends of the bones as a result of absorption of the articular cartilage, and rarefaction of the cancellous tissue in the vicinity of the joints; in the larger joints there is "lipping" of the articular margins, osteophytes, and other evidence of abnormal ossification in and around the joint. Eburnation of the articular surfaces is shown by increase in the density of the shadow of the bone in the areas affected.

(Dr. Dickson's case.)]

_Treatment._--Treatment is for the most part limited to the relief of symptoms. On no account should the affected joints be kept at rest by means of splints or other apparatus. Active movements and exercises of all kinds are to be persevered with. When pain is a prominent feature, it may be relieved either by douches of iodine and hot water (tincture of iodine 1 oz. to the quart), or by the application of lint saturated with a lotion made up of chloral hydrate, gr. v, glycerin Ʒj, water ℥j, and covered with oil-silk. Strain and over-use of the joint and sudden changes of temperature are to be avoided. The induction of hyperæmia by means of massage, the elastic bandage, and hot-air baths is often of service. Operative interference is indicated when the disease is of a severe type, when it is mon-articular, and when the general condition of the patient is otherwise favourable. Excision has been practised with success in the hip, knee, elbow, and temporo-mandibular joints. Limitation of movement and locking at the hip-joint when due to new bone round the edge of the acetabulum may be greatly relieved by removal of the bone--a procedure known as _cheilotomy_. Loose bodies and hypertrophied fringes if causing symptoms may also be removed by operation.

When stiffness and grating on movement are prominent features we have found the injection of from half to one ounce of sterilised white vaseline afford decided relief.

The patient should be nourished well, and there need be no restriction in the diet such as is required in gouty patients, so long as the digestion is not impaired. Benefit is also derived from the administration of cod-liver oil, and of tonics, such as strychnin, arsenic, and iron, and in some cases of iodide of potassium. Luff recommends the administration over long periods of guaiacol carbonate, in cachets beginning with doses of 5–10 grs. and increased to 15–20 grs. thrice daily. A course of treatment at one of the reputed spas--Aix, Bath, Buxton, Gastein, Harrogate, Strathpeffer, Wiesbaden, Wildbad--is often beneficial.

In some cases benefit has followed the prolonged internal administration of liquid paraffin.

On the assumption that the condition is the result of an auto-intoxication from the intestinal tract, saline purges and irrigation of the colon are indicated, and Arbuthnot Lane claims to have brought about improvement by short-circuiting or by resecting the colon.

Residence in a warm and dry climate, with an open-air life, has been known to arrest the disease when other measures have failed to give relief.

The application of radium and the ingestion of radio-active waters have also been recommended.

#Hæmophilic# or #Bleeder's Joint#.--This is a rare but characteristic affection met with chiefly in the knee-joint of boys who are the subjects of hæmophilia. After some trivial injury, or even without apparent cause, a hæmorrhage takes place into the joint. The joint is tensely swollen, cannot be completely extended, and is so painful that the patient is obliged to lie up. The temperature is often raised (101° to 102° F.), especially if there are also hæmorrhages elsewhere. The blood in the joint is slowly re-absorbed, and by the end of a fortnight or so, the symptoms completely disappear. As a rule these attacks are repeated; the pain attending them diminishes, but the joint becomes the seat of permanent changes: the synovial membrane is thickened, abnormally vascular, and coloured brown from the deposit of blood pigment; on its surface, and in parts of the articular cartilage, there is a deposit of rust-coloured fibrin; there may be extensive adhesions, and in some cases changes occur like those observed in arthritis deformans with erosion and ulceration of the cartilage and a form of dry caries of the articular surfaces, which may terminate in ankylosis.

As the swelling of the joint is associated with wasting of the muscles, with stiffness, and with flexion, the condition closely resembles tuberculous disease of the synovial membrane. From errors in diagnosis such joints have been operated upon, with disastrous results due to hæmorrhage.

The treatment of a recent hæmorrhage consists in securing absolute rest and applying elastic compression. The introduction of blood-serum (10–15 c.c.) into a vein may assist in arresting the hæmorrhage; anti-diphtheritic serum is that most readily obtainable.

After an interval, measures should be adopted to promote the absorption of blood and to prevent stiffness and flexion; these include massage, movements, and extension with weight and pulley.

JOINT DISEASES ASSOCIATED WITH LESIONS OF THE NERVOUS SYSTEM: NEURO-ARTHROPATHIES

_In Lesions of Peripheral Nerves._--In the hand, and more rarely in the foot, when one or other of the main nerve-trunks has been divided or compressed, the joints may become swollen and painful and afterwards become stiff and deformed. Bony ankylosis has been observed.

_In Affections of the Spinal Medulla._--In myelitis, progressive muscular atrophy, poliomyelitis, insular sclerosis, and in traumatic lesions, joint affections are occasionally met with.

The occurrence of joint lesions in _locomotor ataxia_ (tabes dorsalis) was first described by Charcot in 1868--hence the term "Charcot's disease" applied to them. Although they usually develop in the ataxic stage, one or more years after the initial spinal symptoms, they may appear before there is any evidence of tabes. The onset is frequently determined by some injury. The joints of the lower extremity are most commonly affected, and the disease is bilateral in a considerable proportion of cases--both knees or both hips, for instance, being implicated.

Among the theories suggested in explanation of these arthropathies the most recent is that by Babinski and Barré, which traces the condition to vascular lesions of a syphilitic type in the articular arteries.

The first symptom is usually a swelling of the joint and its vicinity. There is no redness or heat and no pain on movement. The peri-articular swelling, unlike ordinary œdema, scarcely pits even on firm pressure.

(Anatomical Museum, University of Edinburgh).]

