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Full text of "A Treatise on diseases of the joints"

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••"• " ■■•■ 



LOitlMIt : ritlTtTKI) BT v. CIxniTS AXb tt>Vf, KTAXFOKD trrxFRT 
AND 1.-IIARIXO ClflMt. 






PREFACE. 



NoTUiNO can be more* iiselese than to a|x>logisic for 
publishing a book — if the work be not good enougli, 
no excuse can improve it ; and if it worthily fill a gap 
in the literature of its subject, an apology is unnecea- 
eary. A treatise on diseases of the joints vf\\ni\ to, or 
rather beyond, the current knowledge of the day, has 
long been required^my professional brethren must 
judge, whether the ensuing pages may supply the defi- 
ciency. No author is fit to estimate his own work at 
the moment of its completion, but it may be permitted 
me to say, that the study of joint-diseases has very ranch 
occupied my attention, even from my studentship, and 
that for the last six or seven years, my devotion to that 
subject has been almost unremitting. Those minute 
investigations into the morbid actions of syno- 
vial membrane, cartilage, and bone, with which, by 
the publication of papers in various Quarterly and 
Monthly periodicaU, iny name is connected, were not 
undertaken so much from love for that sort of work as 
from a perception that certain links must be suj)plied, 
certain entanglements unravelled, and error, if any 
existed, corrected. The real weight of my work has 
been at the bedside, and the greatest labour devoted to 
inteq>reting s}Tni>toraH, and remedying their cause. A 



IV 



PREFACE. 



singular circumstance, in connection with those minute 
investigations, cannot however be passed over in 
silence. A desire having been expressed by some 
members of the Pathological Society, that my speci- 
mens, showing tubes in the articular lamella, should bo 
subject to other examination, a committee was appointed 
to report on them. My views, together with a Report 
(signed by Mr. Hulkc), appear in the Eleventh Volume 
of the Society 8 Transactions. Although, in the letter- 
press of the latter, the tubular nature of the lamella is 
denied, one of the lithogi'aphH has a more dentinal look 
tlian I, fearing exaggeration, would havt ventured to 
give. Indeed, if, as is the courteous custom of the 
Society, the Report had been placed before me pre- 
vious to its publication, I sliould have ventured to 
suggest to Mr. Rulke, that a lews markedly tubular 
appearance might bo given to his drawing. 

The subject of malignant joint-diseases has not been 
broached, as it appears rather to belong to a work on 
cancer, than to one treating only of a locality in which 
such a malady sometimes occurs. My best thanks are 
due to my colleagues, Mr, Hancock, and Mr. Canton, 
for the kind manner in wliicli thi^y have placed beds in 
the Hospital at my disposal ; even, witlj the greatest 
courtesy, have made over to my care several patients 
afHicted with those maladies, which I was engaged in 
studying. 

R. Barwell, 



22, Old Iiurlinstou-9trwU 
lite. 18G0. 



CONTENTS. 



CHAPTER I. 
Physiouxiigal Anatomy of the Joints. 

CHAPTER II. 

Acute Synotitis. 
Pa'.hology, Page 28 — SymptoniB, 45— Treatment, 53 — Cases, 57. 

CHAPTER in. 

Acute Rheumatism. 

Inflammatory Datnre, 64. 

CHAPTER IV. 

Pyarthrosis. 

PaUiology,79 — Local Symptoms, 87 — Treatment, 88 — Cases : Traumatic, 90 
— Uterine, 99— Gonorrheal, 101. 

CHAPTER V. 

Strumous Synovitis. 

Tathnlogy, 103— Symptoms, 119— Treatment, 133— Cases, 146. 

CHAPTER VI. 

Rheumatic STNOvms. 
Pathology, 159— Symptoms, 165— Treatment, 168— Cases, 174. 

CHAPTER VII. 

On some other Forms op Chronic SYNOvrris. 

Syphilitic, 181— Gouty, 186— Simple, 189. 



VI CONTENTS. 

CHAPTER VIII. 

H¥I)RA.KTHKOSIt>. 

Pathology, Payc 190— Symptoms, 195— Treatment, 196— Cnaes, 201. 

CHAPITER IX. 

On Loose Cartilages in the Joints. 
Pathology, 206— Symptoms, 208— Treatment, 210. 



ON DISEASES COMMENCING IN THE BONE. 



t^IIAPTEK X. 

Acute Articular Osteitis. 
General Account, 213, 

CHAPTER XI. 

Strumous Articular Osteitis. 

Pathology, 223 — Symptoms, 245 — Treatment, 255 — Cases, 269. 

CHAPTER XII. 

Chronic Rheumatic Arthritis (Osteitis). 

Pathology, 275 — Symptoms, 279 — Treatment, 282. 

CHAPTER XIII. 

Inflammation and Deoenekation of Cartilages. 

General Considerations, 287 — Degenerations, 290 — Inflammation, 292 — 
Atrophy and Hypertrophy, 295, 

CHAPTER XIV. 

Hip-joiNT Disease. 

Seuiciolc^, 296 — Treatment, 320 — Cases, 334— Appendix on tlie Apiiaifnl 
Lengthening of the Thigh, 336. 



CONTENTS. VII 

CHAPTER XV. 

Os Affections of Sywovial Suf.athbs and BursjE in thk 
Neighbourhood of Joints. 

Bursal Infiammntions, Page 343 — Affectionn of Sheathen, 349— 
Ganglia, 357. 

CHAPTER XVI. 

Hysteric Pseudo Disease of the Joists. 

Tathoiogy, 303 — Syraptom8» 365— Treatment, 372— Cases, 374. 

CHAPTER XVII. 

Ojf the Rkstoration op Mobility and Conformity to Crippled 

Joints. 

General, 37T— *^hoalder, 386— Klbow, 387— Hand, 389— Hip, 390— Knee, 39(1. 

CHAPTER XVIII. 

On the Removal of Diseased Joints. 

A. — CHrcumatances which justify removal uf a Diseased Joint, 408. B. — On 
Amputation and Excision, causes of preference for one or the other, 414. 
0.— On some points generally to be observed in Excising Joints, 42G. 
D.^-On the reparative Process after Excision, 427. E. — On the Excision 
of Special Joints : The Shoulder, 429— The Ellww, 432— The "Wrist, 435— 
The Hip^ 437— The Knee, 451— The Ankle, 463. 



LIST OF ILLUSTRATIONS. 



1. ClHCEIXI BENEATH THE AKTIcrijLB LuiEXLA PBOM TBS LOWGB 

Bin> Of Human Tibu, UAasfiriXD 10 puh8 ., 6 

2. DlTTO^ UOlfinBD 100 DIAJU. 9 

3. Ditto, jcaokthed 500 diajih... .. 9 

4. AjLTicrLAB Lahelxa seex or tub Sit&facb 10 

6. AATictn.Aii Caatiiaob, siioirure AjL&AUGxiuinoT Cklls, uaqvjwtmd 

ABOUT 700 DLAU9 12 

6. RkPtD SrttCMors Vlcbb op Cabtiuob, MAOiorrsD 500 diams. .. Ill 

7. Gradual TsAKBPOAHATioy or Cabtilaob 113 

8. Stbdmous Stnovitis of EiBOW 14A 

9. ., M or Kvut ISO 

10. „ „ OF Ancui .. 158 

11. „ ,t or Klbow 167 

12. Section of Feuvb of Rabbit^— HOSHAL—iuoiraFiu) 600 ouin. 231 

18. Ditto, iKnAJiKD—MAONiriKD 500 dixms. 231 

11. Lamina fkom Ca>czlu fbou ri'PZB Eks of Humas Taxx — 

NOUMAL — UAONlFIBIl GOO DIAMS 232 

IS: Lamina prom ditto pttto — oabioos — HAompiEo 600 diams. 238 

16. The AtTTHOB'a Extbndiso Spunt 266 

17. STBirUOUH OaTRITIH (IF ITand S69 

19. „ „ OP Kker ,. 271 

19. M » "P SiiouLujcB 27S 

50. HlP-DIBKAlB— FoeiTlOK OP LsvoTHBNura 303 

21. „ „ SaOBTBMVO 810 

23. DisKABBD AcBTAArLvai AKD Ukad UP Fbhttb 818 

23. Old Hip-moTAai — SnoRTSNisa wiTuorr Diblooatiox 819 

£4. WtBB Si'UNT FOB Uir-biSBASB IN Chilcbbh 881 

2b. Extending Splint wiTn Wibs Pklvic Band roK Hrp-uuKAei ■. 827 

26. ArruoB's Spmnt pob Flbxed Ilkbb 880 

27. Excision of thb llip — Condition aftbb Fofr DfaNTRa .. .. 448 

28. Condition found Ninbtkbn Montujj Arnot Excision or thb Hip — 

rxBIS IN BITD , 447 

29. Ditto Fsmob titrnbd out op Caittt 448 

80. ExoiHioN OP THE Hip — Condition TyrftMnt Ysabs aftbb .. 460 

51. Suobtenino Six Vkars attba Excision of thb Kkbb — piom 

Mb. Pkuuxutdn's Papeb 456 

82, CoNFOXMiTy APTXu BxciaiON of Knbk 462 



A TREATISE 



OS 



DISEASES OF THE JOINTS. 



CHAPTER I. 



PmrSIOLOGICAL ASATOMY OP THE JoiNTS. 

To tho fall nud clear oomprelionsion of the different disciises to 
which any or^nin may be subject, a (Mirfect knowloilj;*; of its 
ffLruoturo is the first aud m<wt m.oessjiry step; tlioreforo it ia 
dcsirabli*, tliiil uny work, which osjiires to ojx^n clear vie^V8 con- 
ccrning its diA^nsop, Rbnnld poramcucc l>y exposing the histolo- 
gical aud phyi^iolo^ncal coudttioiu of that part ; aud the more so 
if that author hold certain views differing from those of pre- 
vifMiH writers on thi^ subj«>ct. The joints tif tho body arc pene- 
raily uf a complicjiled nntnro, containing Hcvoml different eorte 
of tiflsue, and capable therefore of several iormn of the same 
diaease; aQduUhour;h it ih d<»ubtttK-{ true, that with some know- 
ledge of descriptive anatomy, and some clinical exjierienco, any 
one ia aide to set up an empiric and ooarso clasttifieation of 
nrtieuliir thst'ases. yet withitut a clear insight into the ]>Liymulogy 
of Joiiittf it in impusBible to have any very correct uotioua of 
thuir patholog}'. 

The snbject, to which theensiitng ihiiptera are devoted^ is the 
|uitholo)^' of moveable joints, and luirdly tonchoH Mi«in tho 
immovtsible. The diarthrodial or former of those articuliit ions in 
difrtiuguiiihed from the oilier not merely by its ptiwer of move- 
ment, but by the fact that in such mtivement one surittce must 
glido ov«r i!h* other. The py nortlirodiu] joint is not strictly §[)eak- 
ing, immoveable, for in one of ita four t'lass(!s a certain amount 
€<f motion in permitted, namely, in tho ainphiarthrosis. This joint 
RoiisiatB caaentiully in the jiixlapositioa (not contact) of two 

B 



PHYSIOLOGICAL ANATOMY 



CllAP. I. 



bonce Mrith a fibrous fiubstiinco iutcrpofi^'d, whicli nets shnnlta- 
ueoiisly as a bond of union and a means of Beparation, The 
motion, whereof this joint is capable, in jvcrniittid by the flexi- 
bility of the iibro-cartilage, not by any dii^tiuct moveiuent of 
one part over another. 

To our iilua of a diathrodia! joint is nccofisary, that at least two 
pieces of airtilage HbtJuUl be interposed between the bones of the 
articulation ; each piece of cartilage lining the end of each bonoi 
and being not continuous, but in contact, with the other. The 
gliding movement must ttikc place between these cartilaginous 
HurfiicoH, kept moist by a secreting membrane, which closes in 
the ciiviiy of the joint. The essential consttlueutii then of u 
diathrodial joint are : — 

Ist. — The bones, which are jointed together. 

2nd. — The cartilage, wliich lines tho ends of those bones. 

3rd. — Tho synovial Qkcmbrauc. 
IJut besides these are : — 

4tldy. — Ligaments binding tho bones together. 

5thly. — Frequently an interarticular fibro-cartilage. 

The bones, which enter into the formutiou of a joint, may bo 
two or more. In the acapulo-h urn oral articulation is on instance 
of two bones jointed together ; in the elbow of tluce, but two of 
ttiese only are essential to the joint as a hinge, the other l»eing 
added for purposes of its own (if it may be so expressed). In 
the ankle ure tliree bones e-saential to the joint, two forming a 
soclcul, into whieh the head of the third is received. The hip- 
joiut is composed in early life of four bones, but later it abrogiites 
this pceuliurity, the three, which formed the socket, becoming 
united into one. The shape of the articulating surfaces of tho 
bones determines the species and form of the joint ; descriptive 
anatomy divides them into four classea : — 

Ut.— Arthrodia, or flat joint 

2nd. — Enartbroeis, or ballHind-aockot-joint 

Hrd. — Ginglymufl, or hinge-joint. 

4th. — Uiarthroais, or pivot-joint. 

Tho different siiecies of moveraent, whicli theeo forms of arti- 
culation permit, hare been the subject of more or lees elaborate 
treatises, but the shape of tho joint surface has no influence on 
the aotiou of its diseases. 



OP THE BONK. 3 

The hones of the joint may be either long, flat-, or irregular, 
di^xwed iogetlier in any possible noramiitation ; tho larger and 
more im[)ortant ones have, besiilos their otlior rcntrc or eentrca 
of oesificntion, one ibr ea<;h joint extremity. Hio humerus, 
radios, fenmr, tibia, Jlcc, hare all this aeparatioa into diaphysie 
or shaft and epiphyses nr Joint Dxtremitios. The nlnviclo hae 
but one epiphysis at the only end, whieh forma a diartJirudial 

Ijointr the proximal. The metacarpal and moUUirMLl lH)ne9 
hare also but one epiphysis, which is in some inst-iuices at thr.' 
proximal, in oUiers at thi! distant extremity. The ^Imft of tlie 
bone begins to be ossiHed lon^ before the epipliysig ; about the 
sixth week of ftetal life is the earliest bony dopoait ; it takes 
place in the frmur, and at the ninth month most of the larger 
boues have inafle considerable pix^^css towards the fonuation 
of an osseous shaft ; hut the epiphyses remain cartilaginous for 
weeks, even months, a(%cr birth. 

It is not necessary to give her© an account of the ossifying 
proofs in cartilage, nor is it my desire to append an unnecessary 
and therefore pedantii' description of bone tissue; but, in order 
Uiat the jjutiiok^y of certain joint diseases may be rt-^jarde*] 

I &om the some point of sight as is token in t}u8 work, it is 
desinihle that tlin author's views of o^eons stmrturo should bf 

, clearly oxpimnded. Hone is gi?noJTiny liewrilK-'d as a eomjKtund 

lof vartihige ant] phosphate of lime, plentifully supplied with 
among whieh a lai^e uuuiber of branelunl cellu are 
in a more or less definite onler. Let us describe the 
stmcturo in the same Iangua;j:e differently placed, and say : — 
Uone consists of a jiumber of braneluKi cells, whose interstices 

' (intercellnhir spaces) are occupied by a comimund of cjutilage 
ood phosphat4.* of lime, and among wliieh vessels pass in a certain 
definite relation. I5y adopting thiw methc>d of descrijitinn the 
difierunt elements of which bono is coniiHiwHl are reduced to 
tl»eir pmixT relation — flrst the celle. then the intercellular sul> 
stance, and then the vascular supply, 'i'he cells of the bone 
I contained in the lacuiue,* the cell walls lino the spaces, and 
I nujoh'i nuiy he seen witliiu them. Mc.isrs. Tomes and Cara|)- 
M] de Morgan state tlwit they "have had no diflicnity in finding 

rtlie nncloi in recent l»oiie withent tlie aid of chemical treatment. 

• Cullixl. tij tlieir .iiA'-ni-nT INirkioj-', Ixmi! e<iriniiCl»». 

B 2 



PHYSIOLOGICAL ANATOMY 



Chap. T. 



If a. siuaU fragiuent be taken from the spongy portion of a fresh 
Lone, luid freed from udhereut fut, lh« uuule! may he spcn as 
small roumlt'd bodies attiuhcd to the walls of tho lafuntc.*** 
Other obsorvers, (|Uoted by the ftbovo-uamed authoritieB. also 
bolievo in tho pcrsist^'ueo of tho iiuclci ; viz., Good>'ir, tSchwaDU, 
KraUHe, KublnuiKcIi, HeischiDanii, <>UnUier, and D<nuler8. I 
poescss mauy spocimeiLs, in which tlie nuclei are very evident. 
Tin* lax'umu, and the cells oontAiued iu thorn, have not muro 
even, roand, or oval walls, bnt branch out into a great nnmbisr 
of Quo prot^essea, called by Ttnld and Jlowmau caualiculi ; they 
are a<--tunl Hpacea in the iianl tLtsne, containing a membranoU:^ 
matter, but whether tho mombnuic itself be actually tubular is, 
to my mind, extremely doubtful. I am rather inclined to rej^ard 
tiiem aimply as buudles of minute fibres; ihis structure would 
have tho same effect on the traosmift^ion of Huids. A section 
through the dense structure of a long bone, the humerus for 
iustuncc, uhuwa tho following arrangement of parts. The whole 
mass of t!ie bono is disposed round an axis, so that the section 
is ring-shaped: in the outer and inner ed^ of the section tho 
diHj>otiition will be Hhortly described. Between tliose two {Hirts 
tho cells arc seen nsimlly to surround certain vessels in canals 
called Haversian, that run for the most i>art parallel with tbo 
axis of the Iwne — the whole arrangement, canal and surround- 
ing cells, is called an Haversian system ; — certain parts which 
fill up thi! interstices between these circles are named by 
Kijllikor (Jrikrospiselio Anat(imic, p. 292) Interstitial Laiuinm; 
by Qucckett they are more happily termed "Haversiian In- 
terepaccs" (Histological Catalogue of tlie Museum of tho Col- 
lege of Surgeons). In the imicr and outer layer of Iwne, or 
Circumferential Lamiuie; tho cells oro arranginl round the 
axis of the bono; most of them are of the ordinary size 
and simpe of tlie laounto iu the Haversian systcraa ; but there 
are among them certain longer cells, some of which nm 
roand the bone.t others, seen on longitudinal section, parallel 
to the axis; thus there are in the layer next tho medul- 
lary cavity, and next tho periosteum, two sets of long cells, 



* Obaonutioru ou ttic Stnioturo anil 
D(>rclopm<int of Dorio. I'liiliiaiipliieal 
TnuuBoticnu), 1S&3. p. 117. 



t Mtwtns. Tonics nml Do Moroni) ' On 
tlift Dwvtli'pini'.'LtumlHtruoturL'uf Btiiit-.* 
PliiluM|ilucal Tnui^cttoii.s 1853. 



Clur. r. 



HV THK EI'll'liYSIS. 



5 



which nin at ri/^t aDgles U» euch other. I btUiovu these are 
iuleiided f<ir the nipid ahri«)rption and clisintt'gratioQ of both 
thosp strutH. 

iStimo bones, the irregular ones, uh thooc for iostfloce of the 
carpun imd tarvuti, have no liard wlid portion, but are oouipused 
uf »pong\- texture ; the loi\^ Ixmcti even terminate at tlieir 
ji»iiit end or ends in a spuugy jK^rtiiui ; this in nuiet of such 
bonee, m\d certainly in all the hirgcr ones, is formed from Lho 
ejiiphytdti. Mr. 'i'oynlHx* has made careful inveslipitiona into 
iht" u^Heation uf ejii^liysal cuds. The fniUiwing account of tlie 
formation of vessels, to which act he chie6y directed his atten- 
tion, is abrid^LHl from hitj admirable jutper.* The first step is 
vaMcidurizatiuu of the cartilage, which takes place by penetra- 
tiiju of vessels into the ejiiphysal end from the side ; indeed it is 
inipjrtant to ot>ser^'e that the vessels do not uppruaeh within 
a line or two either end of the epiphysal cartilage (that towards 
the joint, nor that towards the shaft). The vessels once formed 
ramify freely throughout the cartilaere ; towards the further or 
joint end they fonn large \vo\w more dilated than elsewhere. 
AXter this vascularity luw continued for R*uic time, lK>ny mutter 
begins to be deposited about tlie centre of the mass; thence 
x^irviuliug outwards in all directions rcnclujs the sides, but stops 
hliort at either end, only just coveriii>; ui the vessels and Icavin^^ 
a line of cartilage, on the one liand between itself and the shaft 
i»f the Uiue, on the other between itself and tlu^ joint. The 
hitter is tlie articular cartilage, of which mure hereafter; the 
fijimcr ifl the epiphysul junction. The value of this arrange- 
ment of an e]>iphYHi5 or ndditinnal Imuio between tlie shaft and 
the joint is. to periuit growth <tf the bone in length, an object 
which is accomplished almost entirely by addition to tlie shaft 
ends. Hence the epiphyses rmiuin unjoined by osiieous matter 
until tlie fuiJ growth of the particular bom.' shall have been 
uttaiiK-d, and this is hiler in scjnio bones than in others ; tlius 
iiw epiphystU bones of tlie upjKT extremity usually become 
united alxHit the sixteenth to the eightoeuth year, those in the 
luwer H.mewhat later; the jimetiou at the distal extremity of 
the femur is the hitest ; it is seldom entirely elostxl in tlie male 
•Oi 



riukMu|jhii 



tlic Urfrautuktion lunl Nulritiuu of Nuit-VuHcuInr AuUuul TiiwitV 
TriuuacUoiKi. isll, i*. lOS. 



