them, and at the same time will not materially increase the flow of pus either as regards quantity or rapidity through the incision. -I think this a most important point in the differential diagnosis. A symptom I had expected to be reliable in diagnosis, the existence of starting pains, which is a clinical symptom almost held to be pathognomonic of the presence of ulceration of cartilage in joint disease, I have not found absolutely reliable. I believe this symptom may exist without that condition of necessity existing, especially in those conditions of peri-articular suppuration where the sheaths of the tendons are the parts affected; it was a marked symptom in the case I related of disease of the ancle joint, where the progress of the case I think satisfactorily proved that the joint itself was not implicated.

In cases of acute disease around joints, where the joint itself is not implicated in the disease, I have noticed that the pus being once evacuated, either by the natural process of bursting or by incision, the pain at once almost completely disappears, while in cases of joint disease, although there may, under these circumstances, be a great alleviation of constitutional irritation and a considerable alleviation of suffering, pain will still remain a prominent symptom, and those starting pains which should disappear if the disease be limited to the exterior of the joint will still continue a great source of distress to the patient. This absence of pain after the evacuation of pus was very marked in all the cases that have come under my notice, and I think deserves considerable attention, and indeed may be held as reliable as differentiating between intra- and extra-articular conditions. I have at present under my care a man with what I diagnose as peri-articular inflammation of the knee. There is stiffness of the limb with long-standing sinuses, but the joint may be handled and shaken without causing pain, a condition which would I think be impossible if the joint were involved. Briefly stated, sinuses around a joint associated with severe pain, especially with starting pains, indicate articular disease. This is no new surgical dogma, but I believe the converse is equally true, though I think not as frequently recognised, that sinuses

around a joint where there is an unusual absence of pain indicate, or at least suggest, a strong probability of the disease being limited to the exterior of the joint.

I now propose to say a few words on the treatment of these somewhat rare and obscure conditions. First, with regard to the cases of an acute nature. I know of no way in which we can assure ourselves that inflammations ending in suppuration around deep joints are limited to the exterior of the articulation. I have therefore nothing special to suggest with regard to their treatment, that is in the early or acute stage. We must wait until the presence of pus is fully assured and then evacuate it. It would not be safe to do as we do in cases of periostitis, that is incise as early as possible, even before we are quite certain of the presence of pus. An incision under such circumstances can do very little harm and may do great good by limiting the stripping of the periosteum and the subsequent death of bone, but in peri-articular inflammation of a deep joint the danger of penetrating the joint, or even of opening up layers of muscles hitherto not involved would, I think, forbid such surgical interference. I think, however, that the progress of the case should be jealously watched and pus set free at the earliest possible date that its existence can be determined, as by this course, if the disease should turn out to be peri-articular only there will be much less burrowing between the intermuscular planes and, while the ordinary advantage of limiting the duration of the febrile condition and the size of the abscess cavity will be secured, we shall also attain, or at all events do our best to attain, the limitation of the extent of the number, of the length, and (if you will excuse the word) the sinuosity or tortuosity of the sinuses. that may remain, indeed an early incision might prevent the formation of a troublesome sinus altogether. The abscess might, and under such treatment would be placed in the most favorable condition to heal without giving much trouble to the patient or entailing upon the surgeon the necessity of any future surgical proceedings. But unfortunately these cases rarely come under our notice in time for our art to attempt to avert these serious contingences.

There is a foolish but prevalent popular notion, one almost universal amongst the poor, that abscesses should not be opened until they are ripe, and that nature is the best surgeon; that if allowed to evacuate themselves there will be an end to the business, but if they are evacuated by the knife of the surgeon the patient is doomed to a persistence of gatherings, in that or some other part; or will be visited by some dire disease, from the matter which should have accumulated at its original home having flown about him. I say this popular but most dangerous prejudice rarely allows the case to fall under the notice of a surgeon until all the damage that delay can effect—and in few cases can delay effect greater damage—has been accomplished; and when the case comes under our notice, possibly, I might almost say probably, after the discharging sinuses have existed for months if not years, we shall find that we have to treat a case which will tax all the resources of our art, even if we find the disease limited to the exterior of the joint near which the sinuses lie.