In mild cases this condition of affairs may persist for months; in severe cases destructive changes ensue with remarkable rapidity. The joint becomes enormously swollen, loses its normal contour, and the ends of the bones become irregularly deformed (Fig. 162). Sometimes, and especially in the knee, the clinical features are those of an enormous hydrops with fibrinous and other loose bodies and hypertrophied fringes--and great œdema of the peri-articular tissues (Fig. 163). The joint is wobbly or flail-like from stretching and destruction of the controlling ligaments, and is devoid of sensation. In other cases, wearing down and total disappearance of the ends of the bones is the prominent feature, attended with flail-like movements and with coarse grating. Dislocation is observed chiefly at the hip, and is rather a gross displacement with unnatural mobility than a typical dislocation, and it is usually possible to move the bones freely upon one another and to reduce the displacement. A striking feature is the extensive formation of new bone in the capsular ligament and surrounding muscles. The enormous swelling and its rapid development may suggest the growth of a malignant tumour. The most useful factor in diagnosis is the entire absence of pain, of tenderness, and of common sensibility. The freedom with which a tabetic patient will allow his disorganised joint to be handled requires to be seen to be appreciated.

The rapidity of the destructive changes in certain cases of tabes, and the entire absence of joint lesions in others, would favour the view that special parts of the spinal medulla must be implicated in the former group.

In _syringomyelia_, joint affections (gliomatous arthropathies) are more frequent than in tabes, and they usually involve the upper extremity in correspondence with the seat of the spinal lesion, which usually affects the lower cervical and upper thoracic segments. Except that the joint disease is seldom symmetrical, it closely resembles the arthropathy of tabes. The completeness of the analgesia of the articular structures and of the overlying soft parts is illustrated by the fact that in one case the patient himself was in the habit of letting out the fluid from his elbow with the aid of a pair of scissors, and that in another the joint was painlessly excised without an anæsthetic.

The disease may become arrested or may go on to complete disorganisation; suppuration may ensue from infection through a breach of the surface, and in rare cases the joint has become the seat of tuberculosis.

_Treatment_, in addition to that of the nerve lesion underlying the arthropathy, consists in supporting and protecting the joint by means of bandages, splints, and other apparatus. In the lower extremity, the use of crutches is helpful in taking the strain off the affected limb. When there is much distension of the joint, considerable relief follows upon withdrawal of fluid. The best possible result being rigid ankylosis in a good position, it may be advisable to bring this about artificially by arthrodesis or resection. Operation is indicated when only one joint is affected and when the cord lesion is such as will permit of the patient using the limb. The wounds heal well, but the victims of tabes are unfavourable subjects for operative interference, on account of their liability to intercurrent complications. When the limb is quite useless, amputation may be the best course.

_In cerebral lesions_ attended with hemiplegia, joint affections, characterised by evanescent pain, redness, and swelling, are occasionally met with. The secondary changes in joints which are the seat of paralytic contracture are considered with the surgery of the Extremities.

In cases of _hysteria_ and other _functional affections of the nervous system_, an intermittent neuropathic hydrops has been observed--especially in the knee. Without apparent cause, the joint fills with fluid and its movements become restricted, and after from two to eight days the swelling subsides and the joint returns to normal. A remarkable feature of the condition is that the effusion into the joint recurs at regular intervals, it may be over a period of years. Psychic conditions have been known to induce attacks, and sometimes to abort them or even to cause their disappearance. Hence it has been recommended that treatment by suggestion should be employed along with tonic doses of quinine and arsenic.

HYSTERICAL OR MIMETIC JOINT AFFECTIONS

Under this heading, Sir Benjamin Brodie, in 1822, described an affection of joints, characterised by the prominence of subjective symptoms and the absence of pathological changes. Although most frequently met with in young women with an impressionable nervous system, and especially among those in good social circumstances, it occurs occasionally in men. The onset may be referred to injury or exposure to cold, or may be associated with some disturbance of the emotions or of the generative organs; or the condition may be an involuntary imitation of the symptoms of organic joint disease presented by a relative or friend.

It is characteristic that the symptoms develop abruptly without satisfactory cause, that they are exaggerated and wanting in harmony with one another, and that they do not correspond with the features of any of the known forms of organic disease. In some cases the only complaint is of severe pain; more often this is associated with excessive tenderness and with impairment of the functions of the joint. On examination the joint presents a normal appearance, but the skin over it is remarkably sensitive. A light touch is more likely to excite pain than deep and firm pressure. Stiffness is a variable feature--in some cases amounting to absolute rigidity, so that no ordinary force will elicit movement. It is characteristic of this, as of other neuroses, that the symptoms come and go without sufficient cause. When the patient's attention is diverted, the pain and stiffness may disappear. There is no actual swelling of the joint, although there may be an appearance of this from wasting of the muscles above and below. If the joint is kept rigid for long periods, secondary contracture may occur--in the knee with flexion, in the hip with flexion and adduction.

The _diagnosis_ is often a matter of considerable difficulty, and the condition is liable to be mistaken for such organic lesions as a tuberculous or pyogenic focus in the bone close to the joint.

The greatest difficulty is met with in the knee and hip, where the condition may closely simulate tuberculous disease. The use of the Röntgen rays, or examination of the joint under anæsthesia, is helpful.

The _local treatment_ consists chiefly in improving the nutrition of the affected limb by means of massage, exercises, baths, and electricity. Splints are to be avoided. In refractory cases, benefit may follow the application of blisters or of Corrigan's button. The general condition of the patient must be treated on the same lines as in other neuroses. The Weir-Mitchell treatment may have to be employed in obstinate cases, the patient being secluded from her friends and placed in charge of a nurse. Complete recovery is the rule, but when the muscles are weak and wasted from prolonged disuse, a considerable time may elapse before the limb returns to normal.