(i 



PHYSIOLOGICAL ANATOMY 



Gbap. I. 



before tlie twoaty-sccond yvar* In one case that fell lunlor my 
Dotioe, a lino of diiitinot cartilage ronuiined a liUlo aftor the 
twenty-fourth y*'nr ; the siibjVct n( this nliHcrvatiiin was gtriimoiiA, 
but not ricketty. The rc^uton^ that this fjjipliyais slioulU rcniaiit 
luuger unosHifiixl than tiny other in th(* body, upfxiars to be, tliat 
the stature to which the indiWdual will attain de|H>ndfi in a 
great dofj^ree upon the h^njrth of the femur; and the upper 
(!piphysio is vory ubUqui*-, aliniist p<>r{)ciidicular ; henou the 
whole bone can only grow at that end by the little that may 
be addtnl to the leng:th of the ueek. and even this will Ik? in 
an oblif|i]it direction ; it therefore follows, that the femur must 
grow chielly fn>m the lower epiphysis. It seema also, that th«ee 
i-piphyriefl are InngeHt in uniting from wliieh, and nut towards 
which, the nutrient artery uf the Ume is directed. 

When tile epi]>hyHal cartiLige has become fully ofiHiflt^L oud 
long before it in unitp<l U} the shaft, it a>»nmeA the fonii tjf a 
spongy Imne, uliioh in its physiolo^cal anatomy is in all wayg 
comparable to the bones of the earpus, tarsus, or other sach 

stmetiireg. Snch li bone dtH«(* 
not consist simply of solid os- 
seous strnclure like that of 
the sliiift, but of thin osseous 
jJates, wliich enclose eaviti^y. 
f%. I. Cmkmi ma tfiMter laaieii* fmn lower I'bf sizc of the cjivities, culled 

ness of the plates, are very variable ; tlw cavities ore fn»m ,^J^ 
to ^'n'n "^ »* ^">*' '" lenjrth and breadth; the phitee al>out ^go of 
a tine in thickness. E^aeh cancelJus is Burn>unded almost 
entirely by liony matter, ouly ptjssesfung small inten-als of 
oommunicatiou, through which vn^sels pasR ; it occupies the 
place, as far as nntrition is concerned, <^ an Havenuan system : 
the plates of the Ixmo being amiiiged aromid them like Haver- 
siuu intersjMices before tht-y aro thinned by the pressure of newly 
formed and growing systems ; where several lamellae unite together, 
or rather perhaps where st'veral spring from u conimun ceutre. t hey 
form a thicker triangular or quaflriIaU;ral mass of sohd boui*. 
The lamellffi are not usually traversf'd by Haversian canals ; but 
occasionally, where there is a thicker and larger lamella, and 

• Hutnrilirc>ya 'IJn Um Hki>lcU>ii.' 





CUAP. 1, 



OF THE EP1PUYS18. 



aiKnetiuiR0 wben a vet«ol [:iQ8Be8 fram onu cancoUtut to iiuoilii*r, 
Ihc-n* is a reg:tiliir Haversian canal with concontrie luniimu luid 
lacuna?. Tho uiiUr cortex of u spoii^' bono or ojiipliysis ie very 
thiu. unci tlic Im'unal arnmgumont in in gcnunil hutcrugeuuuiui, 
€sxcio|)l when* a rejsel, passing to th^ interior, rurms a Havendau 
camil and oou(.v>ntric' lauiiuae. The plates vnckiein^ th*- caxx't^Ui 
ApMar to In? plai»Hi in uii urbitrary ttiul irn*}^lur manner, but a 
Jittle uttcottion mil Hhow that tbcro ie a oortjiin dciioitti plan 
of wrmngi-muut, wfaiclj is the more obrtiTvablr whru sinular 
eecliona frtjm a nTimU^ of like bones in a dry trtatt^ iirt- i-xanniind : 
it vrill thi'n he seun huw remarkably aiuiilar is tht^ plan uf archi- 
tecture in all. Thr ar/>uit;eiiiHnt Ih such iw to givt? the j^rt^atest 
lizuittuit ul" riiipfxirt to the thin ^^utA^r ciirt/'X cif iHine, })articuhirly 
to llmt which is towiirds the joint ; hence there i» a t*>ndt'ncy to 
tliu fomiatiou of triangles, arches, buttressed, Arc. which in 
«onie parti^, an tin* nj)]iur end of the femur, is very perwptiblu 
and beautiful. 

Tho meotmrcments of the different parts atjove ejioken of 
may bo given ns Mow, The hicunre in the solid laminated 
iKme, such as arc iilnccd round cadi llavcr.-uim canal, are more 
elongated than thoet^ iu the Haversian interspaces, or in the 
pbtti's of Bpoii^ry bcnic, and arc in transverse section (nmaiderably 
KiouUcr, w» that we have soverol sots of measurement : — 



Trftnsvenc , 



lACtinaeofHnversian SjBteniBand or- 
dinary LaottiUD of Ctrcumfercittial 
LojuiDO) 



its to ih line in length, 
qtiitfl otirrow. 

fjin line iu length, 
aur 



I ^' 

^m Cells of HaverBMU luterapaces . . ■•^^j^tojhilineinlrettdlh. 

^^^^K houg c«Ub of Circumfurciitial Luniiuai n to ^ line in leugtb. 

^Ronpludioal. I ^'"^ «"* ''^ "^'"P"^ *'™*^ " " 1 1 lino S bwi^th. ■ 
^f IRotind (rare) ^ liue iii r.liamet«r. 

Irt t 11 (i line in length by J, 

Ovalcellfl p inbre«ath. 
liouiid ditto ,'.0 lino *" diameter. 

lUTrndiiu C«nalfl Cf^und)* from rfc toife linedtMneter. 

Itotuid HBversion 83-iilem JUtoM line diuneter. 

Uncellua from Al of line to ft Uno. 



Spongy 
Toiture. 



• (ttiii mlly tbme [jurta up[H«r otwI. Uhvj^ lais drpt-ruU t'titinOy on llii> ohli- 
l ItAVK Utk*ii no nieiirtirtnwiit of llnir (jiiilyof (lit- BL-itiim: thi- mme iiuiy U.- 
Iniii; A^ifl uii'Ur Midi coiidilHifi. for mik**' i siiil ef Uie next iUni. 
IIm'V an- i-hutim-lH i( fi>]]i>WK lliul llii< i 



8 



I'UYSIOLOGICAI. ANATOMY 



Chav. 1. 



Each cnncellns U lined by a fine niembnuie tttippurtiog Teesele 
analogous to, and, whott thn i^piphyKiH in united to the Hhaft, 
c<mtinuons witli, the medullary niorabrane; one and the same 
meinbmne mtnilu'R thrtiUjC^hiHit uU tlto o.ano«^l)i, boin^: coutinaoiu 
with iteclt'. The sal>stAnoo, which fills the cavities, and their 
niembnuniHs lining, is medulla, wbieh is of tHunewliut different 
apivflmn**' iind stnirturt! atdilTurciit ages, hut is the tsani*- wiiothor 
iu cancellous cavities or medulhiry tube. In the young subje*^ 
and when first forniod, it is j)ink or even red. and very soil; it 
becomes subsequently yellow, and comparatively tirm. In the 
former oise it is made up of fat vehicles placed close together, 
crowded among whieh, and tlnw ffrrmin_g [M'rlmjw us lar^:e a 
pn»|M>rti(>n of ihe tissue. Is a lumv nf nucl(»t(Hl cells uf gnmt 
beauty and cleAme8s> the sizi^ of white blood cells, i.e., about 
i^jf line in diameter ; later in life the coUb greatly decreoae 
in quantity, and after maturity tlic medulla appears only to 
consist- i>f fat vesicles. 

The dimensions of the canoeUi, as seen on section, must 
luituratly very much depend u|Hm the dirt;ction in whicli tliey 
ure cut, sinee, as they interrommnnicate, many of them may be 
regarded as channels, and may have indefinite long axes. Im- 
mediately mider that coating of bune next the articular cjxr- 
tihigo, known ii» the artieular lamella, the ravitics are ns a rule 
smaller, and the oucloaing phitcs thicker. 

Tho crust of bono wliicli encloses the spou-r)' structure 
towards the out,side lias been described as containing natural 
lacunsB and eanaliculi, but that which is towards the joint is of 
different stnirtun;, and has been called articular lamella. 

By cutting or scraping away the cartilage, and sawing por^ 
pendicular segments out of the bono and grinding them, thiu 
soetions of tliis substance may be made without much ditTiculty. 
It will then ho seen that tho articular lamella is lighter in 
colour —i.e., more transparent than tho rest of the bone ; iu it 
bono cells and caiialiculi are absent, but there are several black 
opaquD spots of an oblong form, with the long axis at right 
angles to tlie lamella, and two or tlirco of these arrange them- 
selves at a certain distanci.' from each other in inteiTUpted rows 
having the same directiun. The lamelhi is a little darker, a 
little more brown, liko urdinary bone, near its attochetl tliau its 



^?J. 



f»F THE AUTICULAU LAMELLA. 



9 



FIR. 2. CawvIII anil vticulu- ttmelU rton 
U'wcr rrjil of liiinuii UUft, inasiilfM 100 <lia- 



ffi^ ituHiLOP ; it IcKiks ad tliongh at thin [wirt it linil Utii iftoined. 

Iti no iri^tanuL- «I<ies tliL* Uuicltu lie inimoJiatcly oTor, and uuvtrr 

Wilts in, u i*anct'lloiis ciivity ; on llie contrary, vniinary Ikjiic- 

strociun^ ulvvfiys iiiti^rvcnL's Ikv 

fWfeii mch rnvily and tlu* luuiellu. 

Ill pku*(^ tJio iiSBeoMS tiasiie, hut- 

nitrnding a ciivity iiwir ihu margin 

of the lAttiellu, uticroat-hes there- 

(ifl vory mueli ; in otlior places. 

where tilt* cacity is dwper frcni 

the suHuoc. tho oeeeoos tissue re- 

IcA, and thi' iHtiiellii prtijVpts int^i tlif Wiv Htructum; thus, 
articulai' layer ia vtrj' mn.vcu in thickness, it» free edge i» 
Also fteimtod rather finely but unevenly. (Fig. 2.) 

On apldyi"}-' higher powers, one eec« in many cectiona h'ttle 
raoiv Ihtui thin, pnrliouhiTly if they be niuunted in Canada 
linlttfim ; but in tlii>si\ wlirther nuuh.' by grinding down the bono 
I or by rutting tlu'n sbVes with a sliaqi knife, that am preHcrved 
ia lluiil. indieiitii)iis w^re Heen whieh UMUptei) me Vi go on 
tommiuing tho slruelure uf thi^ articular lamella, until at hist I 
conTincotl myseli' that it iti nmlity noiiiiista of a wries of very 
miiiuto iMimllel tubes, whii^h run in a wavy eours** from tlie 
Iwny In the eartilagiiiouH surfaee. Among these, but having no 
'special, ilnny, communi- ^-.,_ _ 7,17^- _^ _.. 
rtiti<in with Ihum, tire the » ■ ' "M 

iHHliesnu-ntioMi^l by Ktil* ( . t a ' "T ' 

likeraanndevelopetl l>nnf , ' | --^ : ' 
c-clU. lu some sectioiiH — |^ 
Uiu0e. namely, wldcb are i 
not made quite parallel 
with the axis of the joint 
Irum wiiieli lliey are tukeii 
— the tubas of tho arti- 
ciilar lamella cannot be ' 
lumlv. out, but tho scL'tiou tui 
U DUDQtidy dotted, from those tubes having boon cut across. Fig. 
13 w a loli-nddy successful represeiilation of this structure. It will 
Sta tn^n that eerUiin [xirtions of the articular lanii;Ila are rendered 
I ilarker tluui othi-rs an<l \\m i» a eoudition very iLitlicult to 



irw ctriictnrr *ad arUrtilv tatDFlhi rrmB 
limw) bnKWTua, KlMiwlng Inliiitar itrnc- 
iM, DMgnKial Ave tUmnclaiK 



PUYSTOLOOICAL ANATOMY 



CBxP.1 



aooount for ; yet perliaps I inuy protty oonftdently tiffirra that j 
arises from th«^ tubular structure haviiij; btH-omo «i liciit in the 
lines that the ranuLs hav<! hueii <iut thmugh, jjiviiig a brov 
darker, aud finely mottl&d charaetC'r to tliat part This straciiirD 
is pimilar in every inamntul in which 1 havo examined tfc~ 
lamella^ but j)erhai)B it is phiiner in tlie rabbit than in any ot 
I hare yet seen. 

iruviuj; thn8 succecdwl in ascertaining the stniotiire, 08 seen 
latiindly, it seemed adiiTsablc to view the same ]»rt fmm above: 
for thiK puriKwe a joint end, with as flat a surfoc*? as possible, 

wan chosen ; eithpr end 



.^■W 



V»krti 



;.v-^ 



<r- 



tM 



'M' 



M 



r 



Fig. 4 Articular Unvlla, wx:ik>i> iMtnlhl tn Burfkee, 
fmtu lower end of hoiaui iltna, ouiRiilflrd Tvir ilto- 
inelcn. 



the tihifl in most &nim 
answers this porpoee snfliei- 
ently : the cartilage Wii 
siTiiped away, a pmall pi 
of the artictdar lameUu was 
detiiehcd, and ground tliin 
emmgh to be tnujsparent. 
In this view the black 
spots or undeveloped boni> 
c'ells are less elongated, all 
tlu' rest of the section is 
studded with dots, which, 
under a suftieieut iK»wer, and 
where the section is very thin, appear as small round lu>h«. 
TIuu structure is the same in all auimafs that I have examined.* 
(Fig. 4.) 

Thus the articular lamella is not an impervious material ; h\ 
pcrbapH this account, which I hare allowed to stand from 
iii-st j>a]>er on the subject, might havo produced less opjiosition 
had the wavy lines which run tlirough the section been mimed 
something difierent to " tubes/' As far as the bony material is 
concerned they certainly are tubes, but I do not, ami never did, 
conceive them to be lined by a tubular membrane — probably by 
compound Sbre.or whatever form of fibrous material the altered, 
cartilage may take. Tlie cluinneK running from the deep ^^| 
osseous to the superficial or cartilaginous suriaoc of the lamelfl^ 



* Tliw Hciiiuiit i»r Oif HrUoular la- 
HK-IU u Uikvu Trum my |itt{)ur mm tUv 



Hiitijerl in thi; 



imp.L 



OF THE ARTICULAR CAHTILAQE. 



11 



permit the pasuf^ iif nutritmt flui'il from t)i« bone to tlio deep 
airfu-e of t\ip (iirtiliigp. Tliis is the (ine im|MirtjLnt [loiiit — it is 
nDiuutpriu) whnt tlio I'liaiinclH, tbnnigh whifli that Hoid }nsH-«, 
\ni railed, whotlier tnWv^, iiHseous int^Tvak, or any dther niunc, 
m bug OH it bo fully uudurfttood, that there is a meclianism per- 
mrtting ftmd to pifmn-titt; thir structure and to iiouriii)) tin* car- 
lila^ from its deep surfaco. 

That {MTt of the epiphysis, wliieli remains onossificd towards the 
juint cavity is tlius st-iKimted fnim tlio ordinary bono tissue, and 
Qow bocomoH articular cartiUign. It is not, a.s it has often been 
aid to b(\ attached to the bone^ but it is contiuaom with it : it is 
[mrtiif the same thing, one fwrtion having received n dejxtsit of 
iiiui!, the other |xirtion not having done so. It varies in thiokni'ss 
lUMnh'iig to the shape of the surface, and always m tluit its form 
Koa «xaf^(*raliou of that of the Wme : thus, if tlic imm^ous surfu<N! 
L bticoacaVG, the cartilii|i;e ig thic*JcL>st at its edges, so that it is more 
H uoDcave than the bone itself. If, on the contrary, we take a eon- 
r^ rex example, the curtiltigu wHl be found thinuei^t at the L-d^es, 
^^Uhitt till' whole Hhapi' is more convex than tho osseous buH«cc. 
^^^pirtihige is a tough elastic mat^^riiU, of a Hemi-trans|»ireut 
Moish appeamnee, and easily out with a knito. Trcate<l with 
^rong ttciftic arid it is dissolved into a jelly, which llulktr calle<l 
» cAondrin^ and which differs very little from gelatiuL'. If thin 
B.8cK;4iona bo made through the substance of the curtilage and 
^HBiDUied by a quarter-inch ]>oWer^ the whole sulwtance will bo 
^^Hnd to be very tnuisluceut, imd to have a finely mottled vt 
pmuulur ii8])ect; and there will be seeoi in it a great many 
Uiflitts of on oval form. Some confusion has arisi^n from these 
lulling boeu named eartihige eel Is. The truth is. that tJiey are cnvi- 
tieMiQ the hyaline substance, having no lining nu'ntbmne, which 
contain from two Ut six nucleated collti. I |irnpoeo l<t call 
throaghout this trtaitiac each Ixjdy, i.e., cells and hollow, the 
carlflage-corpuscle, reserving the word cortilage-cell for each 
on«f of the bodies eontainiid in the cavity. Tlie cells in the cor- 
puscle nnt imfre(piently, wliilenear llieattachedsurfaco, st^parate 
and cause a division by fissure of the hollow into new corpm^cles, 
aiid the observer will find the arnmgemunt of these bodies 
iKimewhat [lecidiar. for if he examine a line vertical section of 
iUiy iurticular curtilage in imy uuiiuul* he will sh-m thottc curtilage- 



ItAT. T." 



corpns('Iea, whirh Ho nr^nr t\w attachHi) siirlaoe woll devoloiN 
iintl nmtniiiing ent'-h from two t^ six nndcatoil wlU, ami ne 
this fiiirfatf not only <iu thf cells in wuTb corpuscle, but 
tliuso lutt«r bodifS, tond to umuigc th«nisolves perpeniliciilArly 
tu tho Biirfuco ; mid when a norimaclt* dividt^ it does so in tl»e 
Kanio lUroction. As tho object is ijossed under the g^loss towanU ihu 
(ree surface, he will bo atrock by a chouge in tliis respect ; 
cells no hmger remam in the hollow so coni^tantly perpeudiiulju 
to one another, and as they diniie, tliey do so as fntjufnilv 
horizontally as iu any other direction ; at last the divisions i 
the j|jruiij)inp* all trnd rttnnigly to the liorizontal ; the cell^ 
theraselvrs la'ctimesfpamt*?. and arc tlattened iu the sumo 
tiou, till at last tlit^y lH«ome mere scales, tliree or fotir layers j 
which (fig. 5), lying cloao together, fomi the extreme free 

of the seclioii ; tliat 
the imattni^lied stirface i 
the articular cartil 
consists of three or fo 
layers of 11atteue<l ix 
lyiug 4uiti^ close togetlw 
and overlapping 
other's edgea. This 
rungenieut lias CBV 
many i >l»servere to 
liove iu tho e^etenoe i 
«; 'an epithelium. If 

^ superficieH of fresh c-ar 

,• * . '^*^ ^^ shaved off thin 

#? ® ?Ji with a very sharp laiife« 

the 8e4;tion will iudeed 
iiBve the appeonince of a 
layer of epithelial udU; 
but if a thiu slice thn>ugh 
ite aubstauce be ejuimiue 
the gradual hurisnml 
arrangement and flattening of the cells will leave no doubt a»| 
tho true structure of its superficies.* (Pig. £>.) 



J' 



bIkmiI tun 
IW-lll ot 

liitn an u14...l.i , ,.i.,.. 



• TIlia iLTiunpcmcnt Itn^ liowcvor, nut I it U (jo flifR^'iiIt to procorc jicctioiia i 
Kxii ilL-DTrilHil an in livtv tUatu. iHtemiw | lit-icntly (liiti. Uiat fro nil tiiruujirb 



CUhl. 



OF THE ARIICULAH CARTILAOR. 



13 



Some oWnrere, Mr. Toynbtf amnng them, fimnd, that in the 
Mm vt-!t8(^lB rim across the cartilage, even into the middle of 
joints. Li ueithtT a Uu\a\ hare or calf, tluit I hml the opportunity 
"fisamiiiing, ronld I dis<'Ovor any sydi arrangoaient> nor any 
Iftce of it in a stillborn child.* Nor have I been able to dia- 
«>v»-r f^pitheliura overlyin-r the cartilaginous surface: wbiit Hfr. 
")rman look for that structure was, I believe, the sujKTticial 
KvCT of cells aA above ilescribeiK which, in the yet unused joint, 
is fiiitr tlutn when it has been subject to wear and tear. 

Tilt! position of these cells and their graiimU separation from 

well ether, and tliuiinutiou in size, prove tluit they derive tJieir 

UQtrimeiit fnim tlie uttarhed surface, and ibis is in consonance 

witli the arrangement in other stmctaires which line cavities, for 

tJtey are all uourisliud by the deep surface. Thiw the altsenco 

'*r presence of vessels npnn the fontal cartilage is of importance, 

Ut-otise if present it would establish the fact of a structure lining 

• cavity l«ing nourL^hcd by it» free surface. lii-sides, as it is clear 

tiiAl, at least during intra-nterine life, there is large pro\T8iou 

for nntritiou of the <:Tiililag(^ from the dfep surfact?, thi; prfi>anee 

of sueji vesst-ls would show that a atnieture liavJng one free, one 

[attAclied surface might l>e nourished from Iwth. Moreover, it 

[uuuld prove that a eelliUar strueture might Ih^ nourished frf)ra 

Itbe surface tijworda which tlie cells grow. Hut the two first 

cts would bo isolated, and tlie last is hanlly conceivable ; and 

[as othew besides myself have failwl to dffecover this arrangement, 

liUere must have been in tiio obsorvatigu of sueh vessels some 

P occult sourcse of error. 

Moreover, the prewioce of a plexus beneath the articular 

lamella, and tlie etmctnre of that bony plate, distinctly |K)int 

onl the attaolieil Hurfaco as the source whence the whole is 

Bnouritihcd. Thns a continual growtlt takes place fmm the 

^Lglpohed towards the free surface, repliu;tng the eftects of wear 

HK' pressure which are proved to be considerable, not only by 

niuuiisted reason, but aUo by our present knowledge of the 

. flattening of cells on lliat surface. 