I will now shortly explain the principles and describe the procédé of the treatment I propose for sinuses around but unconnected with joints. I have explained already why such sinuses are not amenable to the treatment of similar conditions elsewhere, as, for example, in connection with the breast. The principle of the treatment I suggest is really only a modification of what I may call the conventional treatment of sinuses. As circumstances prevent our converting a narrow sinus into an open wound, I endeavour to convert it into a wound as open as conditions and circumstances will allow. My object is to convert the narrow, tortuous sinus into a straight, conical wound, or, at all events, into a wound as straight and as conical as I can. I therefore make a free incision through the mouth of the sinus, in most cases to the length of two inches. Through this I pass my finger into the sinus, thereby dilating and stretching it. I endeavour to penetrate to the extreme end of the sinus and into any diverticula that may be present. I am often able to lessen the number of tracks by forcibly tearing by the finger one into another. Whenever I can I secure the

advantage of a counter opening, but failing this, I am not discouraged, but proceed with deliberation and extreme care to carry out the principle I have enunciated, viz., of making the track assume the shape of an inverted cone, the apex being the blind end, the base being the incision through the mouth of the sinus. I would however desire to impress upon you, as necessary to ensure success, that every diverticulum must be treated in the same way and with the same care as the chief sinus. It commonly happens that dilatation with the finger is sufficient. It occasionally occurs that at some part, possibly a deep part, of the sinus a dense unyielding band is felt upon which the finger makes no trace. To leave this would be to jeopardise the success of the operation. The free egress of pus would be prevented, accumulation would occur, and the sinus would not contract and heal. This band must be divided; and as it cannot be attacked with safety by the knife, from its depth and its surroundings, it is best disposed of by being forcibly stretched by forceps. These are passed along the wound closed, and then opened and forcibly withdrawn. There is often free hemorrhage from this procedure, but 1 have never seen it such as to give cause for any anxiety, and it is readily arrested by pressure or by plugging the wound. The limb is lightly dressed, care being taken that the dressing in no way impedes the egress of the discharge. For this reason picked oakum, which is very absorbent, constitutes a very good dressing.

I omitted to say in my description of the operative procedure that it is advisable to scrape well the walls of the sinus throughout, so as to remove as completely as possible all granulation tissue. The operation and dressing completed, the limb should be immobilized, if possible absolutely, but failing this, as completely as possible. For example: A hip, to which a starch or plaister case could not be conveniently applied because of the discharge, should be supported by sand-bags from the hip to the ancle, and should further be steadied by sand-bags, or supported by weight and pulley, or be slung.

I think it well to briefly epitomise this somewhat discursive paper. I claim the existence of cases of peri-articular disease. I divide them into two classes as occurring in superficial and in deep joints. I know of no means of differentiating with certainty between intra- and extra-articular disease in deep joints in the acute stage. In superficial joints, before the occurrence of sinuses the peculiar phenomena I describe as occurring in opening the abscess are an important aid to diagnosis, while the remarkable absence of pain after the spontaneous or surgical evacuation of pus, strongly suggests the presence of disease outside the joint only. On this account I emphasize the necessity of extreme caution in opening doubtful abscesses near joints.

Finally, I hope and believe the manoeuvre I have described in treating sinuses around but unconnected with the deep joints, and which I might term the conization of sinuses, may be a real help in the surgical treatment of a very troublesome and hitherto a very unsatisfactory class of cases.

PRACTICAL OBSERVATIONS ON CHRONIC

HEART DISEASE.

BY ALFRED H. CARTER, M.D. LOND., M.R.C.P.,
PHYSICIAN TO THE QUEEN'S HOSPITAL, BIRMINGHAM.

(Continued from page 150.)

If we turn our attention to the course of chronic cardiac disease we also cannot fail to be struck with the general uniformity by which it is characterised, independently of its precise pathological nature. The differences which occur are mainly related to the primary localisation of the trouble on the left or right side of the heart, and the vital potentiality of the heart-muscle.

In the first instance the troubles are chiefly of a physical kind. Thus, the heart is imperfectly emptied, and accordingly, the arteries are imperfectly filled, the veins are over-filled, and the circulation as a whole is retarded. When the source of disturbance is confined to the left heart, as happens in a majority