In the course of the last few months I have used calcium chloride occasionally as a hæmostatic agent, and the publication of Prof. Wright's paper led me to look up the notes of the cases in which it was employed.

The first of these was a middle-aged woman with chronic jaundice of six months' duration, believed to be due to an impacted gall-stone. She suffered from pretty free hæmorrhage from the rectum, apparently proceeding from some internal piles, but the bleeding was decidedly more than we should have expected from the state of the bowel. Our first efforts were directed to remove the hard fæces which could be felt in the rectum by the use of olive oil injections, and to keep up a daily action of the bowels by the administration of saline aperients; but as after fifteen days these means failed to check the bleeding, calcium chloride in small doses was administered. every four hours, with the satisfactory result that after five days the hæmorrhage ceased and did not return.

The next case was even more striking, as it was that of an elderly woman admitted with purpura hæmorrhagica, that is to say she had a purpuric rash over the body and limbs, free bleeding from the gums and slight hæmaturia. The free use of ergot, gallic acid, and acid infusion of roses not having been followed by any benefit, on the third day after admission she was placed upon small doses of calcium chloride every two hours, after which the bleeding diminished, and five days later had ceased altogether, the patient making a good recovery.

In the third case, which was one of phthisical hæmoptysis, calcium chloride was used in combination with other measures, but in spite of all treatment a profuse hæmorrhage set in which carried off the patient. At the autopsy we found an aneurism of the pulmonary artery projecting into a cavity, a condition which sufficiently explained the futility of our remedies.

With respect to dose it is noteworthy that Prof. Wright found after giving one gramme of calcium chloride thrice daily for four days that the coagulability became enormously diminished, i. e., to over one hour, and on certain experiments upon himself he

believes this was due to the administration of calcium chloride having been carried too far, for he found that when too large a dose of the salt was added to decalcified blood in vitro, coagulability decreased, and on taking two grammes of calcium chloride three times a day the coagulability of his blood rose during the first twenty-four hours, returned to normal during the second, and in the third fell below normal, so that the best results may be looked for from comparatively small doses. In my cases the drug was administered in the form of the liquor calcii chloridi of the new pharmacopoeia, which is of the strength of 1 to 5, and the dose employed never exceeded thirty minims or six grains, though in the case of purpura this quantity was given every two hours during the day for some days.

NOTE ON TUBERCLE OF BONE AND OF JOINTS.

BY GILBERT BARLING, F.K.C.S.

THE laborious and patient investigation, not yet finished, into the pathological and clinical problems involved in tuberculosis has evolved out of the chaos which prevailed twenty years ago a definite knowledge of its causation, its method of spread, in fact of its life history, and with this knowledge has come the power which knowledge conveys, of successful treatment. This is especially true of tubercle as it occurs in bones and joints. In the treatment of bone and joint tuberculosis a thorough knowledge of the morbid anatomy of the disease and of the manner in which it spreads in the affected parts is most important, because surgeons endeavour now to attack the disease in an early stage, so as to limit, as far as possible, the amount of tissue which has to be removed in the hope of retaining as fully as possible the function of the part, at the same time of exposing the patient to little risk from the operation, and above all, to save him from the destructive tendencies of the disease.

It is necessary to bear in mind that tubercle may occur either

in the form of tubercles or tiny nodules, or as an infiltration, and nowhere does infiltration prevail to a greater extent than in bones and joints. There is in these tissues too a great tendency to caseation, perhaps more than in most parts. The absence of distinct tubercles must not be construed then as indicating that the disease is not tuberculous. Another point to which it is necessary to call attention is the great inflammatory thickening occurring around the tubercular processes, as though the bacilli had a widely irritating influence on surrounding parts, so that a few tubercles in one part of a synovial membrane may cause extensive thickening at parts that are comparatively remote.

