apprehension of examination as those affected with true ankylosis, unless they may have already been subjected to painful investigation; and a delicate nervous female would be sensitive to impressions whether affected with complete or incomplete ankylosis. It is scarcely necessary to mention, that in a supposed ankylosis, the practitioner should be quite certain no tenderness of the articulation from the previous inflammation remains. A completely ankylosed limb also conveys to the hand of the examiner a sensation of union throughout; the tibia and femur in true ankylosis of the knee give the impression of a single bone; and many of the patient's sensations in the limb are referrible to a want of elasticity, which is not absent in false ankylosis even when no motion is visible. Thus, in true ankylosis of hip or knee, the patient is more susceptible to shocks consequent on any sudden exertion-the whole frame may be jarred by an unexpected false step. This is in great measure obviated by the flexibility of the ankle, and powerful action of the gastrocnemii; for as in ankylosis of hip or knee the joint is usually flexed, the patient is compelled to apply the toes only to the ground, and the elasticity of the gastrocnemii may, in some degree, compensate for the stiffness of the affected joint. In true ankylosis of the ankle, the sensibility to shocks reaches its maximum, as no compensating power exists unless the patient walk with the knee slightly bent. This jarring may be painfully felt in the spinal column. The prognosis of stiff-joint is in the great majority of instances favourable. A somewhat prevalent opinion exists, that true ankylosis is not uncommon, whereas extended observation shews that it is comparatively very rare. This is sometimes a satisfactory preliminary information to possess on the examination of a doubtful case of deformity; for although capable of leading to error, the practitioner may be enabled to undertake, with more confidence, a case which but for this circumstance would be hopeless. Angular is more amenable to treatment than straight ankylosis, and is fortunately the more common affection. The proportion of individuals who apply for the cure of straight ankylosis does not, according to my experience, exceed one-fiftieth of those affected with the angular form. Thus, during the last seven years, I have witnessed three cases only of straight ankylosis of the knee.* TREATMENT OF ANKYLOSIS IN GENERAL. The cure of stiff-joint is accomplished by mechanical and chirurgical means, employed singly or conjointly. A large proportion of cases of false ankylosis, being those in which the rigidity depends on muscular contraction without structural shortening, and with little adhesion of the tissues on the flexed side of the joint, yield to the agency of the first class of remedies. The simplest case of stiff-joint is that which, for a few days or weeks, has been immovable from inflammation of the articulation, without its termination in any disorganising process. Popular practice, based on experience, consists in the energetic employment of frictions and passive movements, by which the stiffness is gradually removed; volition returns, and the part is restored to activity. In a higher degree of rigidity, medical practitioners add the use of steam and vapour baths, oleaginous (relaxing?) embrocations, fomentations, shampooing, and the application of mechanical instruments. It is difficult to state after how long a period of immobility a joint may be restored by mechanical appliances. We are credibly informed, that in India religious * The statistics of this subject, derived from the relative numbers of individuals affected with either form who apply for relief, may reduce too low the proportionate frequency of straight ankylosis. As locomotion can be effected with straight ankylosis of knee, persons thus affected may rarely seek the means of cure. devotees, after twenty years' duration of voluntary contortion of the limbs, are restored to symmetry and activity by the energetic manipulations of the native medical practitioners. It appears not improbable, that a greater natural looseness of the articulations in the inhabitants of warm climates, and some influence exercised by an elevated temperature, in relaxing the contracted tissues, may favour this result of oriental skill and perseverance; but the practitioner who would expect similar good fortune in our climate would be disappointed. The difference between the relative facility of elongating the muscles of adults and children has already been alluded to (p. 7). In a favourable case of false ankylosis in an adult, we may succeed in effectually straightening the limb after the lapse of four or five years; but it is rarely possible in a child, unless of very lax fibre, permanently to relieve, by mechanical means, a severe contraction of similar duration. Great muscular shortening in the child is with difficulty overcome; but whatever resistance to straightening depends on cicatrices and adhesions, will be more easily removed in the child than in the adult. Where the immobility and contraction is considerable and of long duration, has resisted proper mechanical appliances, and principally or greatly depends on muscular shortening, the propriety of resorting to surgical means should be entertained. These consist in the section of the tendons of the contracted muscles and ligaments, and of those bands of fascia and adventitious tissue which are situated within easy reach of the scalpel, followed by the application of appropriate mechanical apparatus, frictions, and manipulations. In the mode of operation, the Stromeyerian method—namely, that of subcutaneous section-should be followed, and the limb be suffered to remain at rest in the ankylosed position until the small punctures have cicatrised. The limb should then be gradually extended or flexed, as the nature of the ankylosis may require the progress of this part of the treatment being slow or rapid, according to the size of the joint affected, and the degree of dependence of the resistance to restoration on the superficial or deeply situated tissues around the articulation.* The length of time requisite to effect a cure varies from one week to six months; and occasionally a much longer period elapses before the articulation entirely resumes its functions. The treatment by the combined surgical and mechanical method may be divided appropriately into three stages: the surgical operation, the mechanical reduction of the ankylosis, and the period employed in restoring freedom of movement by passive and active exercises, frictions, manipulations, baths, &c. The first and second stages usually engage but little time; the last, which is commonly of longest duration, becomes often very tedious. The cure of false ankylosis requires, under the most favourable circumstances, the union of skill, great care, patience, and perseverance; and its accomplishment in some instances is so difficult as to discourage both patients and practitioners who are not endowed with the qualities above mentioned so essential to success. The length of time during which an articulation may have been in part or wholly immovable, remaining, nevertheless, capable of restoration, appears sometimes incredible. I have successfully undertaken the cure of ankylosis of the most important articulation, the knee, which had existed twenty-six years. Restoration after ten and fifteen years' deprivation of the services of an articulation is not uncommon. True ankylosis, or osseous union of the articular surfaces, having been regarded as a fortunate termination of articular disease, has rarely been the subject of curative attempts. * See remarks on the "forcible sudden cure of angular ankylosis," in Introduction. The most notable and most ingenious of these is the relief of true ankylosis of the hip, by Dr. Barton of Philadelphia, by sawing through the neck of the femur, and, after obtaining closure of the external wound, resorting to daily movement of the limb, so as to produce an ununited bone, an artificial joint. This operation, in Dr. Barton's case, succeeded perfectly; in the hands of other practitioners, it has been alternately successful and fatal. It is an operation infinitely preferable, in my opinion, to that proposed for the relief of true ankylosis of the knee, by my friend Prof. Dieffenbach, of Berlin; namely, breaking down the osseous union by chisel and mallet. I entertain no doubt of the capability, in some instances, of restoring motion in an articulation between the surfaces of which the deposit of osseous particles has already commenced. I have thus successfully treated two cases of ankylosis of the knee-the one resulting from a punctured wound, the other from fracture, extending into the articulation, produced by the fall of a heavy stone on the limb,accidents both peculiarly apt to produce true ankylosis. In neither case, before subjected to treatment, could the slightest motion between the articular surfaces be detected. The previous history, the local examination, and the phenomena witnessed during the treatment, concurred in indicating the existence of incipient osseous union between the articular extremities (see Cases). ON ANKYLOSIS OF THE HIP. Inflammation of the hip-joint, acute and chronic, may be induced by mechanical injury—a blow, or fall, on the part; or it may arise as a sequela of typhus, scarlatina, and variola, or other general disturbance of the health of the individual. Rheumatism is an occasional cause; but more commonly the inflammation partakes of that specific character denominated strumous. By whichever cause the inflammation is produced, D |