distance from the sides. His gait is consequently very constrained and insecure; he often falls, especially when treading on an uneven surface. He cannot play with other children: his stature is short, compared with his younger brother. A closer examination of the limbs demonstrates the absence of structural shortening of muscles of calf or flexors of the knee, by which, if present, the elevation of the heels and bending of the knees could have been explained; no contracture of either of the ankles or knees therefore exists. The hip-joints are rigid, the thighs being fixed at nearly a right angle with the pelvis, and both are adducted so that one knee cannot be separated a hand's breadth from the other. Motion in either hipjoint can be with difficulty distinguished; the flexor and adductor muscles are very tense, and resist extension and outward rotation of thighs. When in the recumbent position, great hollowness in lumbar region exists; but on elevation of both knees, the spinous processes of the lumbar vertebræ touch the couch. It is therefore apparent that immobility of both hip-joints exists; and as these were the only articulations directly involved, I concluded, with the assistance of Mr. Norwood's history of the case, that the state of the hipjoints was that of false ankylosis. No displacement of the head of either femur was present.

It was not difficult to connect this state of the parts with the abscess that had formed in the left hip, but it was difficult to form an opinion whether the inflammatory effusion and suppuration had, in that hip, taken place exterior to the capsular ligament or within it; and, although external suppuration had ensued in one hip, whether disease of both articulations had not existed, internal suppuration only having been present in right hip. The opinion I entertained was, that, as a consequence of the prostration of strength at the period of decline of the eruption of scarlet fever, metastatic asthenic inflammation had attacked the hip-joints, accompanied by effusion of ill-conditioned plastic matters; that in the left hip, imperfect transformation of effused matters into pus and external suppuration took place; and that in right hip the effused matters were reabsorbed, adhesions in both cases, in the tract of the effused matters, having increased the immobility of the joints, primarily induced by long-continued rest of the muscles in the flexed and adducted position of the limbs. I was in doubt whether the disease had not been within the synovial membrane. Mr. Norwood had also been unable to determine this

point from observation of the earlier symptoms. As displacement commonly succeeds suppuration within the synovial membrane, it might have been inferred, from the absence of displacement of the head of either femur, that the suppuration had been exterior to the articulation-among the muscles only; but, as exceptions in this respect do occur, farther evidence became necessary to complete the diagnosis. It appeared to me doubtful, also, whether so great an amount of rigidity could have resulted from simple adhesions among the muscles.

Such being the view I was induced to take, after full consideration of the case, I recommended the endeavour to elongate the flexor and adductor muscles, and any adhesions existing in or about the joint, by manipulations and instruments. Gradual extension of the thigh was attempted, by placing the patient in recumbent position on table, and fixing the pelvis with one hand on the edge of the table, the knee being depressed with the other. An apparatus was contrived for gradually effecting separation of the knees; it consisted of male and female screw placed between the knees, acting on each through the intervention of appropriate pads. I had occasional opportunities of examining the child during the ensuing months; the only progress observable consisted in increased separation of the thighs to the extent of three inches. After further delay, no improvement of gait being perceptible, I proposed, as an adjuvant to the mechanical treatment, section of the tense muscles around the articulation, which were accessible. I divided, accordingly, the origins of pectineus, adductor brevis, add. long., add. magnus, and rectus femoris, on both sides. Manipulations were recommenced three days afterwards on reunion of the punctures. This was succeeded, in a few days, by separation of thighs to nine inches, and within a month to twelve inches, and ultimately to sixteen inches. So much was gained with respect to extension of limb, that in the recumbent position the knees could be depressed to the couch, the hollow in the loins being nearly obliterated. But although this great change in extent of mobility of the hip-joints existed, the whole of the deformity returned on the patient's attempting to walk. A mechanical contrivance, consisting of steel supports, extending from the ankles to the waist, with springs to maintain extension of the hips and knees, was recommended. In this he could stand erect, the heels touching the ground, and the anterior protrusion of the

lumbar vertebræ being obliterated; but as its use was very irksome, and attended with excoriations, it was soon abandoned. The manipulations were continued until, on one occasion, the child having complained of unusual pain, I ascertained, on examining the limbs, that distinct grating sensations and sounds were perceptible on motion of right hip. The uncertainty in diagnosis, previously alluded to, was removed by this distinct evidence of an altered condition of the synovial membrane, or articular cartilages. The fear of reproducing inflammation of the joint urged me to recommend discontinuance of active manipulations; and as, owing to separation of thighs, he was now enabled to ride comfortably, exercise on a pony in open air was permitted. The lapse of a few weeks shewed that no disease of the hip had been excited; but as the child's health had in some degree suffered from the treatment, and the suspicion of original disease within the articulation was confirmed by the discovery made during the manipulations, and the parents were anxious to incur no risk of increasing the child's affliction, I reluctantly determined to discontinue the application of restorative measures.