Uycra of cells bnwik- 
..jytluD »liLv. Itiiiny 

_^. i w cutting uw«y c*rti- 

We ftwl nrticulu uuiivlbi ^>m tlic cmh 

oelli. Hcmpitkx Uu) otHuiibt muttt^r uwuy. 

&ibeo Inyiiut Iac cortilu^' on u pivco of 



rork, nnd boRinainp from tlie fnniicrly 
t*tia«li..'<l htirnic*-, euttini:; 4lii'e» wllli u 
wtill-nimlf mill .■i\uit\t ViiU-iitiii'n knifi". 

* KulliUur L'ouUI Ti'it niuko *mt aii^ 
vtMK'lH i>ii ttiu Mtrrueu o( ftvUU OLrti> 
lageti. 



H 



rHYSIOLOGICAL ANATORfV 



Chap. I. 



The synovial memhrane, wrapping round each bone of the 
joint aud extentling from one to the other, shuts them into a 
cavity. The menihraui', by and for itsolf, is not a rlosed siio, as 
hiiH usually hcon dcscril>c<l ; hut it is a tube, into the ends of 
whioh the bony and cartilaginous ap|)aratus of tho joint is in- 
serted. It consists of a basement mombrano, inside whioh is a 
layer of pavement epethelimu cells, and on the oxitside a fine 
areolar tisane, known by the name of subsynovial, and which 
carries the vessela fumitdiiug pabulum for nutrition and seore- 
tion to tlie part. 

The mode iu which tlic synovial membrane is continued over, 
or terminates upon, the cartilage, has been a matter of con- 
fliderablo controversy. Some pcrflons have thonji:ht thnt it was 
prolonged over tlie face of the cai-tilHgo; others, that it went 
Iietweeu that structuro and the bone ; and some even have 
supposed that it was split, and tliat a lamina was placefl in either 
situation. Some believe tliat the membrane is prolonged over 
the cartilaginous surface until tJie movements of the joint wear 
it an-ay. My own conviction is, that at no period is tho cartilap;o 
covered by B}'uoviaI tissue, but that the membrane beconi(?s lost 
very near the edge of the cartihif^re. In no young animal will 
any structure bo found like a fibrous, or even a homogeneous 
membrane on tbe cartilaginous lace, and the la8t layer of cells 
cannot be regarded as appertaining to a prolonged synovial 
membrane, since it is ^ery evidently the result of a graduid 
process of eliange, and is the arrangement, towards which all the 
corpuscles tind (^cUs t^^nd even from their ver}' deepest, hiyers. 
H istologiriiUy the synovial membrane and tho apparatus of 
Ixmo and cartilage previously dtscrihed are exact parallels ; tlie 
fiiriuer cwnsists, as just related, iiiterujJly of cells, then of a fine 
membrane permitting fiuids to pass through from a vessel- 
hearinp; 8ubsf>rous ti-'^sue. Tht^ whole cartilaginous apparatus 
consists of cells (with an intercellular substance), then of a fine 
lamcUa, permitting fluids to pass from a vessel-bearing tissiio. 
Thtwe structures, or rather set of structures, being annlogous, it 
is hardly conceivable that nattire should permit such a tautolog)' 
as to prolong the one over the other. 

The membrane Ih then a lube, and in a simple joint, tt.s thi- 
shoulder, has scarcely imy nrnuip'ments worthy of lieing named 



w.l 



OF THK SYNOVIAL MR»DRA>'F.. 



15 



r?ll)j;iims; from tho edge of the cartilage on the hitmoms it is 

igtxl u little downwards on tlic periotitonm, atid U tlit-u 

Qblcd over, cuunieM alung, and lines tlie capgulfir Lignmeut, til! 

il biu-lina the other bono of the joint, wliero, turning Agm'n, 

to a little l*oyon(i the cartilaginous end. In a 

such as tho knee, which posaJi^sst-s int«,T-ftrUeid(ir carti* 

ligwi ftnd iDlormil ligann,'nts, tho iirrangement is a httle inorR 

««nplicated, since tho membrane, as it passt-s from femur to 

lil»io, is intcmipttxi in lis courw by the menisci, lines their 

ni»lH'r then their imdcr surfrtecs, being folded over the in- 

tcntal edge, and from its outer and lower comer is directed 

<* ti( the other bono of tho joint, the tibia ; thus the only part 

•^ the meiiiscus not covered by the basement membrane and 

Ofiethelium is it^ outer tliick edge; and thk is attached by cou- 

wwity uf fibril to the subserous tissue. Tho crucial lipunonta 

*reco?ere<i iu tlie same way by folds from the back luid front of 

It* joint; and there exists, moreover, a fold that mns from the 

ipicc between tlio condyles to tho tissue below the patella; 

miirons ligament. It must be observed that the membrane in 

nn course from bono to bone is not stretched tight, or bound 

close to the fibfroos capsule ; on the contrary, it hangs 

innards in loose folds, which are marked iu all joiuts, 

! jiarticularly in tJie knee, where some of tbem at the side 

lof the ligamcDtum pat4.>lbc have bcon called alar ligaments. 

[8acb A fold tills in the sort of aagidar uitcrval, which iu most 

jjiHuta is left between the cartilages before they come iu uctutd 

trt, and permits a plentiful development of loose subsy- 

{novial areolar tissue containing ]>elletfi of soft fat, and supporting 

Ib rich plexus of vessels, which, lying iu this fold that eueirdeH 

Ibe joint, must run round witli it, and was thus tenned cireulus 

[vaKulosiis. 

The inner surface is not merely smooth like that of an 
lordinary serous membrane ; on the contrary, it is stndded with 
IB uumber of villous-like processes, gynovial fringes, ITieee are 
Imoju closely ploce<l and better developed on tlie Imwe ftdds than 
[ulst^where : they imj particularly well-marked iu the knee over 
{<Uic lateral folds, idar and mneous ligaments, <&c. Those procoasei^ 
limaller than iut^^tiual ^illi, are like them, in as much as they 
Mtre coni|Kised uf vasiTulur ramiiicatioiiM, covered by basitment 



i«t 



niYsioujorcAT> anatomy 



Chap. I. 



membrane and epithelium ; the vcsHeU consist of an artery of 
supply and a vein, tlio latter being rather the larger, between 
whirh ininutr* (yipilliirios nm in a wavy ctMirso. I liave not 
fonnd that they carr}' an absorbent Their purpose is probably 
to increase the surfoou of secretion ; but we know in reality so Uttio 
of this process, that such aplmise hua but Httlo valui^; for nuglit 
we can guess to the contrary,, the peculiar visci<Uty and lubri- 
cating quality of the synovia may bo due to tlie peculiarity of 
surface secured by the presence of these processtss. The fol- 
lowing desciiption is taken from an account of these processes 
by II r. liuiney : — 

"These stmctiircs are situated in those ports of a joint, thcca 
or bursa, where it is least exposed to pressure ; they consist of 
I(K>ps and convolutions of capillarios of various degrees of com- 
plexity proceeding from the surrounding vessoLs, and projecting 
into the synovial cavity ; these capillaries are cncloeed in saccidi 
of basement membrane studded with minute uvol cellules. 
Fn>m the saeculi enclosing the capillaries numerous other 
sacculi; into which no capillaries enter, [iroceed ; these are of 
various forms and sizes, but generally are attached to the primi- 
tive Boccolus by an extremely long and slender filament of 
Hbrous tissue resembling the ])etiole of a leaf, the secoudory 
satx'ulus being its expansion. Sometimes there are several seriws 
of tliese sacculi attached one series to another, exhibiting an 
arborescent appcHmnce ; but in every inntaace tlio secondary 
sacculi arc extra-vasculnr/' • 

It has been a theory in physiology, tliat as tlie synovial mem- 
brane in a closed sac it prevents tmy luImiAsion of air to the 
inner structures of joints, and forms tlicrrfuiv a vacniim, produc- 
ing tliim a preasims fnmi the cxtenor which aids materlHlly in 
keeping the joint-surfaces in contact This theory, however, 
will not bear exumiuation : when two smixith and moist surfaciis, 
which rit each other accurately, are pressi^l to^ither a cohesion 
of contact takes place between them. The cartilages of joints 
U(iiig thus 8m<K>th mid lubricated adliero togi>thcrj more jxirti- 
cuhirly in such joinU us the liip und shouhlor, in wliicli the 
surfaces of contact are large and fit ouch otlier with perfect 
accuracy, while in sucli a joint as the knee, wlui«e surfaces are 
* ritUinln^ntl TmnaactionH, vot ii. i*. 110. 



OirAr. I. 



OP TfTE flTNOVIAT, MEMBTIANE. 



J^ 



not so rociprocal, but little of tjijs c»he«lon of nontiuit is pro- 
duced. It IB evident, tliat such an action oan only taki- place 
between surfaces wtuidly iu rontael at tho time, hut is (juite 
indopendftnt of, is in fact annihilated by, any vacuum estA^ 
blished arouud them ; as it will take placo iji the open air when 
any luoicit smootli surfafos, as metal or platu-glass, conip in close 
contact, but will not bo produced in a vacuum, as in the bell of 
ao air-pump. Thus then thia theory of a synovial vaeuura is 
not only quite unnocossary but is actually vicious, as it dooa 
not elucidate that which it was invented to explain (a fact quite 
explicable of itselQ. but renders it inexplicable, .\piin, if the 
synovial membrano were u vacuum, it would bo forced with a 
pressure of fourteen and a half pounds to tJie square inch 
bt>tween the joint suifaces, and would thuH Iwj pinched ond 
bruised on almost every movement of the limb. The ex|)eri- 
ment of [luncturiug Uie synovial membrane of a hiihjoiut in the 
deaii enl»jei% and producing thereby an instantaneona disloca- 
tion, is open to innumerable sources of fallar-y, and therefore is 
insutlicient t4i j>rove such an untenable theory as that of synovial 
vacuum. The experiments and nuiS(juing whereon this vacuum 
theory is founded were made by E. Weber, of Bonn, and com- 
municated m Miillor's yVreliiv., 1830, p. 54. 

*' Nov I will give aa inveatigfttioD into the iiowor whorobjr Ibe head of 
tho thigh is hold in juxtaposition nith the pelvis. It has been Buppo»cd that 
the limb waa faBtcned to tho trunk by tho strongth of the ukusclce or liga- 
ments, iH-catutu such povcr is tho most vi&iblc. More oareful exoniiuatioti, 
however, has aho^i'n that this is not effected by the power of miLscles and 
li^menbs, but by a far Ibas percopliblo force, namoly, by the preasuro of 
the Burroundifig air. 

" The head of the ttiigh-bonu, which fits air-tight into the globular hol- 
low of the acetabulum, udbores in tluit cavity aa the air>t)ght piston of a 
eyriogo remains in the tube wbun its upper opening is closed. 

" Ab the quicksilver in a barometer is driven upwards by atmospheric 
pressure, so is the head of the femur, when there is no air above it, driven 
upwards into tho acetabulum. I will give ebortly tho cxperimcutd which 
led to this result. 

" Fir9t Ejirrimcnt. — Tho body was brought into such a ix>8itioa that the 
Limb huug freely dowu. If thtMi the limb hung by the musolos aixl liga- 
ments, it would f&U out when those partH wero out through. 1 severed tho 
musolos and ligamciiUt, and the limb did not fiiJl ; ou the contnu-y, tho 
joint Burfocoe remained in close oont«ot.* . 

' Thik is OS easily acc<juuUKl for by Die eoherion of oonlact between tliu csrti- 
lan^nous »\xttaKvi.~ B. It. 

a 



18 



PHYSIOLOOICAJ. ANATOMY OF THR 



(.BArJ 



" .SecrmdErp(rimcni. — Admitting thttt atrooxpheric prcoaro holds up t^ 
limb, it would fnll a8 f<oon as nir wore admitted into the joint cavity. 
bored a bole through tho veaXl of the Aoetabiduni through which air enton 
— Uw limb fell, even though the muiMiles and Ugameut«t hod not 
divided. 

** TVtirH £r;>CT-iTnMf.— -Admitting that atmo6i>herio prasBore is alone auffi-l 
dent to support the limb, it should be again supporUd aft«r baring rall>-n1 
out of tho cavity when air woa prevented &om entering the joint. I ro-i 
placed the bend of the thigh, whicli hod been entirely separated &om the ] 
body, and then, in order to keep air out of tho canty, I cloeed the hole 
which hfld boon bored with my ftngor — the limb was Uien supported and 
again fell down as soon as tho finger was rcmovod." 

Let US examiuQ theee oxporiinents a littlo eloeely before I 
relate some of mj own. Either tho huod uf the tliigU bono is 
in octtuU contact with tho acotabulum or it is notv If they be 
in actual contact, cohraion of contact takes place as between 
any two smooth surfaceSt and a hole bored iu any part Df thotie 
mirfacGS would only aJFvct that cohesion at tho place actually 
Utred* If, on tho other bund, they be not in contattt, tliure will 
citlier by n vacuum (a» far as air is coneoruod) betwc<?n thorn, 
or there will not. If air be Iwtweon them, tho theory of atmo- 
spheric pressure vBinHhcs ; if tbpre be no air Ix'tween tliem, but 
A vacuum. Professor Webor did not ro-catabUsh that vacuum by 
merely replacing the head of a thigh bone in tlie cavity. 
Neither on tho fnipposition, therefore, of a vacuum in the joint 
cavity, nor on that of inter-cohcHion of surfaces, can all the 
results of these experiments be explained. I cannot account 
for tlie attainment of all these phenomena, nor can I pmeurc 
such results ; tliey aro incompatible with one another. One; 
source of fallacy may liave bet-n. that, in bi>ring the hoU-, 
Pntfesaor Weber unwittingly pushed out the head of tho bono 
with tho point of the instrument. 

I will now relate some oxpcrimonta of my own ; the first was 
performed for anotlK^r purpose, and is more fully related in 
Chapter XV., in wliich it ii])|>ears us ExjM>riment III. 

Experiment I. — The subject was placed upon the table on 
tho back ; means of accurate measupoment by needles, fixed one 
in the thigh tho other in tho pelvis, wore udo]»ted. A weight 
of 2.SJlie. was hung upon a system of three pairs of pulleys 
fastened to the ankle, thus constituting an extending force of 
7561b«. : — no change in the position of the limb or in the raea- 



CllAP. 1. 



SO^ALLED SYNOVIAI- VACUUM. 



19 



* 



mircmonfs was foand A hole wns mftdo in (ho inner wall of 
the acetabnlum : — still no cliange in the |>u8ition i>f the limb or 
measurements. For the other purpose above mentioned a wedge 
of anincli thickness was driven in between the femur and the 
acetabulum: when thk was removed thf head of ihn femur 
kept tlie same plaeo, namely, aepamted frtun tlio acelubulum. 
The weight was unfaelonod, and the head of tlie femur returned 
to its Dormal position with a 8ound precisely like that [m)duced 
by disarticulation.* 

Kxpt'riment U., in the presence of Dr. Hyde Salter, Jtdy 6th, 
18G0. — The subject was placed on the back, the weights and 
pulleys preptirttd as l»efore, and tlie same systfm of mcnHurement 
adopto<l. The capsule of the hip was carefully hiid bare with- 
out puncturing, the tendons of the psoas, and iliacus divided, 
and woiplits t-quiil t<i 3o llm. w(^re huug tm the puUeys— a hole 
was rapidly bored in the floor of the acL-tabulum — a minute and 
a ludf after this was done, a suction sound was heard, and the 
head of the femur came out of the cavity. The weights wore 
lifted, and the femur replaced and tightly pressed in the tiavity, 
the finger firmly held over the halo., but whenever any weight 
was allowed to hang on the thigh the hi_-ad of the Ixjue fell out, 
uor could I by any means find the slightest diflerenco whether 
thfi tinger wore held over the hole or not There occurred, 
immediately weight came on the thigh, tai tyozing Round, the 
sound of squeezing soft moist mateiials, and the head of thn 
bone fell trom tho cavity. In this experiment the for«,' exerted 
was very large. 

EjqK'rinieut UL, in the ppGBenoe of Dr. Hyde Salter.— The 
name divi.sitm of muscles and other dispoatioiis wore taken. The 
force was a stone weight on the tliree-pair systom of puUeys. A 
hole was bored in the inner floor of tlie aot-tabulum anil f-ularged 
so tliat the heatl of the Ixino could be folt with the finger. 
During the work the caput fcmoris was struck once or twice 
with the gouge, ami thu femur irouM start outwards or rotate 
slightly, but tlifi length was precisely the same, and no sepirn- 
tion of the articular surfaces could be found, (in this instance 

* Thcflf nmlfai art* inootoiiatilile witU I being entire^ djjilocattfd on Itoring a bolo 
tlioft.' i>f 1^. WuWr's M-c<iiu1 ('SiM!rimi.'iil. in tbo ftcvtauulum. 
ill wliicit lliL- lii|) (uiuiK:i>--a aiul litctiuHiiito | 

c 2 




PHTSIOLOGICAT- ANATOMY OP THE 



Cnip. 



tho weight was not Buftjciont to overcoino tho cohrgion of nor-"* 
taot.) 1 now t<Mik off thp wpiprht ami the rords, and eDdravnuiT^ 
to dislocate the head of the boDe hy lorL-ibly twisting the lim^^ 
iu ©very direction. 1 most nourly succeeded wheu the thigl' 
was rotater! outwards and adducte<l even beyond tho iniddh* liue-*- 
Still it could not bo done until tho L-otyloid ligament wa^^' 
divided, and then only jwirtially without division of the round 
ligament. 

Experiment IV. — ^All the muscles round the capsule were 
dxvidod ; but the psoas was left entire. Tlie capsule close to 
tJio edfi;c of the cotyloid ligament was cut through, learing that 
structure entire. Thin lUvitiion should have dtwtroyi-d tho 
uwchinery for any intrasynovial vacuum, and tho head of tlio 
bono therefore sliouhl linve fallen out of the ca^nty, but I had the 
greatest difficiUty to dislocate the liip, and could only |>aniaUy 
succeed without dividing the ligamentum teres. 

A curious case occurrod to nae. which is related at length in 
tlie ensuing chapter. A man ha<l an opening into the K\-noviji] 
mombrtmc of tho elbow-joint, which, when ho alternately bent 
and straightened tho arm, sucked air in and out of the cavity 
like a pair of bellows. Thia was a strong man, a sailor, who had 
a great deal of ehmbing aud other hard work to do, and yet had 
no dificovcrablo tendency to dislocation. 

Tho whole vacuum tlieory is untenable; tho only fact which, 
at all resembles it is, that cohesion of contact takes place between 
the joint surfaces, but this is not a vacuum : a vneuum is a »j>ane 
containing neither air nor other material — the cohesion we speak 
of takes plaee wheu there ia no space between the parts interested. 

Tho fact is, tliat overj' joint has some special meanB, which 
hold tho hones forming it in dose contact, and such aids us 
atmospheric pressure may yield are but slight in comparison 
with those. CertaiiUy no man gifted with a tolerable apprecia- 
tion of cause and effect conld regard the enonnous power of the 
muscles passing from tlic scapula to tlie tuberosities clc«p to iho 
head of the hunienw witluiut coiu^idnring that their tonicity 
alone would be of large eftect in keeping the head of the bone 
close against the glenoid wivity. Any one attempting to rest-ct 
the hood of the humenit* in the dead Rubji^t raimot fitil to n-mark 
tljeir effects, even as Ufiless flesh ; and moreover he will find the 



CUAl'. I. 



auasYNoviAX, tissue. 



1^ 



lipinmcntg and the tendon (if the bic('[is and othor parte of the 
greatest importance. xVguin, if thrt rotators of the hifw aud 
their direction and attachment bo oousidered, their impnrlani'o 
will not bo slightly regardLxl, and bosidf^ tht^o the pBuas, iliocus 
and ghili^i, in faet everj- rausclo attached to femur and |)olvx8, 
luive the samo ufFcct* Add to thia the resistance of the cotyloid 
ligament, wliicli forms a smaller circle than lies within the 
cavity, and therefore clijis in the bone like a circnlar clamps and 
wo have quite enough to account for the difficulty in ditdocating 
the bone,* Besides, there is the round ligftmont, which in cer- 
tain positions takes considerable part in holding the head of the 
bone in the acetabulum-t Tho knee, elbow, all the joints in tlio 
body, have arraugementA either of musitiilur foiro or ligamen- 
tous roeistanco for keeping tho articular gurfacee in contact. By 
thia means only, viz., actual contiSct of the bones, can any 
ossifitanco from tttmosplicric pressure be obtjiined. A vacumn, 
i.0,, a space unfilled by air between the bonee, could not bo 
muiutaiued : either the surrounding parta must be forc<?d into 
such 8{Mic(j or the liones would be wjut'ezcfl togetlior, for there is 
iu>tliiug to keep them asunder, and so tlie siuice would bo nuni- 
liilated. 

Tlie material wliich surrounds tho basement structure of 
the sj^iovial membrane is called celhdar, or, l>etter, areolar 
tissue. Tliis structure is one of tliu most remarkable in tho 
body, not only for iU wide distribntion, its elasticit}', its pecu- 
har insensibility to certain stimuli or irritants and its quick 
resentment of otlicrs, but also for ita peculiar actions under 
injury, and its enormous power of repair. It consists of the two 
sorts of fibroas tissue, viz., yellow aud white, mingled together 
in an inextricable and beautiful manner. These two elements are 
different in many « nys, aud will require each a separate descrip- 
tion. The yellow fibrons element consists of roimd branching 

for a putkalar account of tJio um of 
the nnmd llEamont. It aitpoun that Um 
TMMtiDO par tae^met w&cruin Uim boxiil 



* In a; cxporinieiit H tbc vefght 
huiig uu Uie pulleys piwlijceJ a force 
fiuflicicut to OTurco»)t< tlm li(,'ajiu*ntuiid 
opeu it oat, anl»*-qiienUy thcrcfon', 
inictlicr OT iu>t nir wnn ivaDiitU->:l into 
tliu cavity, llie bL-m) of tla> boiic full 
out oil tlio iipplii'ittiiin (iftlie force. 

t Tlio rtituiT in n'fi'm-d to a. \n\tvr 



1 



:pdiciLl Juurnitl. vol. iv, 18rHJ-9. p. 13. 



pontiMipar I 
nifty act as a clieclt ligiiment. in rutntiuii 
tiutmmU witb S«xiuu. It In r^'tuli'nMl 
lii'urly tight in iKldui-Uoii with flt'iioii, 
and m adduction with rututiuu filhi-r 
inwonls or uutwunbt; hut only in tliu 
<lr>il-iuuiied poKttiim doeu it l^cor liio 
otniin. 



