swell after continued exertion.

The swelling which in the beginning is hardly noticeable is now more
plainly visible, the knee-joint is evenly rounded and quite sensitive to
pressure.

If the disease is not now properly treated, its further course will be
as follows: the patient may perhaps linger for several months; then
comes a period when he must keep to his bed uninterruptedly because
moving results in too much pain; generally the limb becomes more and
more bent.

Now particularly painful points appear on the joint, especially on the
inner or outer side or in the bend of the knee; on one of these points a
soft portion distinctly developes, the skin becomes reddened and finally
suppurates from the internal parts outward and breaks after a few
months; thin purulent matter mixed with flakes is discharged. The pains
now cease, and the condition is improved; but this improvement does not
last; soon another abscess is formed and thus it continues.

Meanwhile perhaps two or three years may have elapsed; the general
condition becomes greatly reduced. The child, formerly strong and
healthy, has now become lean, the discharges of matter have often been
attended by acute febrile attacks; the patient becomes exhausted, loses
his appetite and digestion becomes more impaired from week to week. Even
now a spontaneous change for the better is possible, though this happens
very rarely; more frequently the disease progresses and leads to death
from exhaustion resulting from severe suppuration and continual attacks
of fever.

Restoration to health is indicated by decreased suppurative discharges;
the openings of the fistulae contract, the general condition is
improved, the appetite is restored, etc. Finally the fistulae heal, the
joint becomes fixed at an angle or bent or otherwise crippled, but
painfulness disappears and the patient escapes with his life and a stiff
leg. This is the most favorable result known to have been obtained in
severe cases. The joint may become a solid bony immovable mass or may
admit of slight movements. The whole process may last from two to four
years.

The former treatment of tuberculous inflammation of the knee-joint was
either of a general or a local nature. The general treatment was
designed to strengthen and nourish, and will continue to be applied in
the future.

The local treatment consisted in the application of salves, brushing
with tincture of iodine, spanish fly plasters, wet and dry b