It has for a long time been a matter of dispute as to where tubercular joint disease begins-whether in bone, synovial membrane, or cartilage. The last, I think, we may now exclude, so we have only an alternative, and the tendency at the present time is to regard tubercle of bone as the usual starting point of most tubercular joints. This is the opinion held by König, Cheyne, and Thomson, and is, in the main, no doubt correct; but the relative frequency with which the synovial membrane or the bone entering into a joint forms the starting point of tubercular disease of joints, varies with the individual joint. For instance, in the knee the synovial membrane is with some frequency the starting point of the disease; whereas in the disease in the synovial membrane is rare, and bone mischief is correspondingly common. whether the joint disease commences in one or other of these tissue is governed, to some extent, by the relation of the epiphysis to the line of reflection of the synovial membrane and capsule. Obviously, if an epiphysis is entirely within this line, it is more likely to be a source of infection to the joint than if it were outside it. Compare, for example, the epiphysis of the head of the femur with that of the head of the tibia.

hip, primary secondary to The question

Synovial tubercle we find varying somewhat; but far the most important variety, because the most frequent, is that which is best described as "diffuse synovial thickening," which, usually secondary to a tubercular bone focus, may be a primary con

The most common event is

dition in the synovial membrane. the perforation of a bone focus freely into the synovial sac, and a rapid infection of the whole interior of the synovial tissue. This "diffuse synovial thickening" may also arise from a bone focus which does not perforate into the synovial sac, but slowly extends into the outer layers of the synovial sac, where it is reflected on to the bone as at the upper margin of the knee joint. Here the tubercular focus in the synovial membrane may remain localised for a time, but eventually it spreads to the rest of the membrane. The same may be said of primary synovial tubercle; it may be localised at first, but eventually becomes diffused. These last two varieties, I believe, can at times be distinguished from the first-described.

A rare form of tubercular disease is one variety of hydrops articuli, in which, with the chronic presence of fluid in the joint, we have only slight general thickening of the synovial membrane, but pendulous outgrowths spring from the surface of the membrane. These may be very numerous, and are at times associated with rice-like bodies,

However synovial tubercle begins, it may end in tubercular abscess or cold abscess in the joint, either localised in pockets or diffused, and it may extend eventually to the tendon sheaths, etc., around the joint.

Tubercle of bone may be seen either as a periostitis or as an osteo-myelitis, or as a circumscribed caseous focus near the articular extremity of a bone, or as the condition known as caries-necrotica with sclerosis of the sequestrum. The tubercular process is essentially the same in all of these, and they merge one into the other; but, for practical purposes, it is useful to regard them as more or less distinct forms.

Tubercular periostitis, in my experience, is very selective; it attacks the bones of the skull, the ribs, and occasionally the vertebræ. Its tendency is to extend widely over the surface of the part involved, and so it may involve several inches of a rib, or several vertebral bodies, or some inches of the cranium, though here it remains circumscribed for a time, and has a

marked tendency to perforate both tables. I have at present under observation a man whom I have trephined for epilepsy due to the pressure of caseous matter from a widespread tubercular periostitis, which perforated the cranium and then spread between the bone and the dura mater. I have not seen a single case in which caseation and cold abscess has not eventually supervened.

Tubercular osteo-myelitis is most familiar, as it occurs in bones such as the bodies of the vertebræ, the metacarpals, the tarsal and metatarsal bones. Here we have the disease beginning in the medulla, causing in a certain number of cases a considerable thickening of the affected bone, with perhaps a sinus leading into its centre. The disease may be diffused throughout the medulla in the smaller bones, and produces a soft caseous mass of some extent, or occasionally small crumbly sequestra, this especially in the vertebræ and sacrum. The formation of a sequestrum involving a large portion of the thickness of the shaft of a long bone, such as results from acute infective osteo-myelitis, is rare; but I have now under observation a case of tubercular osteo-myelitis of the femur in which the sequestrum was very extensive, and formed quite acutely. In this patient fully half the length of the femur was involved, and there is great thickening of the lower two-thirds of the shaft. This osteo-myelitis may extend to the end of the bone it starts in and perforate into the adjacent joint cavity, giving rise to the "diffuse synovial thickening" above described. In the tarsus this is a common occurrence, and explains the difficulty there is in treating these cases satisfactorily. Perforation. into the adjacent joint may also occur when long bones are involved; and I have at present under observation two patients whose wrists I have excised, in each of whom tubercular osteomyelitis of a metacarpal bone extended to the wrist joint and infected the synovial membrane as well as the tendon sheaths around.

Perhaps the most common form assumed by tubercle in bone is the "circumscribed caseous focus" in the end of a long bone,