98 



PHYSIOLOGICAL ANATOMY OF THE 



CKAf.T. 



fibres, which always lie singly, te., never in parallel Imndle^ 
ani] whose ends, whether naturftl or broken, havo a groat ten- 

ileuoy to curl up. Jleyond these qnalities. however, it is on^A 
of tho mu4it voi'yiug IbrmntionH iu the body, iind it. is Tfir7^| 
difficult to observe it constantly under similar oircumfctancvs: 
For instance, Mr. Queckett appears chiefly struck witli its 
curve<l and curling nature, ami both in his doscrijitions and de- 
lineations has constantly figured it as a crooked fibre, giving off 
branches nt cither side which curl spirally. (Quwkett's • liifr 
tolog)'.') Mr. liownian, on tJio other hand, hxiks upon and 
draws the iibrOB straiglitor and inosculating, more like the etna^ 
of an irre^oilarly constructed spider's web. (* Physiolt^eal A»- 
tomy.') Tho truth is, that both thesw! forms arc common — tho 
former most so in the Ugamentum subfiava^ the latter iu the fiw 
areolar tissue, which coun^cts the folds of the poritoneum, or 
lies b*itween two musc.lo^ In that texture wliiidi forms su 
aponeurosis, for instance tlio lower part of the fascia tranf* 
Torsalis and tho tissue near it, both forms are to be seen, but 
the larp;er curly fibres ore more abundant. Acetic acid only 
aOects this yellow fibre by causing; it sliglitly to contract and 
pucker. Wliit^^ fibnms iismie is tliat which makes up tho cliit'f 
bulk of ti^meuts and tendons. As seen in areolar tissui^ it 
appears to consist of bundles of minut^i wuvy fibres which nndu- 
lato in aud out of the meshes formed by Uie yellow tissue. Very 
often tlie bundli> encloses some of these latter fibres, whicli sftei 
to run tlirougli it at an jmgle. Iteicliardt tiupposes, that the 
which look hko bundles of fibres, are not rc«lly such, but 
moases of wavy tissue' minutely striated, and ha^Tnp a re 
able tendency to spb't lengtliwiso. By the additiou of ve; 
dilute acetic acid the fibrillat«d appearance is lost ; ou Ion, 
exposure to tlie reagent the whole of the white elemonti ho' 
ever, vanishes, aud hence it is hardly safe to infer frum the 
disappearance of fibrillation that fibres do not exists 

If wo dissect carefully tlirough the fat surrounding a ginj^ly- 
moid joint, say at tlie frout of the knee, till we oome to what 
appears the? outside of the synovial membrane, whrro adi|ios^ 
tissue begins to fail, one is able to t^ike up with tlie fingt-re al| 
foreqjs, juid to strip off to a certain distjiueo, lliiu tniiisparent 
fihuis Iiiiving the nH|>ci!t of pontinuous membranes. Il 



Cbap. I. 



I'EHIAiri'ICnLAH TISSUES. 




thrsn lio cut off with tho scusars, and placed under a power uf 
250 or 300 diumB., tlie wavy bundles of tlie white areolnr tissuo 
wiJi 1*0 found so nbuudiLiit as nearly to conceal tho yellow 
ohiinent. 'Jlio tismie can bo oonstaiitly spread out with needles 
ihiuuer and larf^; there seems no end to this ]»ower of 
Htrutohing, but tho more it bo thus puUod out tho moro and 
raoro do tho yellow fibres como into viovf. Moreover, if wo 
lake tho film originally »omo way from tho basement Kvnovial 
mombrunc, tho white fibre is markedly pretlorainnnt, whereas 
tlic noarer wo ^i to that membrnnc tho more distinct in tlio 
yellow tissue. This may be best made out iu the examination 
of a ball and socket joint by cutting capsular ligament and 
syu.ivjal membrane quite through, eoparuting the hnmema 
entirtily from the scjipula — taking hold in one pair of forcei« of 
tho edge of tho Ligament, in another of that of the synovial 
nienilmme, nnd dragging them ajMirt, thero will bo stretched 
between tliem many films of membranous matt^'fial ; mid if wo 
examine some of this close to the ligament microeoopioally, tho 
wlu'tc fibrous element will be seen to couoeal tlie yellow ; if, ou 
the contrary, we take tlie i»oiiJou to be examined from quite 
close to the synovial membrane, the yellow predominatt;» until 
we find that tho tissue immediately underlying the fvieoment 
membrane consists of a mosh-work of fine yellow fibres inter* 
lacing and branching iu all directions so as to form the most 
elastic, most yielding, and most even possible support to that 
delicate structure. Thuft, as in our examination we recede 
further and further from tho j(»int surface so do wo Gnd the sub- 
synoviul tissue becoming denser and whiter, until at last in such 
a joint as the shoulder it minglen insensibly with the capsular 
Ugamont. Or, if we woiild wish to put the description into 
other words, we might say tho cajwular ligiunont becomes un 
proce(«ling inwards more and more loose and tiafl in texture; 
its fibres gradually lose their parallelism, and become mingled 
with more imd more yellow tissue until they, instead of forming 
pjirallcl-fibred bands and cords, shape themselves into an 
irregular meshed net, over whose most internal parts the thin 
sheet of synovial membrane is spread, Tliia gradual tnmsit of 
structure may bo exem[>lifie(l in the knee: tliis is a joint which 
is not pnivided with u ciiiwuiar ligament imi|K.'rly wi called, 



24 



rilYSIOLOGICAL ANATOMY OF 



CnAP. I. 



ttUhmigh it ia jirotocted by a more or less dense touph areolar 
structure, consistinp chiefly of wliito fibrous tissuo ooutiiiuoua 
with Ihe Kubsyuoviiil iircolar luembraLie, or rather this cflpsiile 
is the ontor layer of that etructure. It coaneets tlio EEpecia! 
Ugomenta together ; in fact tlicso latter are but stronger \iant\s of 
tlio ordinivT)' cupmile, just m the Coraco-humeral and the lUo- 
femoml lij.':ament.s are but stronger biind^ of the capmilar liga- 
mentfl of tlie shoulder and hip joints. In the knee, and indeed 
in most other joiutd, the eurrounding fibrous structures are 
strengthened by bands of white ini'la-stic fibres whieh the 
tendons immediately in the neighbourhood give uff; tJiis 
arrangement has, liowever, a further object, as will presently 
be shown. 

Tho ligaments of joints are then to be regarded not as isolated 
or separate structores, but rather as constituent parts of the 
periarticular tissues ; the fibres arc stniighter than In tho 
ordinary white tissue, but they are in reality the same structure 
a little differently arranged, and the ordintury white tissue nnia 
among tliem ; also long si>indl(>shapetl cells are pbiced among 
tho parallel fibres. 

Both tho white and the yellow fibrous element are crowded 
with colls of different forms ; they are long and spimile-shaped 
in the wliit4> wa\'y tissue, and lie wedged in, as it were, among 
the fibrilliB ; they are close together both in a longitudinul luid 
in tho transverse direction, not> however, in contact Virehow 
(* Cellular Pathologic *) believes timt they intercommunicate by 
fine tubes given off at either end. However that may Im?, they 
certainly retain their nuclei, and contribute to the nourishmtait 
of the tissue; indeed the whole strueturo is, like other eon- 
uective tissues, to be reganled as a muss of cells with an inter- 
cellular substance. In this instance the cells are arranged in 
liuoSf and the intercellular material is fibrous. 

The exact arnuigement of tlic cells in the yellow tissue is less 
easily described ; many of them are fusiform, or arc even cell 
fibres, and it st^ems in many }>arts as though the fibres were 
only prolongations of the iapvi cuds of the cells. In other 
parts stellate cells are foimd (' Uindegewebskorperchen ' of Vir- 
cliow), and I'ven the rays of tlios^i stars soem to be eontiimed 
into fibres. These prolougatioiiu are also rugarded by VinJiow 



BAP. I. 



NERVOUS SUPPLY. 



25 



a» tuln'H, but this requtrofl moro prortf. Many of tlio coIIh am 
lar^ ami well ilevelt>[»Hl, and cuutain well I'orinetl midui ; tlieir 
action under intlammation is moHt important, as will be sceu iu 
the sequol, and thflir valuo as ntitritivi? agents is undoubted. 

Tho iuterarticuhir fibro-cartilaj^us arc seen in tlieir phase of 
highest developmont iu tlie kueu-joiut ; they consist, on upper 
and lower Burfaces, of a thin covering of membraiufonu cartilage, 
tho thick cusliiou-Uko parUt are formed uf denwj bandn of iilirous 
ttssuu crossing eat^h utlier in every riii-ection, and thus forming 
wide and irregular-shaped nieshos which are filled with fat — in 
fact by far the larger portion of the structure is made up of fat 
thus cnclobod. The cartilaginous portion of Uio titrueturo is iu 
the adult very thiu, and by no means easy to find : iu the yoiuig 
fostos the whole meuiat; may be examined, and wlien its inner 
thin edge comes under the glass its membram^-cartilagiiiouB 
structure will bo evident. Over this material tho syuuvial 
mendjrane pjisses in tlie way already explaine<l, leaving only its 
outer thick edge uncovered — if indeed that may deserve the 
naiae of edge which is in continuity with the rest of tlio areolai' 
tissue around tho joint, for as far as the synovial cavity is cou- 
cemed these structures are outside the joint altogether. At 
(he lower jaw, and tht; steruo-clavicular joint, the interartieidar 
cartilage is not pcrforat^^^d iu tlie centre, but is one continuous 
plate ; lieuco in these instances are two synovial membranes, 
aud therefore two joiuta. 

The nervous supply of joints is complicated, and often multi- 
farious, combining twigs from at least two of the trunks going to 
the muscies of tho limb. The uerve to the joint is doubtless 
sensory, and is one of the sensitive portions of muscular nervee. 
All the mott)r nerves have one or two swnwiry (ilanicnts com- 
bined with tlu^m, which imfuil to the uuis(*le that which is 
culled '* the muscular sense ;" directing and limiting its con- 
traction. In thu same way, there is a joint sense bestowed by 
exactly the same nen'ous means, and, having similar origin with 
the muscular sense, has Uko function, being able to increase or 
diminish tho amount of contraetiou accoi-ding as one part or 
another is compresses!. For instance, obstrve the violent spasm 
whicli seizes iho m\iscles of the thigh, and many of tlie Ifg, 
when loost' curtilage gets betwcvu tJic bones, luid th<.- violence 



20 



PUYSIOLOGICAL ANATOMY OF 



L*HAP. I. 



with which the muscles of a limb contract, when from any mal- 
position in placing it — for instance, when the foot comes 8i(l&- 
ways on the gronnd — the joint in abuormiilly comprossod; this 
contraction is so \'iolent that the tendons and tboir sheathes are 
bruised, forming ono sort of sprain. Ono valuable effect of this 
supply is protection of the sjTiovial membrane by the influenrai 
of the tendons attached to the capsule. 

The synovial membrane would be liable to be pinched in 
many movements of the joints were they not protected by the 
mode in which tbo muscles surround them, and are attached 
more or less strongly to tlie cafisulur ligaments where thoy 
e^ist, or to the subsynovial tissne whero they are aliscnt. This 
attachment is more constant than is generally iniai^ined ; not 
only does it exist in all the larger joints, but also in all the 
small ones that possess a tolerably free amount of motion. 
Sometimes there is a sjieciol muscle for the ca|>stde; W)metimcs 
tlio same effect is produced by the |)artial attachment of the 
ordinary flexor, extensor, or other motor of the limb. The 
method in which thu scapular muscles and the snmll rotators, 
psoa-s and iliacus, arc attikched to tlm capsule of the shoulder and 
hip joints respectively is well known. 

Tlie intimate connection of the triceps, ext-onsor, and anconeus 
with the back, of the brachialis anticus with the front, of the 
BUjanator brevis witli the outside of tlie elliow ji>int, is very 
analogous to the attachment of the quadriceps extensor femoria 
witli tlie front, and of the jiopliteus and semi>menibran(»3us 
with tlie back of the kneo joint* At the wrist the amount of 
movement is very small in coinparison to those joints already 
mentioned, and therefore there does not soem necessity for any 
such protective oppamtui« for the synovial membrane ; bat the 
ankle is provided with an especial muscle to draw tlic mem- 
brane irom the grip of violent extension, viz. the jdantaris. Each 
synovial membrane of the digital joints, both of fingers and toes, 
is in counectiou with the extensor and intoTossei tendons, so tlmt 
ample car(> is taken, even in llutse nmall articulations, to prevent 
pinching or other such injuiy. The iiiterarticular cartilage, 
whose inner parts are but coutinuations of the periarticular 
arenlar tissue, would miturally bt; drawn out when tJie musidos 
attached to Uiis tissue contract ; but they are usually provided 



J 



Ciup.L VASCULAR SUPPLY. 27 

with their own muscniar attachments; thus, in the inferior 
maxillary joint the external plerygoid sends a few fibres to the 
inter-maxillary cartilage, while the tendon of tho popliteus is 
connected with the outer, and some fibres of the semimembra- 
nosus with tJie inner meniscus of the knee joint. 

The nerves which supply these muscles are twigs from th$ 
same branches that supply the inside of the joint ; tho twig to 
the joint is of course sensory, and supplies that knowledge of 
motion, position, &c., which in the muscles is called muscular 
sense, and this sense by a sort perhaps of reflex action causes 
those muscles to act whenever some motion or some position 
places the capsule in danger. It is curious that one of the 
nerves at least of these capsular muscles, namely, that to the 
teres minor humeri, should possess a ganglion ; and I have 
reason to believe that others are likewise so provided — the 
popliteus for instance — but have not yet been able fully to 
demonstrate its existence. 

The vascular supply of a part, that is to say, the precise 
branches whereby blood is brouglit to its tissues, is not, in my 
belief, of very great importance ; but it may be pointed out that 
the epiphysis receives its nourishment not from the vessels of 
the diaphysis, but from certain branches entering its sides (p. 5). 
These are derived from the same vessels which s\ipply the syno- 
vial membrane. For instance, from the circumflex at the shoul- 
der joint, from the articular arteries at the knee, and so on. 

Such is the physiological anatomy of parts entering into the 
formation of joints. It has not been thought advisable to in- 
crease the length of this unavoidably long chapter by any descrip- 
tive anatomy, which moreover is of course well known. It 
must however be remarked, that in order to form correct diag- 
noses of synovial inflammations, it is necessary that the shape, 
divisions, and prolongations of all those membranes, as well as 
the position of the structures which bind them down, be well 
known. 




A JOOir H^ as the |nBoe£Bg chaptar fcoB abewn, a reiy 
oafad appantoi, ^marfimteil of dtflwut tasnes of diffei^g 
qnalitiea. hanL soft, azkd elastic, aemng diffcTvnt pnrposea. ^^U 
they are all redocaUe to cue focm or ciaas of tnsoe — ^Uie coDr < 
nectire. Thoec difiereot pazts are aa closdj placed, and arc a^ 
interdependent, tbat one can not loDg remaiu soond wbiie tlH 
othen an; nndcigobig any »rtire nxwlad diange. But some m 
the stractorea are more liable to dbease than othrrs as indeed 
H most haf^ten tlukt tboae parts which ondeigo much action are, 
ceteris paribus, more likely to get some of it denuiged ; aad 
sncfa derangement is more likely to set np rapid diseaae than 
when the action is very slow. As a niilwny train going at tht> 
rate of sixty miles an hour is at least six times as likely to meet 
with an accident during that hour as one which goee at ten in I 
the same time, and that accident is more likely to be scTerei ! 
Wc sbuU be able to show clearly that the structures which aru 
liable to iirimarj- disease are tlio synovial niembnuie and the 
bunes. From uilhur uf these points the malady may spreafl to 
OTery other port of tlie joint; therefore, after either has been ' 
uflwit^id for a certain time (syuuvial membrane or bone), the | 
other Incomes invulveA Henco neither synovitis nor ostt'itis 
are utterly diOercnt throughout all their stages, because in the 
far advanced couditiuus the one disease nill bo more or leas 
miu}^te4t with tlie other. 

Tho prosi'ut chaptor will bo devoted to primary acute syno- 
vitiH : a disc'aao which perha})s acku<jwledgos moro causes than 
any othor fiiiuple maUidy in tho range of pathology, and wbicli 
thcrolbro may im divided into an olmosl indefinite nMndk*r of 
Bub-classca. each with its pn)|>er expletive aflixed. Perhaps tlie 
cluariiHt way of showiug this would bo to relate one or two 

OMtiO. 



Chap. II. CASES. 29 

Cabb I. — Hannah Parkea, retat 49, was brought to the Charing Cross 
Hospital, Gth December, 1859, and placed under my care, through the 
kiudneaa of Mr. Hancock. She siates that, the night before, she fell down, 
and that her left knee was twisted under her so as to produce intense 
pain, which continued, and soon after the knee began to swell. 

The left knee is much swelled, and has lost its shape ; the form of the 
bones is no longer perceptible, the patella even being nearly concealed by 
a bulging out of fluid all round it ; this is more particularly remarkable on 
each side the ligamentum patella, and beneath the vasti muscles ; the 
patella is lifted from the femoral condyles, and can, by shght pressure, be 
pressed back upon them. There is a good deal of heat, but no redness of 
the part. Measurement gives nearly two inches as the amount of eularge- 
ment,'thu8, tho right knee (sound) measures — 

Just above patella 12HncfaeB. 

• Across middle of patella .. .. 12} „ 
Just below patella 11 „ 

Loft knee (diseased.) 

Just above patella 14} inches. 

Across middle of patella .. .. 13} „ 
Just below patella 12f „ 

Iler tongue is rather white, pulse 90, bowels regular, no unusual thirst. 

9. Calomelantw .. .. gr. ij. 
Pulveris Rhei .. .. gr. iv. M. 
To be taken at bedtime. 
The limb to be placed on a sphnt, and 6 leochee applied to tho knee. 

8th. — The knee is more swollen and painful ; she did not sleep on ao- 
couut of the pain last hght ; the dimensions to-day are — 

Left knee, above patella ., .. 14} inches. 
Across patella .. .. 13| „ 
Below patella . . 13 „ 

It is ordered to be cupped to six ounces. 

Dec. 10th. — She complains still more of pain, which keeps her awake at 
night : during last night she removed the splint, and says she is much 
easier without it, and, as there is no fear of her moving the limb, she is 
allowed to be without it. Hot fomentations to bo kept on the j>art. 

12tb. — More blood was yesterday taken by eight leeches from tlie knee ; 
after their removal a hot poultice was appUed. The dimensions to-day 
are — 

Above patella 14 J inches. 

Middle of patella 13^ „ 

Below patella 12i „ 

14th. — The pain has diminished ; she is to continue the hot applications, 
and a splint bent at a greater angle is to be appUed. 



30 



ACUTE SYNOVITIS. 



Ciur. 11. 



lath.— Qoce on wall : tb« swoUing has dcoreasod sliglitlj. 

Abovo patella 1^1 inches. 

UidiUeofpatclla 13 ,, 

Below patella 12} „ 

IBttt — The pnJD is uov alight, and tho awcUtug appoora le«a t there is 
alio less heat. Fluctuation ia more obscure, u thongh it were felt throt^ 
a thicfcor material. 
21«t. — Dimouaiona — 

Above patella .. 14 inches. 

Middle of pateUa .. 12f „ 

Below patella IS; „ 

S4tb. — Fluctuation much leas distinct, and the shape uf the bunes begin 
to reap{)ear, but eoinewhut allertMl, tlic protubornncea apiworiiig nmuded 
off. When the Lruid k iippbed uver the patella, and the joint movedi a 
oruokling therein is very distinct. 
IHmeuaions — 

Abovo patella 13} inches. 

Middle of patella lUji „ 

Below patella llf „ 

25th. — She went away ; tho kuee stiff, somewhat tender and onUrgwl, 
about j indi in all dimenaions. 

Cabs II.— U. G. came to my houae, 28tb November, oomiJaining of 
great pain in the right kuee and aukle. 

Thoso joints aro swollen and rod, and Tcry hot to the touch ; tongue 
white, furred ; pulae 96 ; much thirst aud headache ; face fluahnd ; ef» 
rather injected. Ordered that eho should go home and to bed, to tako alt 
ounce of caator oil — wrap the painful jointa in flannel 

in tho evening 1 colled and saw her: she hod intense headache ; the oil 
bod operated, and the tongue wua rutbor cleaner. Tho knee was very pain- 
fhl, swollen, red, and hot. No dimensioua were taken, but tho form of tlie 
bonca wa£ hidden by a s<ift putfy awelliug, which bulged chiefly above the 
pateUa and at the mdea of its ligament, and which lifLcxI that bone from 
the femoral coudylea. Tho aiddo ia not ao red nor »o swollen, but ia very 
hot. The swelling ia most perceptible in ft-ont of the malleoli, and at each 
aide of the tondo-Achillca. The urine is high in oolout^scanty, and loaded 
witli litliatvs. Ordered 

Vuii C(dcluci nixx. to be taken m water every six houra. 
I'ilula llydrargyri oUoridi oomp. (gr. v.) night and morning. 