TUMOURS AND CYSTS

New growths taking origin in the synovial membrane are rare, and are not usually diagnosed before operation. They are attended with exudation into the joint, and in the case of _sarcoma_ the fluid is usually blood-stained. If the tumour projects in a polypoidal manner into the joint, it may cause symptoms of loose body. One or two cases have been recorded in which a _cartilaginous tumour_ growing from the synovial membrane has erupted through the joint capsule and infiltrated the adjoining muscles. _Multiple cartilaginous tumours_ forming loose bodies are described on p. 544.

_Cysts of joints_ constitute an ill-defined group which includes ganglia formed in relation to the capsular ligament. Cystic distension of bursæ which communicate with the joint is most often met with in the region of the knee in cases of long-standing hydrops. It was suggested by Morrant Baker that cystic swellings may result from the hernial protrusion of the synovial membrane between the stretched fibres of the capsular ligament, and the name "Baker's cysts" has been applied to these.

In the majority of cases, cysts in relation to joints give rise to little inconvenience and may be left alone. If interfered with at all, they should be excised.

LOOSE BODIES

It is convenient to describe the varieties of loose bodies under two heads: those composed of fibrin, and those composed of organised connective tissue.

#Fibrinous Loose Bodies# (Corpora oryzoidea).--These are homogeneous or concentrically laminated masses of fibrin, sometimes resembling rice grains, melon seeds, or adhesive wafers, sometimes quite irregular in shape. Usually they are present in large numbers, but sometimes there is only one, and it may attain considerable dimensions. They are not peculiar to joints, for they are met with in tendon sheaths and bursæ, and their origin from synovial membrane may be accepted as proved. They occur in tuberculosis, arthritis deformans, and in Charcot's disease, and their presence is almost invariably associated with an effusion of fluid into the joint. While they may result from the coagulation of fibrin-forming elements in the exudate, their occurrence in tuberculous hydrops would appear to be the result of coagulation necrosis, or of fibrinous degeneration of the surface layer of the diseased synovial membrane. However formed, their shape is the result of mechanical influences, and especially of the movement of the joint.

_Clinically_, loose bodies composed of fibrin constitute an unimportant addition to the features of the disease with which they are associated. They never give rise to the classical symptoms associated with impaction of a loose body between the articular surfaces. Their presence may be recognised, especially in the knee, by the crepitating sensation imparted to the fingers of the hand grasping the joint while it is flexed and extended by the patient.

The _treatment_ is directed towards the disease underlying the hydrops. If it is desired to empty the joint, this is best done by open incision.

(Mr. J. W. Dowden's case.)]

#Bodies composed of Organised Connective Tissue.#--These are comparatively common in joints that are already the seat of some chronic disease, such as arthritis deformans, Charcot's arthropathy, or synovial tuberculosis. They take origin almost exclusively from an erratic overgrowth of the fringes of the synovial membrane, and may consist entirely of fat, the arborescent lipoma (Fig. 159) being the most pronounced example of this variety. Fibrous tissue or cartilage may form in one or more of the fatty fringes and give rise to hard nodular masses, which may attain a considerable size, and in course of time may undergo ossification.

Like other hypertrophies on a free surface, they tend to become pedunculated, and so acquire a limited range of movement. The pedicle may give way and the body become free. In this condition it may wander about the joint, or lie snugly in one of its recesses until disturbed by some sudden movement. A loose body free in a joint is capable of growth, deriving the necessary nutriment from the surrounding fluid. The size and number of the bodies vary widely. Single specimens have been known to attain the size of the patella. The smaller varieties may number considerably over a hundred.

a = Convex surface. b = Concave surface.]

In arthritis deformans a rarer type of loose body is met with, a portion of the lipping of one of the articular margins being detached by injury. In Charcot's disease, bodies composed of bone are formed in relation to the capsular and other ligaments, and may be made to grate upon one another.

The _clinical features_ in this group are mainly those of the disease which has given rise to the loose bodies, and it is exceptional to meet with symptoms from impaction of the body between the articular surfaces. Treatment is to be directed towards the primary disease in the joint, as well as to the removal of the loose bodies.

_Loose Bodies in Joints which are otherwise healthy._--It is in joints otherwise healthy that loose bodies causing the classical symptoms and calling for operative treatment are most frequently met with. They occur chiefly in the knee and elbow of healthy males under the age of thirty. The complaint may be of vague pains, of occasional cracking on moving the joint, or of impairment of function--usually an inability to extend or flex the joint completely. In many cases a clear account is given of the symptoms which arise when the body is impacted between the articular surfaces, namely, sudden onset of intense sickening pain, loss of power in the limb and locking of the joint, followed by effusion and other accompaniments of a severe sprain. On some particular movement, the body is disengaged, the locking disappears, and recovery takes place. Attacks of this kind may recur at irregular intervals, during a period of many years. On examining the joint, it is usually found to contain fluid, and there may be points of special tenderness corresponding to the ligaments that have been overstretched. In cases in which there has been recurrent attacks of locking, the ligaments become slack, the joint is wobbly, and the quadriceps is wasted. The patient himself, or the surgeon, may discover the loose body and feel it roll beneath his fingers, especially if it is lodged in the supra-patellar pouch in the knee, or on one or other side of the olecranon in the elbow. In most instances the patient has carefully observed his own symptoms, and is aware not only of the existence of the loose body, but of its erratic appearance at different parts of the joint. This feature serves to differentiate the lesions from a torn medial meniscus in which the pain and tenderness are always in the same spot. As the body usually contains bone, it is recognisable in a skiagram.

There are two methods of _removing the body_; the first and simpler method is applicable when the body can be palpated, usually in the supra-patellar pouch; it is preferably transfixed by a needle and can then be removed through a small incision; otherwise, the joint must be freely opened and explored, firstly to find the body and further to remove it.