Remarks on preceding five Cases of false ankylosis of hip. -Case I. illustrates the extent to which contraction of knee may be relieved by section of gastrocnemii. In Case II. the increased abduction of the affected femur was, for obvious reasons, not the smallest of the advantages derived from the treatment. The observations page 38 will have prepared the reader for the relation of a series of cases not very brilliantly illustrating the advantages of tenotomy. The results in Cases I. II. III. IV. quite equalled my expectations, and the anticipations of the patients. I was disappointed in Case V. only; but I still entertain the opinion, that cautious perseverance in frictions and manipulations, and the assistance of mechanical supports in the manner described, would ultimately enable this patient to walk tolerably well. I have at present under treatment a similar series of cases, more recently operated, the whole of which will, I believe, receive considerable benefit; the deformity, and the fatigue of taking exercise, being diminished, and the gait rendered less unsightly.

CASE VI.

TRUR ANKYLOSIS OF THE KNEE, PRODUCED BY A PUNCTURED
WOUND OF THE ARTICULATION.

Division of the biceps femoris, semi-membranosus and semi-tendinosus muscles, fascia, &c.

AUGUST 9, 1841. T. N., æt. 17, admitted into Orthopaedic Institution. Reports, that nearly three years since, he accidentally punctured the knee-joint by driving a nail into it. Intense inflammation succeeded the injury: the tumefaction was excessive, and the constitutional disturbance violent, requiring blood-letting, the application of a large number of leeches (the integuments appear covered with the cicatrices of their bites), and other remedies. The patient's statement is corroborated by that of his father, an intelligent man; who also mentions, that the surgeon, who so successfully combated the inflammation, gave the opinion that the articulation had been opened. No suppuration took place. The limb appears to have been necessarily laid on the outside, semi-flexed, during the protracted illness of the patient; in this position it became contracted. The son and parent are positive that the contraction has neither augmented nor decreased since the inflammation subsided, and they have never been able to perceive motion in the joint. The surgeons who have since examined it have pronounced the knee to be completely ankylosed. He is compelled to use a crutch.

The knee is flexed nearly to a right angle; the tibia is slightly rotated outwardly, but no deformity of the joint exists. A total absence of motion, and an apparently fixed state of the patella, indicate the probability of union between the articular surfaces having taken place. The attempt to press down the knee produced no tension in the popliteal muscles; no sensation of stretching in the ham, or pain in front of the articulation.

The most careful and often-repeated examination of the patella, assisted by my colleague Mr. Tamplin, did not afford satisfactory information with reference to its mobility. Although we believed its edges could be alternately depressed, so much doubt existed, that, in recommending the operation to the patient's father, he was informed of the probability of failure; but being assured that, if unsuccessful, the young man would not be in a worse condition than

before, the proposition was cheerfully acquiesced in, as the sole chance of relief from so severe an affliction.

The tendons of the biceps femoris, semi-membranosus, and semitendinosus muscles, with numerous fibres of the vastus externus, and several bands of thickened fascia, as well on the posterior aspect of the limb, as those portions attached to both tuberosities of the tibia, were divided subcutaneously. On complete section of the whole of these tissues, firm pressure having been continually maintained on the leg, to render them if possible more tense, a loud cracking grating sound was suddenly heard and felt, evidently resulting from the yielding of structures situated within the joint. The limb at the same moment was straightened several degrees. No attempt was made to straighten it more completely; the punctures in the integuments were dressed in the ordinary manner, and the limb ordered to be kept quiet, in its contracted state.

The limb was free from pain within half an hour after the operation, and the punctures healed without an unfavourable symptom.

On the third day, the apparatus for extension was applied, and with very moderate pressure and little pain the limb was rapidly straightened. Within three weeks it was perfectly extended. At the expiration of the fourth week, no sign of inflammation having occurred to render extraordinary precaution necessary, he was permitted to use the limb. Passive motion, frictions, and manipulations, were recommended. Considerable pain was experienced during the attempt to bend it; but did not interfere with his taking exercise, the limb being supported with a firm steel stem on the outside, to prevent too great strain on the articulation so recently restored to function. Sept. 17. He was discharged, to attend as out-patient.

The subsequent reports of this case confirm the favourable account already given; the lad walks perfectly well; within three months after the operation he was enabled to bend the knee, and complained of no pain after exercise. Although accustomed to those agreeable feelings which are usually experienced by the medical practitioner on the realisation of his hopes of successful treatment, and relief of patients from suffering, I cannot describe the gratification and surprise afforded me by the prompt recovery of this case, which I had considered one of peculiar difficulty and uncertainty.