30th. — She was much in the same condition yesterday ; the pain in tha 
head has decreased, the joints are just the same, but she has some pain hi 
both ahouldera, which is, however, alight, and they are not swolleu. 1 
aaked Dr. Hyde Salter to see this patient with me. 

bee. 2ud. — Yesterday she had a .slight shivering, and tho pain oflorwarda 
in tho shoulder increased, it then left the knee entiroty. To-day the right 
knee has roaumod its normal tcro[K!n.ture and colour, but the ahoiildoni arv 



our.n. 



CASES. 



81 



Toj jHinDil ; tbey ore also red, swoUcn, and hot ; tho swoUing ie most in 
&(ul, toidor the deltoid, which is prc88od forward ; obtwure though evident 
llucULttioo. Ordered the foUovs'iug dmught ererjr aix houra ; — 

K Vini Colchioi tnix. 

Sodie sesquicarboDatie ,, gr z. 
Aqu» AJ-'^- 

(th.— Tbe heart lias b6«Q dailjr exammed, and to day there ia friction 
tt»tai; tho tongue oontinuea whiter ihti nhuuMor otiiJ ankle joints arc leea 
ptioful, but HweUing and pain has begun in the lefl Vdcc ; bi)th hands Iiavo 
txeMUifircted in almost all their joints, pulse small and hard, six leechce 
*(n oitlered to the chest ; 2 gniiu» of calumel and | grain of opium uight 
ud Iteming — to continue the mixture. 

It auwlois, to follow out the cose da^v by day. Under the treatment of 
^ frimd Dr. Uydc Salter (bo eymptoms diininiBfacd. I myBoU* saw her 
QHuUotly^ hoing Interested in tho Joint affection, llio swelling of the 
^*noa» jniuU attAoked gradually dinuDishcd, and with It the pain. In 
•^ I munth frum the first attack every joint liad recovered ila normal 
*^U(I merely occasional uncertain paiua were felt. Tonics being admt- 
'^'^ovd completed tho euro. 

Ciot m. — G. B^ in good circuinstancea and of strong oiofftitutinn, con- 

^'^oM, at tho age of sES, a gonorrIia» ; nine days after the ajtpearance of 

uo coDipIaittt he was exposed to great fatigue ; afterwards ho lost hifl 

■Ppetitc Oil the evening following lie had three or four violent Hbivenng 

^knlh sickneaa and pjun in the head, and sent for me 5th February, 

Ifet The tongue wua furred, red at tho edges, brown in tho centre, more 

l^rtimilarly towarda the back ; pulfio 100, small, hard ; eyea glaxed^ some- 

^lut aoxioua ; bowels con6nod ; urine ncanty, high colotirod, full of bthntcs 

'^Ute gonorrb(ea a^ipeared much dimukuhttd. 1 ordered ft calomel and jalap 

I'orge, and proposed to see him on the next day, 

Gthv— T found him in oonaiderable pain at tlio right kuoe, wluoh was 

1 lli^Uy swollen ; he wos very restloss with the pain in the knee, wliicfa ho 

|<Miipnc«l to what might be felt if a crowbar were forced iu and the bones 

I Oflttoder. The skin over the joint has Its natural colour, but ia very 

I fcot ; palao 100, small : tongue cleaner, still dry and brown at the back. 

Illicpui};e has operat^Ml &ocJy. To apply six leeches to tho kneo. To 

I take the fuUowing [lill night and moming ; the drought three times a 

(lay: — 

9. Oalomolanos .. gr. ij. 
Opii gr. SB. M. 

9. Vini Colchici .. .. n^xx. 
rotowaj carbonatis . , gr. xr. 
Miiituru) Caiuphoroe . , Jj- U. 

8lil. — Tho kDce is still very painful ; the left ahoulder has to day been 
er ; be lice very btill, fearing to move the joints. Uv J.h very tlc- 
Lhe pulbc is small and weak ; touguu utill brown tuid dry. 



To 



32 



ACUTE 8YN0V1T1S. 



Chap, f^ 



AmrnQniee 5eeciuicarbonati» .. 3l 

Tno Opii jyj. 

DccocU Cinchona; jx^. 

Castor Oil when neceeaary. 



U. 



6Ui. — ^The pulse has inii>roved uligktly, less d«ftpoD(lcnt : the right kn 
ii lesi hot, and thero is loss swoUiug ; fluctuation still JisUnot : tho dfr- 
oreose appears owing to the absor])tion of tho fluid outsido the joint. To 
appjjr B blister insido and rather above the joint. 

10th. —Knee still decreasing ; a blister waa yesterday applied to the 
shoulder. Tho foot are still as mucli hwoUou. To leave ofTthc cotton wool 
for two days, and then to use ooh) lotions. 

l'£i\\. — A blister to the other tddc of the knee: to take five grains of 
quinine, in the fonn of a pill, three times a day. 

This patieut become couvolesccut under a strong tonic system uid fre- 
quetit blistering to protuute absorption of fluid, about tho latter end of 
March. At that time ht.- could walk with the asMtftantx- uf two sticks: it 



oODtinue the modtcioo, and to bake strong brotlis ud six ounces of «i 
dfti^. 

11th.— Ho is still in rery great pain ; the knve is more swoDeii, the erer^^ 
liug 18 soft, fluctuates iiU);htly and pita a little : there is cfFusiOD both i 
the joint and in tho ^-teriarticular tissue ; the general etato ta tho same. 

14th.' — Knee still in sauio condition; the shoulder is painful t4vdair^ 
and perfaa|3s may bo Hwollen. The eyes aro rather suffused, the face ptie^ 
ej^prBBBiou deapaudent The gonorrbtea is aow very slight. To apply sisz 
more leeches to the knee ; a guttA-percha splint was also applied. 

16th.— The shoolder is now swollen, and since last report has been very 
painful ; it in very hot, but of natural colour ; tender. To omit the piU, 
and add to each dose of tlie mijiture 

Liq. Opii Sedativi . . v\xv. 

Vini Colchici n^ x. 

Slst — ^The left wrist has now began to be punful ; tho right ankle also ; 
tho whole foot is BwoUeo, prcaeutiug a white appearance similar to that 
observed in phlegmasia doleua. 

24. — Ttic right knoo i» rather lees painful, (wrbaps olao not quite ao 
much swelled, but fluctuation its as plain, if not jilaincr than before ; the 
tonguo and pulee is still just the same ; he has no denre whatever for 
food. 

28th. — On the evening of the last report the left knee was attacked with 
(i^ii, which was for three hours very severe ; then decreased ; the joint ta but 
slightly swollen, is still slightly painful ; feet very much swollen and very 
painAil. Tho modieine has begun to [Hirgo, but I cannot see that it has 
produced any benefit : — to leave off all medicine for a day or two ; to take u 
much broth, soup, 6eh, egg, as con be inauugwl ; ton ounces of wine a-day ; 
to wrap the feet in cotton wooL 

March Snd.— The purging haa ceased ; there is a slight improvement jn 
couotcnoncu and manner ; tongue cleaner, pulse much the same. 

To take two tablespoonfuls of tho following mixture tliree timw a day i-* 



Cta^, U. 



CASES. 



3» 



^^** tut til] the bt^nnmg of June that he porfccti; rocovored the aso of 

■"isjojuta. In I808 he bad another gonorrhcca. I gave, from the very 
^i^ quinine; he had no Ko-oaUed gouorrh(ual ihouinuttBoa, but wbotber 
^e tonic prevented it, or whether it would have como on at all, cannot bo 
•ffinned. 

Cui IV.— Sarah Crowe, rotat 20, was admitted into the Charing-Cross 
W Hospital 11th December, 1859. 

H .About the beginning of Decomber alie had on a pair of boota in which a 
Vp9x>jeoting nail had wounded the right heel ; the place was painfii^ though 
^Hearljr skinned over on the 8th. Ou tho morning of the 0th she was 
^w-oke by pain in tho right groin, which waa tender to the touch, and 
^yx^ thought it a little swollen. However, she went to her eiuployiucnt 
(aedeotarjr), and about noon tho pain suddenly ahifte<l to iho knee and 
wihs very severe; the joint also awellcd. In spite, she says, of great 
**tfTenng, the g<H through the 9th and 10th ; on Uio 1 1th came as au out- 
P<ktieDt to Ur. Eacoock, who took her in. 

The log waa swollen to the middle of the thigh ; some glands in the 
H fToiu were enlarged ; there were red liucs running up frt^m the ankle in 
H tliu course of tho absorbents, and of tho poatcrior Baphonous vuin of the 
K '^is and mtphenoua vein of the thigh. Tlie knee was awoUen, fluctuating, 
f U:h3 tcfulor, but preserved its natural colour except where crossed by the 
'*ddone«I TosselB. Pulse SK), email ; tongue, white ; bowels, ojwn ; old 
*^uud at the heel wna laid open ; a drop or two of pus escaped. 

I Ordered to take the following as a pill, three tiwos a day : — 
9 Hydrarg. Chloridi , . . . gr. ij. 
Opii gr. SB. M. 
Six leeches to bo applied to the knee. 
Uttf — ^Tha knee and thigh are more swollen, the latter more partioz- 
^Mly at the outer side ; tho geuoral condition much tho same. 

l!^th. — ^Thcreiscndcnoeofau aocumulatiouof pus benetith tho faacia lata 
«n Uic outride of the thigh, four inches altove tho joint ; au opening was 
tude m tills situation ; some pus esra^wd at tho time. 

To take the following draught three times a day : — 
^ Ammoniie aesquicarb. .. gr. v. 
Decooti CUichonie .. .. ^. M. 
Bggs; roa.st meat; four ounces of wine. 

Slat. — ^Tho opeuiug made in tho thigh gives exit to a oonsidemble 
•{mntity of pus. She is in considerable pain from tho knee ; which is 
uum swollen, but remains of the bamc colour as at firat. Add to the 

ihaaghl 

Trw Camphora) oomp. 3j. 

Mih.— In le«s pain ; the kne«; otherwise ^Ue same. The aapbenous vein 
of the thigh feels hardeiiod and knotty ; the groin is swollon and tender. 

3rd Jan., 1S59.— ller appetite has fallen of^ and she complains of 
hiHhdaehfti Bowola confined ; probably from the amount of opium taken. 
Mist. Hhci CO. jy to bo taken every oilier morning. 

D 



34 



ACUTE SYNOVITIS. 



Caw. 



tl. 



eO^-Mndi kM padn in ihs kaeo. wfaioli is Igm MroDen. Int the gr''^ 
eoDtizuiM pftinlol ; the rod lineB have been alowljr ilieiKiaeii;^. 

To take Ibe foHciwiDg pill night and moniing : — 

PiL HjdrBi^yrL gr. r. 
The draoght, three times a dAj : — 

Mint. QoiiiH! ij, 
A blister to the knee. 

10th. — Hardly any pain in the Imee except from the blirtor; it is bc'^ 
little ewoUeu ; the wound in the thigh has healed ; the ^UmU in tho groiiJ 
Htill efiUr:ged, but hard. 

18th.— The groin in still swollen ; a blister to be appUed over the 
^■oda. The knee only rerj elightly enlarged. From thi5 time the tjoat^ 
nunt waa only directed to the state of the groin ; tbe fluid iu the knee* 
joint becoming gradually absorliud. 

Cabz V, — E. B,, Bitai 32, had contracted a Byphilitic sore at Aldcrshott; 
by some moanit he liad either not disoorercd this, or had ne^K-cted it. 
Camo to me, NoTember SCtfa, 1858. Hod already lepra syphilitica. I 
bad known this gentleman some years (uid was rather afraid of the ofitMiU 
of mercury ; treated him, therefore, aa mildly aa I beliored was safe. 

He had been under my care seven days, and was taking tluioe in tho day, 
9 Potaasii lodidi .. .. gr. iij. 

Uecocti Sorsao Jj. M. 

And HL Hydraig. Chlorid. Co. gr. v. every night. 

8th August, 1896. — I was sent for on account of the patient being 
nnable to walk from pain and ewelling of tho left ankle ; the joint was 
slightly ewoUen, rather hot, uol red. Ho was not aware of having jeooiTed 
any sprain. 

Hot poultice to the part. Calomel gr. U., Opii gr. i., to be taken Jmme- 
diotely. 

9th. — Ho BuCere^ last night more than usual fi-om pnin in the left shin, 
and to-day the ankle is very visibly swollen iu front and bchiml tits 
malleoli. 

Ordered 6 leocheH oiid hot fomentations to the port. To take 
Pil. Hydragyri gr. v. night and momiug. 
I^ Saponis oo. gr. t. at bed-time. 

llth. — Tlio joint still swollen ; loas pain at night. 

As the medicines began to ad'eot tho constitution tho swelling in the 
ankle mibNidcd ; the inflommatiou from the first was not very acute, 
belonging rather to the subacute' order. Even when the nocturnal [nina 
and cruptioiiH had diKappearud, and no sypliilitic signs were left, tho 
aynoviaJ inflammation lK»came chronic, 

I'hoseareaU caaosof Bynovitia; and olUiongh theinflamiuatiou 
of the Byiiovial membmno is that alone which they have in com- 



CkAr.0. 



CLASSIFICATION. 



35 



oioti, yet, locally, the morbid notion is, np 1o b certain point., very 
murii alike in onch : tJiere is pain, beat, BWtilling, the ordinary 
rignj* of inflammation ; in mme the rednesn ext^nids flxtpmally— 
'in ofjiore, it does not do so. The oauso in each is different. The 
first arose from violence applied to the part ; the second, from a 
tjrttemic condition; the tlunl, from a gonorrhcea; tlic fonrth, 
ftom a fever ; the fiftli, from a sypliilitic disease. In the first 
case only can the disease bo said to be local ; or as local a» any 
dJaeaw produciii;r more or less fiyniptomatic fever cnn bo ; it ie 
therefore culled simple synovitis : hud tlio malady followed a 
voond it would have been called traumatic syuovitis. The 
Koond example is one of rheumatic fever, acute rheumatism, or 
WUe polyarticular rlieumatism. The thiixl is erroneously called 
gonorrheal rhfum&ti.sm. The fourtli is synovitis from pyaemia. 
TIkj fifth ifl sj'philitic synovitis, more acute than usual. Tho 
gctteial^ or systemic symptoms of all these coses are different, 
ud^m their variation must the particular form of ^e com- 
plaint be diagnosed. 
, It ia very difficiUt to give any good reason for tho cjstrpmc 
fiartiulity which tliis disease shows for certjiiu joints. If it arise 
from cold, there seems some ground for saying that a 8Ui>erticiu] 
joint, like the knee, would \h'. chiefly attacked ; but why shrndd 
^a*mia, when only ouo articulation is the seat of ita peculiar 
ivitis, nearly always attack the knee? Gonorrheal rheu- 
matism often attacks no other juiiit. and never, ns far as my 
rcwearches have gone, leaves the knee unaih'Cted ; and 1 do 
QOl know of any cose of |>olyarticular rheumatism in nhich tho 
knee lias escapetl, though we find many rc^'orded in which other 
juinlH have remained free. It is, I believe, bettt*r to avoid 
RpiMmlativc reasoning on such points as this, and where there is 
no littlo clue to guide us, to be content with the f*»ct^ — which may 
^ be thus stated. That of all cases of acute synovitis (leaving out 
H^ riieantatic fevers) eighly-Hvo per cent, occur in tlie knue. 
^B ^WHh regard to ago it may be snid, although we have no 
^^ reliable statistic* to guide us to an actual percental tvckoniug, 
tlut the diseiiso is most common among males (agiun omitting 
Mcote rhiHimutism), and occurs most frequently at that i)eri<»d 

I of life when muHCular strt^ngth and IxMlily activity ore moat 
^icrnvrfiUU dvvelu|)ed. 
n 2 



36 



ACUTE SYNOVITIS. 



Cnxr. IT. 



It is extroraely rare that we have an opportnnity of examining 
pfltholo^'c^Uy into the changes prodnced Ly a simple a<Mite 
Hvuovitis. Tlio disease is not fatal> and therefore, if the iwtieiit 
Hhould die from other ruuseB, the syuovitiH will probably have 
become cliroujc^ or (IiKa]>|jearMl. However, onee in my life it 
was permitted mo to examine siioh a etiso: — the resnits are 
reported hero. »^ 

C4flE VI. — A man, aged 40, was bniught to St. Thoma.s'9 Hnflpita], haviug 
ftUcn « ooDBiderablo height ilirough a skj-light, and roceivcd on injur; to 
the bead. 

He was bleeding from the right ear, had a sevoro bruise over the fore- 
head, oud was iuHenAible ; he ^vaH taken at once to the waiilit. Tlio next 
day, aUo, bo remained insonaiblo ; but it vran found tbat the !oft knee vas 
hot and fluctuating, not red, having all the local egrmptoms of acute ayno- 
vitis, hereafter to be more minutely described. The tutme conditions 
continued for four days ; on the fiflh morning ho died. 

More than au^ciont injiu7 to account for death was found in the head 
by the gcnUctuan who examined it. I mado a careful observation of the 
knee, _ 

The joint contained about an ounce and a half of syuoria, which was 
nlightly turbid, opnleecent, and in which floated shrods of &lfie membrane, 
aome semi-tranaparout, otheni opaque and white; thcae latter being more 
evidently fibrous ; one of the shreds was loosely attached by one end to 
the synovial membrane, the rest floating frooly in the fluid. The whole 
membrane wat^ intensely injeotod, the vessels not being on the surlaoe, 
but as though visible through' a film; in some parts tlie injection was 
much more violeuttban in others; the deei>est in colour were the fringes 
around the patella, the so-called alar ligaments, and the subcruroal cul-do- 
sac ; in many apota of those parts were actual extravasationa, which, again, 
were not on the surface, but beneath a fine film. Ln the lutiu injected 
parts of the membrane long tortuous vessels could be distinctly traced. 
The surface of the membrane itself was finely roughened ; on holding it 
up and looking towards the light over the surface it was seen to bo covered 
with papilla-like or velvetty elevations ; it looked hkc the surface uf the 
duodenum when the valvuloe oonnivcntcs arc straightened out The mem- 
brane was easily torn, and very easily »trip[>eil from the underlying tissue, 
which was highly injected and iutiltratcd by a turbid scrum. 

On the ituior condyle of the fumur was a H^wt an large as a aixpenoe, 
whence llie cartilage had entirely disappeared ; the edges of the uloer were 
perfectly smooth, sharp, and clean. The rest of the cartilage was entirely 
healthy. 

AlUiough Uiis is a very early examination of ejnovitis, yet 
the inflammation htul advanced to the fourtli day, and therefore 
tlie appi^araiiees observed are not to l>o rt-gardei.! as ihosfii of 
tHjmmeuciug aeute diseiwe. It is im|tf)S8ibh', or nearly 80, tliat 



i 



Oskt. II. 



MORniD appKarancks. 



87 



in tliG haman subject we ever shoulrl have an op|»irtnnity of 
"King ita actual first ntiaok ; Ltit there can be no doubt timf its 
(list risible sign is rongestioD of tho Hub8f*mus tissiio. An old 
iiotino filed, n3 Uie first cflect of synovitis, dryness of the mem- 
Iwafi; and I see, in a recent book on Joint Diseases, that its 
witkar, Mr. Kryant, of Guy'H Ho»]>ita1, still adheres to that idea. 
TV tlieory, however, has no facts to siippijrt it, and was supposed 
to be set at rest by the experiments of M. Kiehet of tho H6pital 
BooB-SecoursT of M. Bouley, of M. Rey, niul of others, none 
rfwhom mention dr)*ncert as a result of artiiicinlly rxcitcd and 
WtftiUy wutciied synoWtia, The firat author indeed expressly 
dniiies its existenff. He liad opened, at different times, the 
jfniitA of several dogs, and observed hour by hour tho alterationa 
hkiiig place in the B)'novial membrane. He says* — " Aflor ten 
lioun* the membrane lost its [tolish, but T never at any time 
ttmlil lind that it was drier tliun in the normal condition — this 
tlirness of the serous membranes in the first stage of inflamma- 
tion is admittc<l l>y all autbors, yet noUiing is less proved, and it 
tA In explain their crackling (bruit parchenmni) that this parti- 
cnljir ciindition luis been invented." 
Tho first effect, then, of the inflammatory iriitation is conges- 
Ftkm of the subsynovial tisene, acoomimnied by rapid secretion 
1 of aerous or tliia synovial Uuid into the joint. This congestion 
\ia most marked, wherever that tissue is lax and abundant; 
whereTer» on the contrary, it is sc^nt, and binds tlie bitsemont 
membrane tightly down, thert) but little congestive redness is 
||icre«^ble : hence tlie loose folds overhanging the cartilage, 
ribwl in the hist chupter, are those where redness is most 
rked, and where extruvusatinn most readily takes place. Of 
[extTAvasation it may be observed, that it is always found more 
I tilnindtint, and always spread over a larger surfucc, tho wore 
THpid and rU^trueiive the conrse of tho ease, and that in the 
Imotit rapid altaelcs tho fluid poured into the cavity of the joint 
[itself will Ix! tinged with blood- The qmrntity of effusion into 
[the joint varies very much, partly with the amount of inflamma- 
[tittn, partly with its quality; sometimes the ofiiision will be 

* Aiuhft imr lea Tnmeura DlAitcliM. I of M. Riohct'i cxpuiimonU i» givon 
I t\r- )'Arai|pint(' Roynlo do I ftirUior oil 
. luDU' ivii. A fuller nccouut I 



ACUTE STNOVmS. 



CSAV. 1 






snfflcient to prodaoo considerable difrtenaion of tlie joint, and 
Uieroby increase of pain of inflammation. With the quantify 
of t^flusi(_ui (•orr(;'Mjx>ndH also the amouut of hypertrophy of the 
synovial villi. In Uiu normal state these are only large en* 
to prevent the membniuc iip[ieftniig quite suHHith ami polislic 
like the inside of an onlinary serous sac ; in this acute inflanimii* 
lion they fdve the membrane a rough velvctty appearance. 