The characters of this type of loose body are remarkably constant. It is usually solitary, about the size of a bean or almond, concavo-convex in shape, the convex aspect being smooth like an articular surface, the concave aspect uneven and nodulated and showing reparative changes, healing over of the raw surface, and the new formation of fibrous tissue, hyaline cartilage and bone, the necessary nutriment being derived from the synovial fluid (Fig. 167). The body is sometimes found to be lodged in a defect or excavation in one of the articular surfaces, usually the medial condyle of the femur, from which it is readily shelled out by means of an elevator. It presents on section a layer of articular cartilage on the convex aspect and a variable thickness of spongy bone beneath this.

The origin of these bodies is one of the most debated questions in surgical pathology; they obviously consist of a portion of the articular surface of one of the bones, but how this is detached still remains a mystery; some maintain that it is purely traumatic; König regards them as portions of the articular surface which have been detached by a morbid process which he calls "osteochondritis dessicans."

_Multiple Chondromas and Osteomas of the Synovial Membrane._--In this rare type of loose body, the surface of the synovial membrane is studded with small sessile or pedunculated tumours composed of pure hyaline cartilage, or of bone, or of transition stages between cartilage and bone. They are pearly white in colour, pitted and nodular on the surface, rarely larger than a pea, although when compressed they may cake into masses of considerable size. With the movements of the joint many of the tumours become detached and lie in the serous exudate excited by their presence. They are found also in the diverticula of the synovial membrane, in the shoulder in the downward prolongation along the tendon of the biceps, in the hip in the bursal extension beneath the psoas.

The patient complains of increasing disability of the limb, movements of the joint becoming more and more restricted and painful. There is swelling corresponding to the distended capsule of the joint, and on palpation the bodies moving under the fingers yield a sensation as of grains of rice shifting in a bag. If the bodies are so numerous as to be tightly packed together, the impression is that of a plastic mass having the shape of the synovial sac. The stiffness and the cracking on movement may suggest arthritis deformans, but the X-ray appearances make the diagnosis an easy one. We have observed two cases of this affection in the knee-joint of adult women, one in the shoulder-joint of an adult male (Fig. 168), and Caird has observed one in the hip. The treatment consists in opening the joint by free incision and removing the bodies.

_Displacement of the menisci_ of the knee is referred to with injuries of that joint.

INDEX

Abdominal aneurysm, 313
aorta, compression of, 269
embolus of, 93

Abscess, 46
acute circumscribed, 46
of bone, 448
Brodie's, 448
chronic, 139
cold, 139
embolic, 66
formation of, 47
Hilton's method of opening, 50
pointing of, 48
pyæmic, 287
residual, 141
of skin, multiple, 382
stitch, 51
treatment of, 49
tuberculous, 139, 141
peri-articular, 514, 517

Achillo-bursitis, 432

Achillo-dynia, 422

Acidosis, 251

Acromion bursa, 429

Actinomycosis, 126

Active hyperæmia, 39

Acupuncture in aneurysm, 308

Acute arthritis of infants, 440
necrosis of bone, 439

Adductor longus muscle, rupture of, 408

Adenoma, 202
malignant, 209
sebaceous, 393
of skin, 393
varieties of, 202

Adiposus dolorosa, 186

Aërobes, 19

Air embolism, 265
hunger, 276

Albumosuria, 195, 474, 492

Aleppo boil, 129

Alexins, 22

Ambrine, 13, 238

Amputation neuroma, 344

Anaërobes, 19

Anæsthesia, after nerve injuries, 347

Analgesia, 347

Anaphylaxis, 23

Anatomical tubercle, 134

Anatomy. _See_ Surgical Anatomy

Anel's operation for aneurysm, 307

Aneurysm, 300. _See also_ Individual Arteries
abdominal, 313
acupuncture in, 308
amputation in, 310
by anastomosis, 298
Anel's operation for, 307, 310
arterio-venous, 263
axillary, 318
of bone, 498
brachial, 318
Brasdor's operation for, 308
cirsoid, 299
Colt's method of wiring for, 309
compression for, 308
consolidated, 304, 305
differential diagnosis of, 305
diffused, 302
digital compression in, 308
excision of, 307
of forearm and hand, 318
fusiform, 301
gelatin injections in, 309
Hunter's operation for, 307
iliac, 318
of individual arteries, 312
inguinal, 318
innominate, 314
intracranial, 316
of leg and foot, 320
ligation of artery for, 307
Macewen's acupuncture for, 308
Matas' operation for, 307
Moore-Corradi method, 308
natural cure of, 305
old operation for, 307
of ophthalmic artery, 317
orbital, 317
pathological, 301
pulse in, 304
rupture of, 306
sacculated, 302
suppuration in, 306
thoracic, 312
traumatic, 263, 310
treatment of, 306
varicose, 311
Wardrop's operation for, 308
X-rays in diagnosis of, 304

Aneurysmal varix, 311, 316, 318, 319, 320

Angioma, 284
arterial, 299
capillary, 294
cavernous, 297
racemosum venosum, 287
venous, 294

Angio-neurotic œdema, 348
sarcoma, 199

Angler's elbow, 406

Ankle, cellulitis of, 58

Ankylosis of joints, 503. _See also_ Individual Joints

Anoci-association, 253

Anthracæmia, 121

Anthrax, 119

Anti-bacterial sera, 23
-diphtheritic serum, 111
-streptococcic serum, 23, 109
-tetanic serum, 117

Antibodies, 22

Antigens, 22

Antiseptics, 242

Antitoxic sera, 23

Antitoxins, 22

Antivenin, 132

Aorta, abdominal, compression of, 269
aneurysm of, 313
embolism of, 93
ligation of, 314
pulsating, 305, 314

Arborescent lipoma, 423

Arseno-billon, 163

Arteries, anatomy of, 258
compression of individual, 269
contusion of, 260
digital compression of, 269
gangrene following ligation of, 94
gunshot wounds of, 263

Arteries, ligation of, for aneurysm, 307
punctured wounds of, 262
repair of, 266, 268
rupture of, 260
wounds of, 261, 262