Very soon nftor the increase of ofliisiou has commencod, the 
membrane becomes pulTy and swollen ; tlio epithelial layer 
falls offy leavoa a boro surface, the efiFdeion becomes more 
fibrinonp, and often at the same time ojialesceut in charactfr. 
Bits of false membrane or semi-detached slireds are fuuud 
adhering to the inside of the sac, while similar, and also 
softer, shreds will bo fouml floating in the fluid ; sometimes 
these ore very nearly colourless and transparent, frcqticntly 
white and floociileut like pieces of wooL Some of these floatin g , 
lloccnli are formed upon the inner surface of the synovial men^H 
brane, and are afterwards detached ; but many are solidiflcd il^l 
the fluid by a sort of orgiuiio cryRtallizatiou. Such pieces aru 
occasionally precipitateil ujwn tho cartilages, where they adhero 
simply hy virtue of their gummy coii8ist<?nce. 

The fidse membranes, which form ujjon tlie inner surface 
the synovial membrane, must not be supposed to bo tho cause 
of the tliickeiiing whic^h that stmcture undei^ea ViT)' sou 
after the eflusion of fluid, tlie membrane and the periartieiili 
tissues become thick and more or less tough ; therefore even i 
the false tissue could produce the thicktning on tlie free surfa 
it could not cause tliat on the outside of tlie synovial sac ; bd 
if vie make sections through tho tissue wo shall And that 
whole thickening material is one and indissoluble. Beyond tho~ 
point wlitTo the induration takes place tliere is more or lea^J 
exsudatioa of a thick yellow serum. ^H 

The following pai-agraplia are for those of my readers who are^ 
interested iu points of minute pathology. ^^ 

The efi'usiou by an inflamoil surface of a flaid capable of ^Wi^H 
taneoiis coagulation is undoubted ; some of this liquid coagulated 
on the spot whence it is poured forth, some of it is dissolved in 
tho ordiuaiy secretion of the membrane. Tlie fluid is organia- 
able lymph, and it is, if not actually elimiaated by tho wliito 



ero I 




PATHOIXXJICAI* CHANGES. 



39 



wrpBades of the blood (as I taught in 1854, aad crtill tliiiik 
jTolnible)/ is at l&u8t su infliieuced by thorn, that it contaius 
genu of similar cleaieutj!. It is u[xm Uieno. genns tliftt tlie 
>el»6i)iiei)i chaugt»« of Uio Huid dcfwiid. Tlie funnatiou of tho 
Use luembruiiw aud tlocculi, from uu vfTiucd lluid ((.^ougidublo 
'nn|ih) intiflt not be coufoundL-d with another much more impor- 
tant process. It is, I beliove, rare, except in rheumatic lullam- 
Oatious, that a fibrinous cfTu^iion proper remains permunently 
•dlierent to, and becomes vascularized on a synovial eurfacu. 
Sickening from such canae could affect such surface only, 
vliexcAB we know tliat all the periurtieular tititiues are thiukencd, 
tor couguUblo lymph is never efiusod except on a &eo surface as 
of a carity or of a wound ; thickening, sol idili cation, and repair 
of injury iu tlu' substance of a tissue, take^ place by auother 
action* This process may be called grunnlntion, as it is pre* 
oisuly similar to that which occurs in a wound healing by the 
ttound intention, or iu an old abce;8s which is filling up. It 
ooneistit la a groviiii, at both aides of the busement membrane, of 
uuel«-'ate"l, romid, aud oval cells. Those which sprout from tho 
free surface increase the size of tho villi, tind give the membrane 
Fm Telvelty look, and as they grow tliey gradually push oft' any 
ifiUite membranes that have consolidated on the surfoocf This 
[growth is not an exsudation, uor an ctTusiou ; it is not a material 
, fluid at first wliich subsequently becomes solid, but it is a trno 
growth commencing at once by the sprouting of cells frum germs 
kor^ptnally in ihu tissue. The growth tliat takes place on tlie at- 
[tached ode of the basement membmne is precisely similar, con- 
ting of round aud oval nucleated colls, which fill up the meshes 
^of tho subareolar tissue, and produce the solidification whicli 
always accompanies synovitis. Between those two new growths 
of oella the basement membrane of the s^'noviol stmeturo is 
(oat; the whole seeming a thickened moss wliich, as tho case 
goes ou, Itccomcs more Hbrous and tough ; but while tlie inflam- 
mation lasts tho new layers of the thickening (therefore the 
nnust internal and tho most external) i>Iainly show cellular con- 
drt ence. The [)arts of tlie tissue further away from the focus 

^fioe OmreU ou HironK umI Wenk I t Thin u gvuunUy, but not whnyv, 

^ laHaiatttatioui. Mi^oal Tiuii-e umI Uu: ou*f. 
(ia»i.-tU.\ Juuu 23. ISM. ct M.i|. 1 



40 



ACUTE BTNOVTTTS. 



Chap. H. 



of inflammation are infiltrated by a yellow serom. It fulluws, 
when tlio ooU-growth from the inner aspect is protly coiiwder' 
able, that the intomal surfjwo boromes wavy or nodnlated ; it 
first masses ti^ether, concealing the villi, and it is evident 
from onr dcscrijrtion of the ligaments and their coutiutiuu^nees 
with the other librous tissues aruuud the juint, that whi^n the 
inflammatiou spreads sufficiently far outwards from the centre 
theae become involved.* 

At some port off his stage of e£fi]siou and thickening most cnsee 
of simple synovitis stop, either checked by treatment or by 
the natuml limits of the disease. Such is usually the case 
with simple synovitis, synovitia from pycemia,t and acute rhea- 
matiam ; J tho cartilages have not been affected, for they reply 
more slowly to an irritatiou than do textures which arc supplied 
with blood-vessels and nerves; tlie ligaments in far advanced 
instances are somewhat altered, being thickened, and the llbreB 
separated. Tlio abovcHlescribcd pTtxTesaeH diminish first in in- 
tensity, then cease, then commences retrogression, the cngorgo* 
meut disappears, and tho gujxTubundaut fluid in tho Jiant 
decreases in quantity. The granulations shrivel, are in part, 
absorbed and partly converted into imperfect areolar tissuep 
which remains like an old scar, causing some thickening, with 
loes of pliability, and of elasticity in the periarticular tissnes. 
If the amount of fluid poured forth during the disease have been 
large, it will have caused such distension of tho 8)i)0\*ial mem* 
braue that tlie latter will ]>erhaj)s never, and cert&inly only 
aRer a lapse of time, regain its nonnal dimensions, and in its 
cavity tho synovia will remain rather more abundant than natu- 
ral. From these ranses the joint does not recover its original 
size; if it be Bm>erfic'ial tlie increase will be plainly perceptible; 
moreover it will feci stift' and weak for years after the disease, 
being extremely liable to renewed attacks of inflammation. It 
may also be lefl subject to painful sensations which seem to 
dc]K>nd on, or at least to ha greatly influenced by, ever}' change 
of weather, and which gra<lually disappear unless the |)atieut be i 
advanced in life, or of a rheumatic coustitntion. ^^t 

• For a fortliLT ucooout of thld ptoccm aoc Uit- Putbolugy uf Htrmnoni Hy. 
Dovitia. t Soe Olup. III. t Stw Cbiip. IV. 



cuT.n. 



M. RTCHET'S EXTERIMKNTS. 



41 



I Synovitis. — III many cases, liowever, and porticu- 
Inrir in thoae that result from a wound, and also in the worse 
fonu of Pycemia* many more advannod and injurious aotk)n3 
tab place ; and we may at once quote tlie giimmary of M. 
RKlict's cxpctrimeuU to point out tike BUC<N;'6sion of morbid 
KtioQS in such cases :■ — 

"HtTtog opened a joint in senHvl dogs, and ocnnetiinea several joinbi of 
tk iimo dog, I was enabled to cetAblish the foUowiDg foots ; but not 
■itbout difficulty, owing to tlie extreme agitation of tfao oiiimAls and to 
UoanaQ dxtent of their s^-QovioI meoibnutCB. 

"Tbo meubrane, citbur exposed or touched with aomo irritating liquid, 

eaild be Been after the lapse of Oom four to six hours to bocomo reddened, 

tlie/«>tncw appeariog to belong more ]>articularl/ to the suhsorou» tissue. 

"After ten boars the membmno lu««t its polish, but I never at any time 

cuild 6nd that it was drier than in the normal condition. This dtynesa of 

Uie serona membranes iu the first stage of their inflammation is admitted 

by an authors, and yet nothing is fiirther from proof. This pocuUar state, 

■rtiicb has neror been shown by direct obeervniion to exint, hoa been 

I invented to explain their crackling (Irniit |>archemin^. May this not be 

explained by the loss of polish, itself determined by the fulling away of 

' its epithelial layer ; or, to s{>eak more clearly, may it not be caused by the 

I of their habitual flexible condition? On the next day the rudiiCH!) 

1 more superficial, and more particularly as though distributed in 

' iMtches resembling spots of oochymosis. The serous surlace was dull, und 

oorered by a lero-songuinolent layer, which soon bccamo more ahunilaiit. 

After forty-eight hours the synoria became thicker, and aasumed the colour 

of wine-lees ; the synovial membrane beneath thli began to get grauuUr. 

** On the third day, real but badly formod pus flowed from the wound ; 
Uie •ynorial membrauu at this time ■^ca nooily uniformly red. Tliero was 
much sanguineoiLS congestion in the neighbouring titisiies, and when the 
syuOTtol surface had been well wiped with a piece of linen, there were soeu, 
on looking against the light, fine granulations, which I would oomporo to 
tboiw obaerred on the inner surfave of the eyelids in nid blepharitis, but 
I ibejr were more marked. During the following days all thene ap|>eivraneea 
increased, and from the fifth to the twelfth day was obwrved upon the 
BUT&oa of the ttynorial membrane a pseudo-uiuuibranotm ux^iulutiuu, 
whioh seemed to mo to form intimate adbesjons with tho granulations 
aboT* described. At a later i>oriod the synovial mumbraiie could bo seen 
to swell, to form a ^nge, a ti*uo chcmfwia, round the cartilages, whioh, in 

Ithe midst of all this dis<>rder, preserved their normal whiteness. 
**ln one case, when I killed the animal aixty-threo d^'s after having 
iu)eated pure alcohol into his synovial membrane, causing thereby a f^cly 
■appuraticg inflammation with neighbouring ahcessos, I foimd thoae 
sjnovial fringes encroaching so greatly u|ioa the cartilaginous surfaces aa 
•Imofil to conceal tliem -, uevcrthelosa they oould be displaced by the end 
oi tbe fiugor ; and then it was pcrcvivud that they not i>uly hod controctod 
no aalluMUons to tlio cartilage, but oUo that the&e latter had ^uUcnxl no 



48 



ACUTE SYNOVTTTS. 



r.ir- 



chaoga, except a slight loss of brillioticy, aod Umt U107 were thiniMr ibMC^ 
natural." 

This occouDt, as far as it goes, may certainly be accepted off 
representing a good view of the actions taking place in trau- 
inutic synovitis, although tliese cases aro exceesivo. But in tl»e 
huinau being blood is not bo constantly uor so largely mixed 
viith the ^novia as these exfierimonts would lead us tu suppose 
is the case witli animals, and pus is niuoli more readily formed. 

The fluiJ, at first poured into the joint over-obundantly by 
the simple iiillammutor>- exaggeration of iU usual function, is 
clear synovia ; this gradually btK^omes turbid, and more fibrinous, 
some of the fibrin may coagulate into a semi-traiisparuut jelly, 
in a little time the opalescence increases, and now the oo- 
agidatcd fibrin is white, opaque, and floceulent, and in time the 
tluid iu tlie joint is pure pus. 

Thus, if there be no specific mark of tJie pua-cell (see p. 43] 
so is there no sharp boimdary between a liquor rendered turbid 
by their presence, and pure pus; there exist, on tlie contraryj 
innumerable fine gradations; and in wat<ching a caso of tnt' 
matio synovitis, the surgeon will obsei've, that the fluid poured 
forth from the wound becomes more and more turbid, and loeee 
gradually the threadinesa of synovia, aud then becomes pus ; bi^i 
between the two pure liquoru lie many stages in which he wil^^ 
not bo ablo to namo the discharge cither one or the othorJ^^ 
Wliile these chaiiges in the quality of the discharge are going 
on, and rarely in acute ajuovitia before pus is formed in the 
joijit cavity, tlio cartilages imrliciiwte iu the disease : they begin 
to ulcerate. This action comuienccs on tlie superiiciul surface, 
aud spreads deeper to the attached surface of the cartilage; the 
earliest perceptible sign of this j>roce8s is a loss of the smooth- 
ness and transluceucy of the surface, aud its colour becomes of a 
dead or opaque whitish yellow. Such change occurs iu 8|x>ts, 
at first small, but gradually increasing ; soon aflerwords 
spots either liccome simple holes, or tlicy first become thr 
and fibrous, and then erosions with velvetty edges. The fo; 
is llio most rapid form of the action, and it leaves ulcers with 
sliai-p defined edges, " looking as though they Imd been cut 
with a chisseL" (Sh- B. BroJie, 'Diseases of tlic Joint*,' 
V. p. VA). Tlio latter is a slower form, aud tho ulcer thorol 



SUPrUBATION. 



43 



pMaoed lias u peculiar appearance, being lined at its side and 
Wtom by Hbroiu walls of velvetty consistence. Sometimes, in 
•"ipimrativo synovitis, tbeee ulcers are very small and ninnerons, 
1(» cartilage looks " worm-eaten," Ultimutely the ulcemtions 
fftwh the bone, and Uiia structure becomes involved ; tliey tben 
spMuid oven more rapidly, so that on examination of such a joint 
we may find the honv laid entirely bare or only covered hero and 
tium* by thinned, irregnlar-shaped, and ja^ged-edged pieces of 
Hftened cartilage. If ihe bone be split open, all tliat part which 
inderlies the orticidar lamella will be found gorged with blood, 
and much rodder tiian normal — as I have fouud at (xuit^mortem 
exuuiuations by com})aring the fellow bone. 
Wo will examine these processes more minutely : — 
\\li(»n previously de«(Tibing the formation of pus m a joint, it 
Tas remaTk(>d that the syno^'ia became opalescent and turbid by 
wwpetision.thercin of a uumber of colls, nuck'i, and cxifudation cor- 
puai'lea. When the action U very intense, the first two of tliosc 
oonstitaents, besides being produced in large quantitieti, mul- 
, tiply Tory considerably, and render the ilnid tliick, cream- 
^ nduured, and 0[>aque — in fact, pnriform. The formation of 
[ these bodies in quaiutities so imnmicmble is a subject wuilhy 
enquiry, and which tias, indeed, exuiUid the attuntion of [latlio- 
logirits even from the* moment wluni tlie pus-cull waa first di»- 
^lOorered* although it i& only of Inti:* yoatv that tho true significa- 
tion of them has been defiuL-d. Tho pus-cull, wi Itokiian.sky 
oLeervGB (' Lehrbuch der Pathologischen Anattimic,' 3tc. Aullage, 
bd. I, 8. 136), is not a body differing, specifically, from ovory 
&thcr coU ; and, therefore, it is not right sharply to sejjarate pus 
fim those neoplasms which have a solid intercellular materiaL 
^aget oonsidore Uiis cell as a degeueratetl granulation cell, and, 
» a certttin degree, he Is right ; for, when tlie normal cells of 
I synovial and siibsynovial tisCTie take on the action which 
iucce the granulation alx)ve described, a quantity of theaa 
f<»ve«tep the amonnt of multiplication ncceasarj-. and assume a 
felopmont of multinucleated granular cells, which are true 
ellii, and wliich, |)oureti in great quantities into the ji>int 
with the fluid snrronnding them, fill the cavity with pua.» liwt 



Vlrdiuw'* Oclliilitr FaiUiTlotfiv. «. 3Sd. 



Wubor iu Vin;Uijw*5 Arcliiv. JhL 



11 



ACUTE 8TK0VITIS. 



Giur. IIw 



tills is not the only aomve of pns in juiiits, fur vAi'ilo tlic avttuu 
in question is going on in the inGmbrano, the cartilageB, it has 
been said, begin to ulcerate. This ulc:eration of partilage con- 
BistB in an exutfgerut^ growth of cells, commencing at tlie firee 
surface and pcniitruting decjier oud dee|ior. The cartUajro-t'or- 
pusolee and their cells, in a nonnal statt*, diminiith as they pro- 
ceed from the attached to the free aspect, hat a section through 
uIc(>ratiog cjirtilage ahowa that at a certain distAUce from the 
det'p snrfuce, i. c., as £ar as tlie irritation reaches, these cells, 
iuste^id of becoming snmller, suddenly ussume an exaggerated 
growiih, become not only larger in size but in quantity, and dis- 
tend tbo corpuscle inordinat4>ly. In an advanced, couditiuu these 
bodies contain not merely four or six cells, as in tlieJr normal 
state, but an IndcBnitc number of brood-cells, multinucleated 
cells, and Ixtro nuclei ; and they frequently burst, sotting these 
matters free {s&e ' Kedfern on Abnormal Xutrition of Articular 
Cartilages '). At this time the last layer or two of cells, which 
normally aro dry aud flattened scales, therefore iuca]>able of 
furlhiT action, become detached, ami may fall offoue by one, or 
iu little membrane-like pieces into the joint cavity. If an arti" 
cular cartilage be examined at that jioriod when the cells have 
first commenced the aUive-ciesmbod superabundant growth, 
poitions of this layer of flattened c^Us may be stripped off lilco 
a membrane, have indeed been mistaken for one; but a careful 
oxumiuation will bIiow its true nature. Tlie disease must be 
cunght at a particular phase, that this menibrnne-like detat'h-' 
ment of the last layer of cells may be found. The great increafie 
of cell-action, overatepping the limits of nutrient power, is fed 
by the hyaline substance, whicli it eats up bodily in this most 
rapid forms of disease ; and in the slower, convi'rta it first into 
fibres by devouring only parts in parallel lines in the direction 
of the cell-growth. The Uirgc cells press to the surface, as in 
normal cjirtilage, but more quickly, aud many of the corpusclea 
burst on the free surface, leaving erater-likc cliasms bchiDct, 
which add lo tlio roughness of tlie librous ulcer. The cells are 
tliUM ttt.'t free in a state of great generative activity into the 
cavity, where tliey mingle with, are, in fact, uudistmguuable 
from the pus-cell, oud multt^ily as it dooa The amount of pus 
thus formed from the cartilage-colls is conuidernhlo, uud sliarcs 



Cntr U. 



SYMPTOMS. 



45 



*Jie immlont action with Uie colls from the gmnnlnUon tissue, 
•walready dcBrribed.* 

Thri nlcenitioii iu the cartilage, whirh [>roc«(Hl« in reality from 

tttoflammatiou (hoo Chapter V.) makes, like all oth^ inflani- 

itttiimg, increased demands for pabulum ; hence the ve8s»el« 

Btiuted beneath t!ii> artiL-ular lamella become h^^ierapmic. In n 

■ortdme the innfiromation sproadfl to the bouy tissue, caries com- 

"Wnca, aud f^T^iiiliiiion in the sponj^y texture of the bone. Those 

pwtiiof tho cartilage whinh have not ^H^-lded to ulocration are 

flewingrent mnaanro deprived of nutriraent, and fall into fatty 

<k|getieratiuu. 'The 8upj>uration and deHtniction of the Ixjne 

iprettds more and more; abce.ssoa furm in the periarticular 

Imrics, among the muscles far &om the joint. The pain ia 

most severe, {uirticuhirly at night, and at laHt tlie |)atierit is so 

worn that dnath or auiputtitinii biicome inevitable. 

Tliii* 8kut4*h is, of oonrso, tjtken from the worst and most 
intractable form of cases. Id many instances a carefully 
plamied treatment, aided by a strong constitution, may prevent 
the excess of stipparation anfl tho spreading of destructive 
actioUf and at last succeed in tiaving both Umb and life. 

Symptoms. 

Tho Bymploms of this disease are, of course, those of inflam- 
iion — fiaiu, heal, redntss, swelling; but there i.s another 
ultar to them as joints — position. We will pjuunine the 
firsl three syniptoms by themselves because they are so alike 
in nil placi'K that very little need be said for each jiarticular 
juint> but the swelling and the position diO'er so much for each 
4irticti]utiun, that a deflcripfion of them iu the more important 
{4irt4 is a ueceaeity. 

yyhvn the diijoase has been prodm-wl by violence, the pain 
at the moment does not disappear entirely ; it may even become, 
daring a certain sjmce of time, less and less severe, but a sense 
of weight aud inability to move remains : tliia is followed by 







V*n-hoir'» PuvncliyuutoM Ent- 1 odlcttl. Bilroth, Ih-Jtmipu ziir Patholo* 

111-, An-'liiv.. Ua. iv.. h.3. ». 234 ; ! gisLoa Arm»<troiy. lUiKitoniky IjoUt- 

! lIt EntatvUau); ilea Eit«n Wli il«r Piaiiolugi«clien Auatumie; 

. ltd. XT., Il 6. ». +*;7i 3tc' iiuBiigf, «, 131!. PukiIu U-clurcB. 



46 



ACUTE SYNOVmS. 



OMAr. 



an increase in the pain, piThnpn by thn*bl>inK, anH aa tlio diecr 
Ifecumea estiUilished the stiftoring is i'roquently fievere. Wbe 
tho attack ariseB from exposure, the patient is gODcmlly avokl 
in the n^bt by jMiin. It is sometimes dt^scribed as bciujjj Hki) 
aa internal bruise, sometimes as tliougb hot iron were in tbrl 
bone. In otJier instances a sensation of great distension is the I 
chief eoiuploiiit, tho patient afKrmin};;, that lie feels &r though a ' 
irrowlwr were between the bones witli which ^he joint were 
being forced asimder. The pain in eortnin joint«t [mikm's ah«o to 
other f»ai-t^ of the liinb : th«p, s>iioviti8 of tlie elbow produces 
pain nuiiiiug douu the arm to the little Anger, and dometimee, 
but lees frequently, to the buck of tho tliumb and index. MTien 
tho disease is situated in the hip, it causes also pain iu tJie 
kuoo. 

Heat is a constant symptom, even when tho disease w situ- 
ated as far from tho surface as tlio lu'p ; but the heat, in different 
cases, ia uut only difTorcut in degree but to a certjitn extent iu 
kind. When a surgeon places liia hand over a knee siinTtiring 
from simple synovitis, ho will Hnd it hot; if it be a tninnmtic 
cose in tho early stage, still hotter ; but the heat will not appear 
very near tho hand ; the skiu itself i>eem8 as though it were not 
BO hot as is a deeper-lying structure : but if wo take a case of 
acute rheumatism, the heat may or may not he greater, but 
it comes immetliately next tlio han<l ; it is quite supeificiaL 
In pyoemic and gonorrheal cases, ou the ooutmry, there is nnt 
geuerally so much heat as iu simple synovitis ; in fwt, iJie 
whole skin of the hotly is hot, but the joint wherein the poiu is 
situated appears harrlly, if at all, hotter tlian other porta. 

The redness varies iu a very similar manner : in acute rheu- 
matism tlie joints atbickt><l are very red ; iu simple syuovitis 
they are only slightly rediienetl. Tho pynomic and gonorrheal 
form do not cause any redness of the skiu at all •* iudeod I have 
sometimes tliought that the joint was actnally whiter* more 
pallid, than its follow. 

The swelling is canaod by increased secretion into tho syno- 
vial sac, and jmrtly, tliough to a less degree, by tho hyiH^rtemia 
and efTusion into tlie siirrouuding tissues. In forming a diag- 
nosis of tho case, however, it is necessary that tho surgeon 
* Tlio Hkiii over fiiflaniod aUftvrfloiiil vf^iu mnt nl«orbciil« ia excvptot 



i 



QuF.a. 



M. DONNF.T*S EXrKniMKNTS. 



17 



ihoiiid convince himself tijtit tho fluid tnmofnction, whiph hisprac- 
IwdhuiKl readily discovers, be really in the eyiioviol mcrabrmie, 
tbd not iu auy ueigbboiiriu^ bursa or olher piirt. To do tliia 
h taoA he a(?r|uaiiit<Hl with tlm nhnpe and cirfumstAiiceji of tlic 
^^torial calargement ; the membrane is bonnd dowii in all joint* 
t>T ligameuts and by teudons, whiclx, in the natuml condition of 
pirtft, are prominent ; but when it is pressed ontward by a force 
liwn within, these liands nisist the pressure, and they become 
ciliier contn^aled or furm depressions : hence is a rather different 
iDtttomy of the swelling for every joint, according to the posi- 
tuu of ligament and tendon crossing it 

The posution wliich a limb assumes wlicn one of its joints 
liwomes tile seat of acute tRsoaso, is very imjwrtantjDot merely 
IS a dia^^ostic sign, but also as a point wliicb can be mado 
aeful iu •treatment. Every joint, when it becomes inflamed, 
ammcs a ccrtaiin jKisition us surely as it becomes congested and 
hot ; and in this position only can tho patient obtain anyttiing 
like ease. Many rcawms hnve boon assigned for this invari- 
ability of posture, and among others that the particular position 
MBamed by each joint is that in which its synovial membrane 
r|mri}S the lar^ust cajiacity, and tlierefore that in which tlie 
Tosed fluid would exercise ilie least prc-ssuro. In order to 
this, as well as to scttJe some other points, M. A. Bonnet,* 
[of Lyons, mado some experiments on the dead subject, by tho 
jrciblo injection of Uuids into all the largo joint cavities, and 
tlie positions which the parts assumed. He gives a 
tery detailed account of tliese expeiiments, not only in general, 
''bat in each particular case, which renders it far too long to 

» quote here ; but the gross results, taken in connection with 
clinicul experience, are interesting. It is well to premise, that 
when the sjTJOvial membrane of a joint was forcibly injcttotl by 
IL Bonnet the limb always assumed tho same position, whatever 
might have been its jiosturo before tho injection was made. 
This position of the joint is that which allows tlio grf^at+st 
possible capacity to the synovial membrane ; as is proved by the 
CJKt that when tlio membrane is teuse foivlble change in the 
positioii of the limb causes its rupture. 



* Sea 'Makdiw dus ArticuUtioiu,' by A. Uoauvt 
8a;taL*c 



Purid, Uoillicn^ IS45, p. 



ftp. . 






The Skovtder. — ^Tlio deltoid looks a little fuller than natnral 
the bi*oad groove miming downtvard from the acromion, an< 
scpuratJiig tlio ohest Tivm tlie shoulder, is in t;rtat meas< 
oblitoraled or rendered imrrower ; likewise the depression 
the back below the oojomion is lost; the axilla is also shallower, 
and when the surgeon places liis finger in that cavity, aud 
presses upward aud outward, pain is cxporionced. 

The |>osition wliich the patient, while sitting or etandi: 
. assumes — that- which I would call the charaoterigtio poBi6 
to hold the elbow in the sound hand, keeping it a little in front 
the body and awny from the side. 31. Ltonnet • found, on forcil 
injecting the joint, that the humenis was abducted till it form 
with the ribs an angle of 35"^, at the same time it was carried 
forwards. Siimelimes the bursa under the deltoid muscle 
eonies innjuiie^l mid swollen ; this aflTeclioii reiider» the dolt 
more prominent than is the case in synontis, and the other si 
are alseut; a crackling, a fluid crepitus also is felt in the bursal 
ulTec^tion wliieh is alfsent in the synovial disease. 

The JClbow. — At the back of this joint arc two depressions, one 
on each side the triceps tendon aud olecranon process ; the lower 
part of the outer of these contains the junction between the head 
of the radios aud the humerus, which, in the natural condition of 
parts may easily be felt When the elbow-joiut is the seat of 
synovitis these depressions are obliterated, the synovial mem- 
brane rises high beiieiith the triceps tendon, and can bo made to 
Huctuato from one side to the other beneatli it; the depres- 
sion that should 1k! felt hetwfnm the radius and humerus is 
exchanged for a fluid euhirgement ; the depression also between 
the olecranon and intcrual coudyle is in the same couditioiL 
ViewtHi from the front the joint looks bnrador thiui natural. 

The oharaoteristie position, is with the fore-arm bent at a lit 
more than a right augle on tl»e upj>or arm, and the liand in a 
position w hich places the thumb upwards ; the [uitient uaually 
holding the wrist in his sound hand. Bonnet says, under the 
iuHuence of forced injectiou the ulna is always brought to stand 
at nearly a right angle to the humerus, aud at the some time 
tlie radius takes a position between pronation and supination. 



• Op. oit, ToL ii, p. M». 



cr*^. n. 



AT THK HIP. 



I 



The Ifrwrf. — Koutultlio back of this joint there runs, in acut« 
Ijfnuvilis, A bracolet-like swelling, wIurIi in more marked laterally, 
«u eiilier side of tlie eitcasow of thy fingere, unti Ujtweeu the 
tttinsor (iHsis, mctAear]>i, and extonKOre jtrimi and secnndi iutor- 
ii'tdii pollicia ; in front also, at either side the flexor tftndona, it is 
pPrteptible. It cannot bo niistakea for enlarj^oment of ton- 
ikim aheathea, for those bcliind an? wry superficial, genoially 
li- or triticareatod and fosifomi, the long axis being parallel 
»Hb that of the ann, not^ as in synoWtis, at right angles* witli it ; 
HI front onlargcraont of the large tendinous shoathe produces 
nn*Jliii^ in the palm and wrist — a bisacukted swelling. 

S%e Hip. — It is more difllcult on accfiunt of thn depth of this 
jooff to di»tiiigtiLsh the swelling produced by aouto synovitis. 
The tumefaction is to be seen and felt in the groin below 
ftrapart'e ligament, and also behind the great trochanter — the 
iiitnrai depression in tlits place is more or less obliterated. 
^Vhen the fluid is large in quantity some swelling may be felt 
on the inner side of tlio ttiigh, whote it joins the perina.'Uin. 
The pain, which in this complaint is often very intense, is chiefly 
ri'ferred to that part of tlie thigh, and more rarely to the knee, 
M in chronic hip dii>ease. Generally the limb appears length- 
ened, aud is a little (lexed, abducted, and n.it;ite<l slightly outwards. 
Tho clianwtt'riHtiL' [Kisition is tliii* : the thigh ici bent on the 
peWia. a little abducted aud rotated outwards. In reclining, the 
jmtieut iiHually lies on the affected side, tlie Imeo drawn up to 
about 120^ with the body. AVhile sitting, the (latient may be 
Men tenning with the elbow on the sound thigh, holding the 
knoe of the affected limb iti his hands, and supporting that foot 
acrosH the ftxit of tho other limb. M. Boimot * says that a 
forced injct^tion causes tho femur to bend at an obtuse angle 
tu the pelvic axis, at the same time it becomes abducted and 
rotatod slightly outwards, 

Twii burHae abuut the hip joint may by their enlargement give 
risB to symptoms, which w^juld lead a careless observer astray. 
Oiv ' -li the gluteus mnximiis muscle would, wlien inflamed, 

pn> aiiul tho ti*oehaiitor tumetaction similar to that canned 

by joint inflammation ; but the swelling is difl'usod over a larger 
dniuuference ; it is not mert^ly behind, but is also above aud 

• Op. rif- vr.I. n.2«i. 

E 



50 



ACUTE SYNOVITIS WITH 



Ciup. It. 



snporficial to tho trochanter; it crackles on moreznent of tho 
part; morco^'er, in such a malady no ingniual enlargomout ta 
pruiluued. Between the eoiijoiued touduu of the pAoiis and iliuona 
mnscica and the bone, is a bursa wliich sometimes, though mndy, 
becomes inflamed ; in this case Die 8welling and tondfrni^ss 
in the groin will be hardly riistingnisliable troni that of joint 
discaae; but tlicro is no swL'Uin^ behind Oie trtwhautor. More- 
over, although when tho hip joint k inflamed, eertain positions 
are, as already pointed out, U'*9 painful than others, yet the dif- 
faronce is not uetirly so great as it is in inflammutioQ of thi^ 
bursa. If, in sueh a case, the thigh be straightonod on tho ))eivi8, 
and rot(itod a little inward, the (Miin is intense; but if the thigh 
be much bent towards tlio abdomen, turned a little outTrard 
and sujiported iu this position, the part is quite at eoAO. Thus, 
inflammation of eitJier of these burna-' is easily to he distinguished 
frora synovitis of the hip joint ; but it is tight to state- that the 
psoas biu^a and synovial sac sometimes, though raivly, uom- 
TOUuicate, as tlic s^'novioLmembranc of the shoulder eoinotimos 
communicates with the Imrsa beneath the deltoid. 

At Ote hiee synovitis is vory easily distinguishable on ac- 
count of the saperfieiid position of tlie joint The shape of the 
part becomes altogether altered, the natural deproifisionp are 
filled up, tlio elevations concealed, so tliat the whole loolcs like 
a bag bound in at Uie sides by tho lateral ligament ; for in- 
stance, tho patella and iis ligament, insti^'ad of presenting a 
prominence bounded by lateral depressions, lie in the midst of « 
puiTy tumefaction, being almost concealed by the bulging out of 
the synovial bag at their sides. On each side of tho patollft 
and its ligament, the swellings thns caused may bo felt distinctly 
to fluctoato from one to tlio other; the patella it£eU' is buoyed 
up or pushed away from the femur, it floats and rocks upon the 
accumulated fluid beneath ; by slight pressure it may be 
pnslied back into its place between the femoral condyles, and 
may be felt to strike against them with a gentle impulse. The 
fluid swelling rises up between the bone and the extensor muscles, 
whither the synovial membr^e, often even in a healtliy state. 
and always in tliis disease, extends very liigh. When the secre- 
tion is rather hirge in quantity it causes also fulness of tlie 
popliteal space. 



r.TI. 



SUPPURATION IN JOINTS. 



61 



The position of the joint ia semitlexod at al>uut an angle of 
120". 3L IJonnct* found also that forced injoctions into tlie 
irial membmue plHoed the bones in thia potutiuii. 
Two bursa? are situated in front of tho knee joint, a hirge 
<itie lietween the patclU and akin, a small one between the ligar 
Weninm patellse and tho tibia alwve the tuberosity; this latter 
WBietimfs comninni rates wiUi the joint. It is sciurcely con- 
ctivible how inflammation of either of these can be mistakeD for 
ijnovitij* of the knee. The former bursa, uheu inJlame<l, caoHcfl 
L I TL'rj' proraincfut swelling over the j)atella, rendering' this 
H Kpon markedly protuberant, while in Bynovitis it becumos 
H cunceoled and less prominent Inflammation of the latter bnrea 
^L JhKlnccs hnt little swelling, wliicb is just on each Eiide the upper 
^P )ivt of the tibial tuberoaity, but it never rises high eiioiigli to 
be mistaken for knee-joint diseatio, and the seat of swelling and 
of|Hun in uniL'b more limited. 

At the ankle tlie BwelHiig lies in front in a half circle extend- 
ing from malhtolus to malleolus, and lUso behind these proccfiHoe 
ff bone. Fluctnatitin nmy 1ki felt fmm one to the other without 

tdithciUly when the efliision ia pretty considerable. 
jVcute synovitis of this form is always accompanied by inflam- 
matory fevoj" according to the amount of the inflammation, and 
to the size and importance of tho joint. When it occurs at tlie 
^Iiip and shoulder (rorc cases), particularly at the former, this 
fii^orbancc is well marked. 
Tlie symptoms wliich indicate suppuration iu the joint are 
oliecuTt* OM h)iig us no o])euing enables tlie surgeon to sec whether 
pure poB or turbid synovia be flowing away. The surgeon's 
inger detects the presence of fluid, but doea not inform him of 
ita oalnre, and thorrfure he must judge by other and mure 
uerul sigiu;. If the patient have, during the inflammatory 
attjick. a riynr followed by raoru inteustj^ pain iu the joint and by 
greater fevorislmess; if tin* tskiu of tho part become moru red 
and the* efliision into tJio pc'riartieulor tissues more oousiderable, 
lattUe tumour lose some of the cluinu't* fistic marks above 
itioned, and become more roimd and shapeless, the proba- 
Ulitv is that pns is being formed. It is to be observed tUut it 
i^ nut the mere predeuce of pas, wliieli we wish to distinguinli oh 

• 0|.. Pil.. vol. ii. p. 152. 

K 2 



52 



ACUTE SYNOVITIS. 



Chap. IT. 



an important point, but rather thR pus-prodacing inflammation 
from ony Io«8 TioUmt and injurious. The pus itself is not phy- 
fiically different to sjoiovia, or other fluid, its preseuco therefore 
cannot be directly diagnosed, but the violent and hiiety inflam- 
mation which produces puB ia destmctivG, and has certain 
charactcristicB wliich may Ix; c-asily distinguished. The general 
symptoms are those whereby wo can chiefly judge the presence 
of this matter. At)«r the rigor above mentioned has occnrred* 
the fever from which the patient suffered will change from the 
inflammatory type to a depressed or tj'phoid character. 

The jiuUe does not diminish, probably increases, in rapidity, 
and IxM^me^ small, the iac.e is drawn and anxious, the eyes dull 
and heav}'. the tongno bro\iT», furred, and drj- ; in fact ho will 
suffer the symptoiua for which we may safely refer to general 
surgery under tho name of typhoirl, or low fever. 

The punilent inflammation does not continue long withoat 
involving the periarticular tissues as well as the mere cavity ; 
all the parts around the joint, ligaments, and areolar tiasne, 
become softened ; abscesses form in them, which are generally 
in eommuni<'atiou with the joint ; tlieao uuiy bo felt as nearer to 
tho surface than tho rest of the fluid ; and al^er a time, if the 
case go on long enough, they will |K)iut, Soon the skin gives way 
at tliese .spots, and openings into tlie joint nre formed from which 
pus, sometimes pure, sometimes tinged with bloody occasionally 
of a browuisli colour and fetid, will plentifully flow. Tho 
joint, on account of the looseniug of tlie ligaments, will ho move- 
able in abnormal ilirections — for instance, the tibia can be 
rotated on tho femur. As the cartilages will by this time have 
disappeared in great part or altogether, the l>one« of the joint 
can be felt to grate together. At last the whole limb swells aud 
becomes ccdematous, abscesses form among tho muscles evon at 
considerable distances from tho j».iint. 

The patient by this time is reduc^ to the last degree, he is 
delirious at times, has lost all appetite, sweats profusely, has 
diarrhopa, and other syrajitoms of the worst typhoid character. 

Tho pain is intense, indeed tho most horrible tortures of 
which humanity is capable are produced by tin's disease, yet great 
as all these evils are they may be complicated by another, vis., 
pyaemia 



Ciur.n, 



TREATMENT. 



53 



TnEATMENT. 

Tlio trpfttmeut must Ix; divided into general and local. An 

amlf inlfimimation haa an pffe**! Uf*on the gcnpml sysU^m, ami 

ihriHigli tbe sjstoin may be ilself aftected. Tbe reraedii^s belon*^' 

to tlw c1h88 called ontiiililogistic Among these ore General 

Bleeding, Purgatives, Dlnrelios, Jroroiin', and Antimony. Tlio 

first of these, bleeding, need very seldom indotMl be resorted to ; 

the axtmA ia valoablo ; at firat a slight mercurial, followed by 

*lijiirag(^c cathiii'lii,', lias great power in dimluisliingllie fevor» 

sod limy advantageously be followed by dinretics and diapho- 

Ktics, Mercmy, if tbe local iutlauuuatiuu run high, is of avail 

fli jtersouj of a strong constitution ; it may even, if nec<'8sary 

bs |injdio<i till it touch tlic gtims ; but in those of a strumous 

liabit its use ehonid be L'miloti and cart-fully watched, lu these 

ftersom I prefer antimony ; 1 have seen very beneficial results 

foum itfl employment, and it is devoid of the danger which 

mercury involves. Antimony and nitrate of potash will together 

be sufficient to keep down the inflammatory condition in most 

I ; and, when aided by local means, have a marked eflect in 

Suing aeuto PjTiovitis. Oiu: euiitioii, however, in the employ- 

[ment of all htwering luedidnes is very noetwsary, namely, that 

' they mngt not be pushed to the point of producing debility, for 

when tliat state comes on, suppurative iutlammatiou may be 

lindnecd. 

A point well worthy of consideration is the pain and the 

injon" it may do. Pain is an evil in itieJf, from which every 

snrgeun is bound to savo his patient, as far as possible ; but it is 

rliPtnd''!'. I am convinced, a cause, when it lasts, of additiomil 

diseased action : it is a direct irritant Thus, if the patient, 

in spite of all the local means which can bo employed, never- 

Uieleas Buft*<?r severe (win, tliis evil ought to be subdued by opium, 

or if that drug, from any idiosyncrasy, be inadmissible, by other 

anod)nieH or narcotics. Much praise is due to a combination in 

these cases of antimony and opium. Tlie antimony, by do- 

■ prPBfiing the lieart's action, or promoting absorj)tion, or both, 

j enables tlte iitlter drug ti> ai't much more reaililv, and therefore 

[AmalU'r <|uantitie8 may be given; the effect of sucrh a prescrip- 

|liun is oflun very marktxt. Tlic value of calomel and opium 



ACtfTH STTfOVHTS. 



ITAP.l 



nce<i liflrdly l>« mentioned, indeetl upon this comliination niimy 
snrgeons depend for tlio troatmeiit of all acute iuflaniuia- j 
tions. 

Of the -local means perfect fixity of the part is the ranst im- I 
portant. It lias already been mentioned tliat the synovial mom- 
Itraue is more capacious in certain jwsitions of the joiut^ than in 
otliere, and in a state of inflammation, when the membmno is 
filled willi fhiiil, that jjofiition will K' nearly alwaj-E the one 
chi«eu. But this jHMrtnri! is not always that which id most favouiv 
able for treatment. Thus the knee \>-ill naturally ausunie too \ 
btmt a po:*ition, and it must be confined in a straightor postiin; 
than it would itself assume. I put the limb ou a otruight splint 
at the back ; but it is necessary, in so disposing it, to place a 
nilher thick pad under the popliteal region, otherwise con- 1 
8idt^nd)le pain will be produced. It la to be remarked that the 
joint below the aflet;ted one should also be confined. Thus, in 
fixing the slionhler, not only xhfndd the upper but also the fore- I 
arm be fastened to the side, otherwise rotation of the joint will 
not be prevented. lu fixing the elbtw, the ttTist must also be 1 
confined, or supination and pronation can take place, and so on. 
The fij)lint, therefore, must be long enough to ini'lude both 
urtieulations. Leather or pasteboard is preferable to gutta ' 
jwrcho, partieularly for children, as this last confines the «'Uta- ' 
neous secretions. The splint for the knee should be stiffer. 1 
prefer, as above saiJ, a wo<.iden splint at the back. 

Local depletion by the cupping-glass, or by leeches, is very ] 
valuable; but iu superficial joints, us the knoe, nnither should 
be applied immediat<;ly over the synovial membrane: 1 have 
seen ill efiecta follow the neglect of tliis rule ; they should bo 
pimped abovti the joint, i. o. between it and the heart In 
dealing with deeper joints, aa the hip and shoulder, the applica-j 
lion may be made as close to the part as possible. It is bettarj 
not to ttMi-Hct any large quantity of blifod at once ; the amount ' 
will nf course depend on the age and con.stitution of the patient : 
young children very rai*ely, if ever, rei^uirc tliis remedy for a I 
synovitis ; and even a strong man should not lose more at a | 
time (locally) tlmn from four to eight ounces, either by cupping | 
or by the apjiliiation of from eight to twelve leeches ; the I 
reuKHly nmy however l»c reiterated. A caution respeetinji the 




Cmr. n. 