Arterio-sclerosis, 282

Arterio-venous aneurysm, 310

Arteritis, varieties of, 282

Arthritis, 501. _See also_ Individual Joints
acute, 506
of infants, 440
deformans, 524
gonococcal, 510
neuropathic, 532
ossificans, 503
pneumococcal, 509
pyogenic, 506
rheumatic, 523
rheumatoid, 524
septic, 506
scarlatinal, 508
trade, 525
traumatic, 524
tuberculous, 512
urica, 522

Arthrolysis, 505

Arthropathies, 532
gliomatous, 534

Arthroplasty, 505

Articular caries, 502, 514

Artificial hyperæmia, 39

Ascites, chylous, 325

Asepsis, 18

Asphyxia, local, 97
traumatic, 254

Atheroma, 283

Avulsion of nerves, 375
of tendons, 411

Axilla, cellulitis of, 58
hygroma of, 328

Axillary aneurysm, 318
artery, embolus of, 93
lymph glands, 336
nerve, injuries of, 363

Bacilli, 19

Bacillus aërogenes capsulatus, 99
anthracis, 119
coli communis, 27
diphtheriæ 109
drum-stick, 112
of Ducrey, 154
of glanders, 123
Klebs-Löffler, 109
of malignant œdema, 101
mallei, 123
pyocyaneus, 29
of soft sore, 154
of tetanus, 112
tubercle, 133
typhosus, 29, 452

Bacteria, death of, 21
general characters of, 18
pathogenic properties of, 19
pyogenic, 24, 29

Bacterial intoxication, 21

Bacteriology, surgical, 17

Baker's cysts, 539

Bazin's disease, 74, 169

Beck's paste in sinuses, 145

Bed-sores, 73, 103

Bence-Jones on albumosuria, 195, 474, 492

Biceps, bursa under, 430
dislocation of long tendon of, 409
rupture of, 407

Bier's artificial hyperæmia, 38

B.I.P.P., 143

Birth palsies, 362

Biskra button, 129

Bismuth gauze, 247
injections in sinuses, 145

Bites of animals, 223

Black eye, 219

Bleeder's joint, 531

Bleeders, 277
bruises in, 218

Blisters, 376
purulent, 55

Blocking of nerves for shock, 252

Blood, count, 30
cysts, 214, 220
transfusion of, 11, 253

Blood vessels. _See_ Arteries and Veins

Bloodless state, treatment of, 276

Blood letting, general, 42

Boil, 379
Aleppo, 129
Delhi, 129

Bone. _See also_ Individual Bones
abscess of, 448
aneurysm of, 498
angioma of, 491
atrophy of, 479
bacterial diseases of, 438
Brodie's abscess of, 448
cancer of, secondary, 499
caries of, 437, 438
changes in ulcers of leg, 79
chondroma of, 487
cysts of, 477, 500
diseases of, 434
due to staphylococcus aureus, 438
endothelioma of, 492
exostoses of, 191, 481
fibroma of, 491
fragility of, 479
grafting, 16, 436
gumma of, 464
hydatid disease of, 467
hyperostosis, 435, 464
hypertrophic pulmonary osteo-arthropathy, 480
hypertrophy of, 435
lipoma of, 491
lipping of, 527
malacia of, 473
marrow, function of, 434
myeloma of, 491
myxoma of, 491
necrosis of, 438
neuropathic atrophy of, 479
osteoma of, 481
osteomalacia of, 473
osteomyelitis of, 65, 437, 438, 451, 453, 473
fibrosa, 476
osteoporosis of, 437
osteopsathyrosis, 479
ostitis deformans, 474
Paget's disease of, 474
periosteum, function of, 435
periostitis, 437
pulsating hæmatoma of, 498
pyogenic diseases of, 438
regeneration of, 436
rickety affections of, 468
sarcoma of, 492
sclerosis of, 435
scurvy affecting, 473
secondary tumours of, 499
surgical anatomy of, 434
staphylococcal diseases of, 438
syphilitic diseases of, 461, 465
transplantation of, 436
tuberculous diseases of, 454
tumours of, 480
malignant, 492, 499
metastatic, 499
thyreoid, 500
typhoid, infection of, 452
X-ray appearances in diseases of, 445, 455, 485, 491, 496

Bovine tuberculosis, 136

Brachial aneurysm, 318
artery, embolus of, 93
compression of, 269
birth-paralysis, 362
fibrositis, 413
neuralgia, 371
plexus, lesions of, 360

Brain, joint affections in lesions of, 537
syphilitic lesions of, 161

Branchial dermoids, 211

Brasdor's operation for aneurysm, 308

Brodie's abscess, 448

Bruises, 218

Bubo, 329
bullet, 153
of soft sores, 155

Bullet bubo, 153

Bullets, embedded, 231
varieties of, 230

Burnol, 238

Burns, 233
classification, of, 234
electrical, 239
pathology of, 233
by X-rays, 239

Bursæ. _See also_ Individual Bursæ
adventitious, 426
affections of, 426
individual, 428
diseases of, 426, 428
hæmatoma of, 426
hydrops of, 427
hygroma of, 423
inflammation of, 426
injuries of, 426
loose bodies in, 427
syphilis of, 428
tuberculosis of, 428
tumours of, 427, 428

Cachexia, cancerous, 207

Calcanean bursa, 432

Calcification in arteries, 282
in muscles, 416
in tuberculosis, 136

Callosities, 376

Callous ulcers, 79, 84

Cancer, 202
arsenic, 395
of bone, 499
cachexia in, 207
chimney-sweep's, 395
colloid, 210
columnar epithelial, 209
contagiousness of, 205
cystic, 210
definition of, 202
degeneration of, 205
encephaloid, 210
_en cuirasse_, 204
glandular, 210
glandular infection in, 203
increase of, 207
of lymph glands, 340
medullary, 210
melanotic, 210, 341, 397
paraffin, 395
pigmented, 210
radium treatment of, 208
rodent, 210, 395
scirrhous, 210
of skin, 394
spread of, 204
squamous epithelial, 208
ulceration of, 205
varieties of, 208
X-ray, 208

Cancrum oris, 102

Cantharides plaster, 42

Capillaries, anatomy of, 258

Capillary angioma, 294
loops, 3

Carbolic gangrene, 95

Carbon-dioxide snow, 297

Carbuncle, 380

Carcinoma. _See_ Cancer

Caries, 437, 438
of articular surfaces, 502, 514
sicca, 438
syphilitic, 462
tuberculous, 455

Carotid aneurysm, 314
artery, compression of, 269
tubercle, 269

Carpal ganglion, 214

Carron oil, 238

Cartilage, grafting of, 16
repair of, 7
ulceration of, 502, 514

Cartilaginous exostosis, 191, 481

Caseation in tuberculosis, 136

Catalepsy, 116

Catgut, infection by, 51
preparation of, 245

Cautery in hæmorrhage, 271

Cavernous angioma, 298
lymphangioma, 327

Cellulitis, 52
in different situations, 58
diffuse, 52

Cephalic or Kopf tetanus, 116

Cerebro-spinal meningitis, 115

Cervical adenitis, 332
rib, 360

Chalk stones in gouty joints, 523

Chancre, concealed, 152, 153, 157
erratic, 153
extra-genital, 153
hard, 151
meatal, 152
multiple, 152
relapsing false indurated, 172
soft, 154
urethral, 152

Chancroid, 154

Charcoal poultice, 84

Charcot's disease, 533

Cheloid. _See_ Keloid

Chemiotaxis, 32

Chigoe, 130

Chilblain, 378

Chimney-sweep's cancer, 395

Chloroma, 200

Chondroma, 189, 487
multiple, 544

Chondromatosis, 488

Chondro-sarcoma, 189, 200, 487

Chordoma, 200

Choroiditis, syphilitic, 177

Chylorrhœa, 325

Chylo-thorax, 325

Chylous ascites, 325

Cicatrices, varieties of, 400

Cicatricial contraction, 4
tissue, 4

Circumflex nerve. _See_ Axillary Nerve

Cirsoid aneurysm, 299

Claw-hand, 369

Cloacæ in bone, 443

Cocci, 18

Cœliac artery, aneurysm of, 313

Coley's fluid, 201

Collapse, 254

Collateral circulation, 267

Colles' law, 178

Colloid cancer, 210

Common peroneal nerve, 370

Compound palmar ganglion, 217, 423

Condylomata, 158, 174

Congenital fistulas, 60
telangiectasis, 294

Connective tissue, repair of, 6

Contracture of joints, 502
of muscles, 415
paralytic, 347

Contusions, 218

Cornea, syphilitic ulceration of, 177

Corns, 377

Corpora oryzoidea, 539

Counter-irritants, 37, 42

Craniotabes, 175, 176, 465

Crural fibrositis, 413

Crutch paralysis, 351

Cupping dry, 39
wet, 42

Cutis anserina, 36

Cyanosis, traumatic, 254

Cyst, 212
atheromatous, 389
Baker's, 539
blood 214, 220
of bone, 477, 500
dentigerous, 193
derma, 210
exudation, 212
ganglionic, 215
hæmorrhagic, 220
hydatid, 213
implantation, 212
of joints, 538
lymph, 214
lymphatic, 219, 328
omental, 329
parasitic, 213
retention, 212
sebaceous, 212, 389
serous, 219
venous, 289

Cystic adenoma, 202
carcinoma, 210
hygroma of neck, 328
lymphangioma, 327, 328

Dactylitis, syphilitic, 176, 460, 466
tuberculous, 460

Dancer's sprain, 406

Deafness, syphilitic, 178

Deformities. _See_ Individual Regions

Delhi boil, 129

Delirium, in surgical patients, 255
traumatic, 257

Delirium tremens, 256

Dentigerous cyst, 193

Dercum on adiposus dolorosa, 186

Derma-cysts, 210

Dermatitis, 239, 292

Dermoids, 210

Diabetic gangrene, 96

Diarsenol, 163

Diapedesis of red corpuscles, 32

Diaphysial aclasis, 483

Diffuse aneurysm, 302
cellulitis, 52
fibromatosis, 194
lipomatosis, 187
neuro-fibromatosis, 355
osteoma, 485
suppuration, 52

Diphtheria, 109
antitoxin in, 111
intubation in, 111

Diplococci, 19

Dislocation of nerves, 351, 369
pathological, 514
of tendons, 408

Double cyanide gauze, 247

Drainage of wounds, 222

Dressings, surgical, 247

Drill-bone, 418

Drop-finger, 411
-foot, 370
-wrist, 365

Drunkard's palsy, 351, 364

Duchenne's paralysis, 361

Ducrey's bacillus, 154

Duodenum, ulceration of, in burns, 236

Dwarf, rickety, 469
syphilitic, 178

Eburnation of articular surfaces, 557

Ecchondroses, 527

Ecchymosis, 218

Echinococcus, 213

Echthyma, 158

Eczema, varicose, 292

Elbow, angler's, 406
cellulitis of, 58
tennis, 406

Electricity, injuries by, 239

Electrolysis in angioma, 297

Elephantiasis, varieties of, 360, 384, 386

Embolism, 281
air, 265

Embolism, fat, 254
of individual arteries, 93

Embolus, 281

Emigration of leucocytes, 32

Emotional shock, 251

Emphysema, 99, 102

Emprosthotonos, 214

Empyema of joints, 501, 518

Encephaloid cancer, 210

Endarteritis obliterans, 282
syphilitic, 161

Endo-aneurysmorrhaphy, 307

Endothelioma, 196
of bone, 492

Epicritic sensibility of nerves, 343

Epidermis, grafting, 12
repair of, 4

Epiphysial cartilage, 434
junction, 434
in rickets, 469

Epiphysiolysis, 440

Epiphysitis, 437
syphilitic, 465

Epithelial tumours, 201

Epithelioma, 208
chimney-sweep's, 395
lupus, 384
paraffin, 395
in scars, 402
sinus, 500
of skin, 394
trade, 395
varieties of, 208
X-ray, 395

Epithelium grafting, 12
repair of, 6

Epulis, 491

Erb's paralysis, 361

Erysipelas, varieties of, 107

Erythema pernio, 378
nodosum, 442

Evaporating lotions, 41

Exfoliation, 438

Exophthalmos, pulsating, 317

Exostosis, 191, 481
bursata, 481
cancellous, 481
cartilaginous, 191, 481
false, 192
ivory, 481
multiple, 483
spongy, 191, 481
subungual, 191, 404, 481

Explosives, wounds by, 231

External iliac artery, embolus of, 93

External popliteal nerve. _See_ Common Peroneal Nerve

Extravasation of blood, 259

Exudates, varieties of, 33

Exudation cysts, 212

Eye, syphilitic lesions of, 160, 176, 177

Facial artery, compression of, 269
erysipelas, 107

Fainting, 249

Farcy, 125

Fascia, grafting of, 16

Fat embolism, 254
grafting of, 16

Fatty hernia, 187
tumours, 184

Feet, trench, 96

Femoral aneurysm, 318
artery compression of, 269
embolus of, 93
lymph glands, 323

Fever, 35

Fibro-adenoma, 202

Fibroblasts, 3

Fibroid, recurrent, of Paget, 199, 392, 420
uterine, 195

Fibroma, 194
of bone, 491
diffuse, 194
recurrent, of Paget, 199, 392, 420
of skin, 391
varieties of, 194

Fibromatosis, diffuse, 194

Fibro-myoma, 195

Fibro-sarcoma, 199

Fibrositis, varieties of, 372, 412

Filaria Bancrofti, 326

Filarial disease, 326

Finger, chancre of, 154
drop-, 411
mallet-, 411

Fingers, gouty affections of, 523
whitlow of, 55

Finsen light treatment, 138

Firearms, wounds by, 225, 227, 230

First intention, healing by, 2

Fistula, 60
congenital, 60
lymphatic, 325
varieties of, 60

Fluctuation, 49

Fomentations, 37, 41

Foot, cellulitis of, 58
drop-, 370
Madura, 129
perforating ulcer of, 73

Forci-pressure in hæmorrhage, 271

Forearm, aneurysm of, 318
cellulitis of, 58

Foreign bodies, embedded, 6, 231

Fracture, pathological, 444

Fraenkel's pneumococcus, 28

Fragilitas ossium, 479

Friedländer's pneumo-bacillus, 28

Frost-bite, gangrene from, 95

Furunculus orientalis, 129

Galyl, 163

Ganglion, 214, 215, 217
compound palmar, 217, 423

Ganglionic neuroma, 353

Gangrene, 86
acute infective, 99
emphysematous, 102
from angio-sclerosis, 98
bacterial varieties of, 99
from burns and scalds, 95
cancrum oris, 102
carbolic, 95
from chemical agents, 95
clinical types of, 86
varieties of, 88
from constriction of vessels, 94
diabetic, 96
dry, 86
embolic, 92
from ergot, 98
from frost-bite, 95
gas, 102
from interference with circulation, 86
following ligation of arteries, 94
line of demarcation in, 87
malignant œdema, 101
moist, 87
noma, 102
phagedæna, 153
Raynaud's disease, 97
senile, 88
traumatic, 94
from trench feet, 96
white, 93
from whitlow, 99

Gas gangrene, 102

Gasserian ganglion, removal of, 375

Gauze, varieties of, 247

Gauze, sterilisation of, 245

Gelatin, injection of, in aneurysm, 309
in hæmophilia, 280

Gelatinous degeneration of joints, 515

Giant cells, 3

Glanders, 123

Glands, lymph. _See_ Lymph Glands

Glioma, 196

Gliomatous arthropathies, 534

Glio-sarcoma, 200

Gloves in surgery, 244

Gluteal aneurysm, 319
fibrositis, 372, 413

Glycogen reaction, 30

Glycosuria in perforating ulcer, 73

Golfer's back, 405

Gonorrhœal bursitis, 428
joint lesions, 510
lymphangitis, 325
myositis, 416
ophthalmia, joint lesions following, 510
rheumatism, 510
teno-synovitis, 423

Gout, joint affections in, 522

Gouty bursitis, 428
joints, 522
teno-synovitis, 422
tophi, 523
ulcers, 77

Grafting of bone, 436
of epithelium, 12
of mucous membrane, 16
of skin, 11
of tissues, 10

Granulation, healing by, 5
tissue, formation of, 2
syphilitic, 146
tuberculous, 136

Granulations, 2

Granuloma, 42

Groin, cellulitis of, 59
filarial disease in lymphatics of, 326

Growing pains, 451

Growth fever, 451

Gumma, 168
of bone, 464
peri-bursal, 521
periosteal, 521
peri-synovial, 521
subcutaneous, 76
syphilitic, 168

Gummatous infiltration, 168

Gunshot wounds, 225, 227, 230

Hæmatemesis, 259
post-operative, 275

Hæmatoma, 220
bursal, 426
pulsating, of bone, 498

Hæmaturia, 259

Hæmophilia, 277

Hæmophilic joint, 531

Hæmoptysis, 259

Hæmorrhage, 266
arrest of, 266, 270, 272, 274
arterial, 259
capillary, 260
cautery in, 271
constitutional effects of, 275
digital compression in, 269
external, 259
forci-pressure in, 271
intermediate, 272
internal, 259
ligature in, 270
in operations, 269
prevention of, 269
primary, 266
reactionary, 272
saline infusions in, 276
secondary, 273
styptics in, 271
torsion in, 271
tourniquets in, 270, 272
toxic, 275
from varicose veins, 292
venous, 259

Hæmorrhagic diathesis, 277

Hæmostatics, 271

Hair, syphilitic lesions of, 159

Hand, claw-, 369

Hands, disinfection of, 244

Hard chancre, 151

Healing by blood-clot, 6
by first intention, 2
by granulation, 5
by primary union, 2
rate of, 9
under scab, 6
by second intention, 5
sore, 69, 81
ulcer, 77
by union of granulating surfaces, 5

Heart, massage of, 265

Heberden's nodes, 529

Hectic fever, 62

Heliotherapy, 139

Hernia, fatty, 187
of muscle, 408

Herpes, syphilitic, 156

Hilton's method of opening abscess, 50

Hodgkin's disease, 377

Horns, varieties of, 389, 391

Housemaid's knee, 426, 431

Hunter's operation for aneurysm, 307

Hutchinson's teeth, 177

Hydatid cysts, 213
of bone, 467
of muscle, 421
thrill, 214

Hydrocele of neck, 328

Hydrophobia, 115, 118

Hydrops, 501, 518

Hygroma of axilla, 328
bursal, 427
of neck, 328

Hyperæmia, 32
active, 39
artificial, 36
passive, 38
in tuberculosis, 138

Hyperostosis, 435
syphilitic, 464

Hypertrophic pulmonary osteo-arthropathy, 480

Hysterical joint affections, 537

Ice-bags, 41

Ichthyma, syphilitic, 158

Igni-puncture in nævus, 297

Iliac aneurysm, 318

Immunity, 22

Imperial drink, 40

Implantation cysts, 212

Infantile scurvy, 473

Infection, accidental, 241
by catgut, 51
mixed, 20
prevention of, 243
of wounds, 241

Inflammation, 31
changes in, 32
chronic, 42
clinical aspects of, 33
constitutional disturbance in, 35
general principles of treatment in, 36, 39

Inflammation, leucocytosis in, 36
stages of, 32

Infusion of saline solution, 276

Ingrowing toe-nail, 403

Inguinal aneurysm, 318
lymph glands, 323

Injuries, 218. _See also_ Individual Tissues and Regions
constitutional effects of, 249

Innominate aneurysm, 314

Inoculation tubercle, 382

Insects, poisoning by, 130

Instruments, sterilisation of, 245

Intercostal fibrositis, 413

Intermittent claudication of vessels, 98

Internal popliteal nerve. _See_ Tibial Nerve

Interstitial keratitis, 177

Intestine, repair of, 9

Intoxication, bacterial, 21

Intracranial aneurysm, 316

Intra-cystic growths, 202

Intubation of larynx, 111

Involucrum, 443

Iodine, catgut, 246
for disinfection of skin, 245
reaction, 30

Iodoform gauze, 247
injection of, 142
in joint diseases, 519

Iritis, syphilitic, 160

Irrigation, continuous, 54

Irritable ulcers, 79

Ischæmic contracture of muscles, 415

Ischial bursa, 430

Ischias scoliotica, 372

Ivory exostosis, 481

Jaws, actinomycosis of, 127
changes in, in rickets, 470
cystic tumours of, 193

Jigger, 130

Joints. _See also_ Individual Joints
ankylosis of, 503
bacterial diseases of, 506
bleeder's, 531
Charcot's disease of, 533
chondromata, multiple, of, 544
contracture of, 502
cysts of, 538
developmental errors of, 505
diseases of, general, 501, 506
disorganisation of, 502
empyema of, 501
gelatinous degeneration of, 515
gliomatous arthropathies, 534
gonococcal affections of, 510
gouty affections of, 522
hæmophilic, 531
hydrops of, 501
hysterical affections of, 537
impaired mobility of, 502
iodoform in diseases of, 519
loose bodies in, 529, 539
mimetic affections of, 537
nerve lesions affecting, 532
neuro-arthropathies, 532
osteo-arthritis, 524
pneumococcal infection of, 509
pyæmic affections of, 508
pyogenic diseases of, 506
rheumatic affections of, 523, 524
rigidity of, 502
scarlet fever, infection of, in 508
spinal diseases affecting, 532
starting pains in, 502, 517
synostosis, 503
syphilitic diseases of, 521
tuberculous diseases of, 512
tumours of, 538
typhoid infection of, 508
white swelling of, 515, 518

Jumper's sprain, 406

Keloid, 194, 401

Keratitis, interstitial, in syphilis, 177

Keratoma of nail bed, 391

Kharsivan, 163

Klapp's suction bells, 39

Klebs-Löffler bacillus, 109

Klumpke's paralysis, 361

Knee, cellulitis of, 58
ganglion of, 215
housemaid's, 426, 431

Kopf or cephalic tetanus, 116

Kyphosis, 471

Labourer's back, 405

Larynx, syphilis of, 177

Leeches, 41

Leg ulcer, 72
varicose veins of, 287

Leiter's lead tubes, 41

Leontiasis ossea, 485

Leucocytes, emigration of, 32
varieties of, 29
wandering, 3

Leucocythæmia, 340

Leucocytosis, 22, 29
absence of, 30
digestion, 30
after hæmorrhage, 30
local, 32
physiological, 29, 30
post-operative, 30

Leucopenia, 30

Leucoplakia, 167

Lightning stroke, 240

Line of demarcation in gangrene, 87

Lingual dermoids, 211

Lipoma, 184
arborescent, 423
of bone, 187, 491
diffuse, 187
intra-muscular, 188
multiple, 186
nasi, 393
periosteal, 187
subcutaneous, 184, 186
subserous, 187
subsynovial, 187

Lipomatosis, diffuse, 187