TREATHENT. 



55 



npeCitMm of local bleodiug i» d(«iral>U' ; for then* comos a limo 
vjien it may bo injnnonfl; a iirae when the morbid condition 
i*MM to ilepond 9<> miioli on activif y of the tissiioB as on a Idsh 
if oootniotility — a t^jpical asthenia of the blood veesela. Loiidl y 
tiiij roa^liliou is acoomj>auied by a ccxttatiuD or great dimiiiatioit 
rfkeat, probably also of ]>ain, while the swellinp; continues, and 
tbe mdnesB aesumes a dnslder hue, wherein presffuro of the 
finger leavMa white spot more durable than while active inflam- 
nmtion ("ontinnea. At the same time the symptomatic fever has 
■nncli declined, or has assumed a more irritable and lesB Rthento 

Hot fomentations and poultices, wliich g:reatly relievo during 
ijhB fir^tt part of Oie dit^enso, have also thifi eflW't ujioii tho vi<»se!s, 
in a lesiH marked degrt^o ; lieuee thi'ir action ali^o rr-qniree 
latching. 

If the disease have reached thia stage the treatment miint 
be clianged; with the chiuige of type, tonics, flteel. acids, and 
quiniju; are extremely nseini— the opium may be diminislied, 
then discnutinued. Locally, the bcwt appUcations are t»ld mid 
presBUrt^. if tJiis ktter can In; boruu. whiih is the cast.' if there be 
110 longer active inllammatiou. It is ver)' useful to mark how 
t(i judgt* whether ut no pressure is available, A certain point 
L of cftch juijit is ol)Served to be always the 8i>at of the moat severe 
1 pun ; if on pressing njHm this spot no, or very Blight, teiKlemeas 
lie felt, tl;^lit bandaging will not only lie paiidess but actually 
(il(:«sunible, Th<'«e s^iots are mentioned iu anotlier chapter.* 
The bandage nmy be kept cold with an evaporating lotion, or 
■itii iced water. 

Generally, however, the joint instead of falling into this con- 
[tlition miiv lose all its acute symptoms aud suffer from a linger- 
I iiig inilammation of the sub-acute or chronic fonii. <JomUi?r 
.irritation by means of blisters, or iodine, the iodide of jutass 
I uintment* ^ir B. Brodie's acid lotion,t or other means Miill be 
I niffi<*ient to subdue this, if no constitutional state keep up the 
irritati«jn, in which case the tliscase falls under another heading. 



• l*«;ChBp*crV.,Tr€«tineutof8tm- 
liDoiu SyuoTitu. SliouM^r; in front lio- 

' : wriftt: 



hi 



:>lMlI UU 



ICJ 



f(.inur riiidwiiy b«tir«>» pntolla oiitl ill- 
lemnl laliTFi] ligament: nnkle; in &unl 
of iHitt-r iiiiillfoltin. 

t Aciili Hul|iliiirici fort ^t*. Oliri 
olivi ^IM. (JU<i li'ti.'biiitli I'M ' 



56 



TRAUMATIC SYNOVITIS. 



Ctur. 11. 



liVheii this last condition is subdued, friction until motion (at 
first pnssiTe and then active) should be resorted to in onler to 
promote ftlisorption of ih*^ new grrowlhs. The former of tlirst- is 
very vahiaUc for euiKrticial" joints, and often restores Uoxi- 
bility and perfect shape to tlio part more raj>idly than any other 
means with which I am nrqiiaintod. It slioidd be npphed with 
the bare hand, but a little Hour, starch, or oxide of zinc, may be 
used to protect the sidn. Active motion should not be allowed 
as long as the points above meutiont'd remain tender. If the 
(liscuso bo in u joint of tho lower extremity its use must be still 
further po3t|K>ned, and o%'en when first given up to the jiatieut's 
management shniUd be protected by tight strapping. 

I have deferred making mention of a treatment that bus 
been much recommended when the cfTusion is large in quantity, 
namely, subcutaueons incision of the synovial membrane ; for 
it has not fallen to my lot to bo driven to such a resource. It 
is founded on the idea that the tension of the sac prolongs 
inflammation, and there is no doubt that sucli may be the case 
when the lluid greatly distends tbo membrane. A tenotomy knife 
passed under tho skin may be easily made to incise the sac to » 
considerable extent, the fluid then flows out into the areolar 
tissue, whence it will be absorK-d. If pare be taken to exclude 
air, no suppuration will follow this little operation, and it is 
quite credible that tho uiflammation would be more mauageable 
when all tension lind ceased. In a case whose symptoms war- 
ranted tliis treatment, I should not hesitate to put it in practice. 

Acute suppmutivo ^uovitis, whether or not resulting trom a 
wound, rutpuri's a few words. It is certain that an oj>emu(; 
freely admitting air into the joint cavity will produce suppurative 
synovitis; but the same disease will follow an iiijiu-y without 
wound, and even idio|jatl)ic synovitis; whiM on the otlier hand 
all surgeons must tmve seen cases of woimds into jomts, which 
wore not followed by any evil symptom. This partly depends 
upon the form and size of the wound, upon its rajiid closure, and 
Tory much upon the state of the |)erRon's health at thu time. A 
wide gaping wound into tho joint, allowed to remain open, will 
generally cause the disease ; but sometimes u little wound will 
produce it, however well treated, while often a larger wound 
will not do so — for sometimes iJie hcaltJi is in such u state that 



Cur. a 



TItBATMKNT. 



57 



8 soppuratire iuflaiumation will commence on the slight*^ pro- 
I TOition — while at other times woanda will heal, and injuries 
be recuverdd with marvellouii rapidity. 

CinVir.— On the 14th March, 1859,1 saw H. L., a young vomui 
nponvbose knoe a boi) had that moming been so iucautioiisly incised, 
^ it WW feared tha joint wan niwoetl ; the circumstance leading to this 
«it[iietOD WMon escapa of aynovia. The boil was close to the ligomentum 
ptcOoB; doBO to aud nuuiing paraUel with which was aii incisod wound, a 
link more than on inch lung, from which synovia oozed, and whou tho log 
*Mbetit flowed pretty freely. This flux proved uothiug, sioce, although 
ntlut plentiful, it might bo produced hy the bursa in Ihia situation. I 
fbn£in) warmed, oiled, and carefully introduced a thin pif^be, when it 
ink at once to a di^pth clearly showing it to have entered the knee. The 
tttfraaioDi waa withJrawn, a gutta percha splint [iloocd ou tho limb, and 
Iba lottnd dosed bj^ pointing its aurfaco with collodion, and covering it 
*ilb ft piece ofsoap plajster; the object being not merely to prevent the 
•Btimoe of air, but aJao tho exit of synovia, which would tend to kwp it 
Opm. The wound healed without a sign of synovial iuHammatioD. 

CiaTIir. — ^The fallowing case was kindly sent me by my colleague, 

Vt.CWiton. 

Hiarjr Short, sailor, estat 32, was sent to me on tho S5th April, 1S59. 

H« Cime for ulcers about the right elbow, of which he gave the following 

■Wunt! — Three yeaTB ago, while at aea between Madras and Calcutta, 

^wH broke oat on board ship a complaint which he calls scurvy -boils ; 

•"fsrJ of the crew were affected. He had aeveral boils on different parts 

•fbiabody, tho worst being about his elbow, and nearly a fortnight after 

*^ lad opened into an ulcer, the boue began to get bare. Ou his 

"^^tt Calcutta he went into hospital, where the sore healed ; ho saya 

K '^ DO bono oame away ; but in this he must bo mifitakon. 

H 'fhett ia now a large scar, with uneven eflges at the back of tho elbow, 

H "pOB »hich four Hmall ulcerations hove again appenred^one in the oontro 

H ^^ tleep and fistulous. Around this spot the elbow is deformed by a de- 

H fWioD which, judging by eyesight, merely appears to result IVoui ab»onoo 

P ^txina. On examining the [Art more dosely by touch, it is evident that a 

P'^'UoB of tho olecranon in ahftcnt ; tho part ftiill remaining is attached like 

*M«UDO)d bone to the triocpA extensor tendon ; between that detached 

P*« ilid the reat of the ulna i» an intorval which corresponds to tho de- 

pfttmm above mentioned, and which varies from tbree^quartors of uri inch, 

'W (he anu ia straight, to one inch and a tptarter when it is bent, oud oven 

' b fioriy two iocheH when the cubit ts strongly Qexetl, In the centre of this 

7*00 is tho fistulous ulcer already debcrihod, nut of which aynovia Hows 

fmdy. When ho alternately bends aiid stnughteiu the arm, rather quickly, 

>irli sucked iiito,tlicii driven out of this opening, with an evident impulse; 

•iidal the same time the synovial sue is first separated from, afterwards 

■peUed against, the bones of tho joint, making a Happing noise like the 

valve of a pump before the water ban risen. When ho had continuod 

Action aome timo the joint loolteil a httio swollen, and on prnKsiiig it 



58 



SUPPUTlATrVE 8TN0VITTR. 



C»Ar. n. 



with tbo bftnda air ootUd be «xpoIlod rw>m the synoviftl ua. Tho toaii 
ox)>eriencetl iiu )iaiu iinr any slifiiioss of the juint, aud Bcemefl Burprised 
wlieii told tu keep it at rest-. 

The tieAtmcut was simply rest, closure of this opening \)y adhesive 
pUister, and the internal use of iodlDO. Ttio tUcera gradually healed ; that 
leading into the joint liardly slower than the others, because all flow of 
synovia was pi^vented. Ou the 30th May he waa wall, and aboul to ataii 
on another Indian voyage. 

August, ISOO. This man hsH returned : the ulcer into thejoiut ia again 
open, but UD inilamtrmtoi'y symptom haa shown itaelf. 

When 8 wonnd has been made into a joint, the cimnccs'of 
oscapiug suppuration ore, cdfrU parihm, proportioned to the 
timu it rcMnnins o|>en ; it should therefore be instantly closed 
agtiinst all entrance of air, nnd kept at rest ; tJie patient most 
bti watched that the first m^a of inflammation may be com- 
bated. It may be well, particularly if tho bowels have been 
ohiggisli, to g^TO some mild form of apc^rieut at unee, that to 
case inllainmfttion begin one may have a day's start of it Tho 
opium trt'atmeut comes again into eousideration, and if now a 
patient wei-e to eomo under my eare with a wound of an impor- 
tant joint as yet uninflamcd, he shouhl probably bo kept opiated 
for several days, I have known the most terrifying looking 
iujuriea — tbo prow of an outrigger run four nnd a bilf uichw 
into a man's loins; a knife plunged into the abdomen, no fliat a 
wound of the stomach seemed a uettoasity; tu*ea railings ran 
through a thigh — ^all treated by narcotising — all get well without 
a bud symptom.* Locally, ice, or at legist very cold water con- 
stantly renewed, is tlie very best application. ^| 

If inflammation ^t in, antiphli^^ties may be used, but wflF 
tho greatest caution ; wo are to expetrt suppuration, and wo 
must hnsbaiul our patient's strength to the utmost. I prefer as 
soon as this action has eommencud, to give only salmes to calm 
the fever ; to j>ut on |)ttnltices ; use hot fomentations — do all that 
is possible to biing ou the purulent stage, aud its chatueterlstao 
or suiijtnrative ty|)e of fever, then to commeuce a stimulant 
and ttinic treatment — wine, ammonia, quinine, tlie mineral acide^ 
aethers, and a stro^jg diet. Now whether or not narcotism have 
been used, opium will he indispensable on account of the [jain, 

* Tlio flr»t of ihfwi wa* nii<ler Hu« j oxcclleiit iM>l)oaip]4> Mr. Ttnnoi>rk, lo 
i-art' iif my frimd I)r, Jnliun. of llkli vi\u.-m I ifwn inttJi> ut>lttui|ii>iu ; and 
UKOiil , tbr -i-*imd iitidL'r tliul of my ' llic (lilri! iimli r uiv own 



Cnir, JI, 



CASES. 



50 



wfiioli is fttrocions. This stage of traunmtic synoWtis corresponds 
sdjlivjeatly with a uoa-trftumatic attack whicli has become sup- 
purative, and tlie following point in treatment becomos im|wrt- 
UL If tlic wound in tJie joint be small, or if theru bo no 
twind. slmll the synovial sac be incisod to let out the'pns ; or 
ibill it be eviifoaled by ft trocar ; or alinll it be let alone ? 

In n paper n-ad by Mr. Gay Iwfore the Mwiica! Society of 
Lcodon ('^fedicnl Times and Qnxeiie* vol xxiv., 1851, p. 54<»), 
lfa»t able rargfon recommeutla free incisions into the joint, on 
lie plea that they allow shreds of cartilage, which may bo shed 
into the cavity* to escape. It is for other reasons tlint I cordially 
wsmieud the value of such treatment. Some Fn'urh antlio- 
rtiw^ Petit, Bt)yer, and olln-rs, might also be ipioted in favtmr of 
lluBplaxu A joint once suppurut<!d lias lost tliat sensitiveness 
tit the contact of air which it normally poBseeses: it is an 
MWeaa, ami one cause of the great constitutional disturbance 
[■roduccd by llie disease, is eoutiuement of matter deep among 
InnM and tough Hlirons stnietun-A Tlicrefore, if a depending 
put of the joint can be in any way reached, it sboidd hv widely 
UK-iswl; but the part muet be dujh-nding. Pn-H mupt not be 
allowed to Btaguato and putrify in the receases of the cavity, or 
p.^nmia will be pretty certijin. The difliculty of getting at tho 
liqi, except by a very deep cut, would render such meuud iuaj>- 
flicaijle to that joiut The trocar would be a bettor method of 
t'mptying the cavity; but the greatost caution must be used 
iJmt no air be pennitted to entt?r. 

Ciaa IX. — Uearj Short, mt&i 31, came into Choriug-Cross Hospital 
aber SOtb, 1859, having sli^iped down on the ice and hurt hii^ kneo. 
hy tba kiodnuMt of Mr. Uaucock ho is put. uudor luy cart;. . 
Tbeiv ta syuovitis and much intlammatory fever ; the swelling tilU out 
lUw suborurcal bursA very consider&blj, forcos the [wt^iUa awajr from th» 
flcQitir, luiil coUfles the [jitplitciU Apooe to bo much lean huUnw. Ttioru is 
n treuiuhiiwiicw about, thiii mau, oud au appcaranco gonrrally which leads 
[Bie to ooiutider him a ilnmkait]. 

Ued ; a Btrai^lit itpliut wiUi fout-board, duly padded, nt tbu bock of the limb. 
Bowob conati|iat«d : a purgu vt bluo pill and bJack. draught : culd lotion. 
21»t. — EviiluuUjr the accident baa atteotod hiui: hu la over truuiulous; 
^it liiUe last mgbl, 
Ontered to take tho fallowing piU uigbt and morning:— 
Ciil. gr. ij., Opii gr. sa. 
The dropH ever^- night : — 
Trw. Opii TT\,xx. 
Four ouncw of (rin. 



ACUTE SYNOVITIS. 



CBAr. 11. 



24ih. — Detter ; but little pain in tho knee ; the tremulousneaa is gone : 
askMl for more giu : reftiwd. Let him go ou. 
S8th. — Blistor above tho joint to bo drcseed with simple ointment. 
3rd Jan., I860.— The joint to be strapped. 
10th.— Diaobarged cured. 

We bftve seen by Gase» VIT. and VIII. that wounds in jointe 
lire not always followed by synoWtis ; the next akovtA that trau- 
matic synovitis need not always be snppuriLtiro. 

Cui X.— Chnrles C'ostrull, aitat 22, Klroiig atid rfibust, shoemaker, ran 
an awl into bis knee, 2iid July, 1860 ; and uu Ihu 4th, fouling paiu iti Um 
joint, camo to Cliarin^- Cross Hospital. Mr. Caotoo, \iudur wbucte cm lu 
come, took tbo niau in and kiniUy gnve over lh« caao tu me. 

There in considerablo synovitis of the knee-joint : tho shape of the 
svrelliug, tbo buoyancy of tho pati^lla, tho lieat of tho part, and the inflam- 
matory foVer, sufficiently attest the fact. Ordered — iJod; wooden sjilint 
with a foot-board to the back of tho limb ; 6 leechea above the joint, a 
poultice aflemarda. Five graimi of bluo pill to-night and an ounce and 
a hair of compoand senna mixture to-morrow moniiug. 

6th. — Tho fevor continues; pulse hard, !}2 ; holiaa not so much pain 
over the joint, but oomplains greatly of jmin at the back of it ; this, he 
saya, wafl novcro in tho night and kept him awake. Ou examining tiie 
splint I found that the imds, which I bad directed to bo (mt under ihu 
popliteal region, had boon neglected. I placed two thick jmda, ono loAgor 
thai) tho other, under this part ; the smaller one being in the middle, im- 
int>diate]y behind the joint ; this rolievcd the {>ain at once. 

Ordurud to take the following draught every six hours : — 

a Vini Antimon. potasaio-tart. ntzx. 

Tr. Opii inxij. 

AquEB .y. M. 

7th.— He is loan fererinh and penpires &e«ly ; has very little pain in th« 
joint, exceiit at night on a point of the inner condyle, just iutertial to 
the pateJiftf and this is sometimes very jiainFuI ; there is much fluid in the 
knee-joint. Ordurcd a blister above the knee, in front, going aonum 
tho whole lower uud foi-e part of ihu lliigh ; to bo dressed with simpto 
ointment. 

12th.— The blister has nearly healed, though it rose well ; the jwin and 
amount of fluid both diminished ; a blister to be applied below the knee- 
joint, that is to say, across the head of the tibia, to be treated in the i 
way. 

Jt!th.— Better : the fluid haaninch diminished. Cold lotion. 

Slst. — Tlie limb was tightly strapped. Leave ofl" the draught. 

23rd. — The joint so much diminished that the strapping has to 
renewed. 

.Tlst.— He vtoH allowed to walk with a crutch on tho 2(!th, aud two days 
afterwards a stick sufliced. Uc now l>cgs to bo dtsoliargod. 



f^t.n. 



CASES. 



61 



Tl)« threo following: are coses of suppuralivo Rjmovitis ; — 

CisB XT.— Mftigt. M.. ectat 0, full down on the 9th July, 1858, on a 
bauHann, which nhe waa earrying; broke it and cut her arm inside the 
*Diov ; sbo bbd a good deal, and when this was stopi^d tho wound was 

iDtli.— Synovia waa obeerved to esoapa, and on the 

Ittb. — A rigor set in ; the elbow becamo very painful Bnd Ba'oHen. 
Ordered tartrato of potash and Mima draught, immediatdy ; t«u drops of 
Imduam at bedtime. 

13th. — ^Tbe pniu ia moet Bevero; there is much fluid in tho joint, which 
da be IdH through the thickened Uhhucb ; tho opium hiiH made her eleep. 
I kid the joint open, for a R|iaoe of au inch and a-half, along the inner odge 
ttftlieolecrunon and triceps t«i)don ; much pus escaped. 

to tako the following, three times a day :— 

^ QuincD Bulph gr. j. 

Acidi acetici fort .. nix. 
Liq. ammon aoeU .. ;;ij. 

AquiD Jj. Itf, 

Continue the laudanum at night. 

15Ui. — She is lees ferorish ; tho wound discharges freely ; tho pus in 
bealthy: she could eat some chicken to-day. She is to have meat when- 
erer she can eat it, and a glass of port wine, doily : strong broths. 
17th. — Is better; appetite improves; puu much less; diminish the 
QUID to seven drop«. 

ti.— Allowed to get up for a few hours ; discharge less ; wotmd 
[up. 
This patient got well : when the wound in the joint bad healed, before 

I,Um external one had skinned over, 1 had friction UHud over tho rest of the 
joint, and then {Mumive motion at the end of the folluwiug month, 
August. In a fnrtni}.'ht afUir, there was stiU a little thickening, and she 
eoold not quite straighten the arm ; in all other respects she vvus well. 
I CAftK XI].— Charles Hudson, aetat 3&, carpenter, came to me at the 
Charing Cruss Hospital on acoouut of a wound over the knuckle of the left 
ling-fingor, 22ud June, ISOO. 

On tbe 13tb of that mouth he had hurt his hand, jamming it between 
a plack and the wall, and at tho same time a rusty nail wounded it over 
th^ knuckle. Tho wound became, us he said, vt-ry bad ; oud is now very 
painful, the pain running up the arm ; there are no red lines, nor any 
HtlargazDeot of epicondylcian glands. « 

22ud. — ^Thore was a suppuratrng sore over the back of tho mctaoarpo- 
phalangool joint, with pole, OaLby gianulatinna. In its centre ran, directly 
down, a narrow sinus, into which, a probe being peased, came against no 
doid bone. AVben the phalanx was pressed against the metacarpal bone, 
without either Aexing or straightening the joint in tho Ica.st, pus noweil 
,ty freely from the sinus. There woa evidently on o]>ciiing into the 
which was filled with matter. A free Incision was mode, laying the 
•od the joint open ; a splint was placed in the front of the finger. 



R2 



SUPPPBATITE SYNOVITIS. 



Chaj-. U. 



The man vas ordered to carry the hand in a aling, supinated, that the 
jtitH might flow out ; to put a poultioe upon the wound, and to take the 
following drauglit throe times a day : — 

^ Spt. .^:th. chJop.. „ mx. 

KOat. Quiaa: Ai< U. 

25th.— There has been a free discharge ; pain loss ; wound looks 
healthier. 

2lHh. — Wiiund sccius incUned to heal ; no pus now escapes on preaaiug 
thti joint Hurfiictui tu^othcr ; the man is in no pain ; the wound i^tpoan 
healing from the bottom, and aouudly. 

:iut\ July. — The wound is skinned over with a blue cicatrix; Z am not 
quite confidunt of Ujo Buundnuas of the healing, as there apix-ars to be 
fluid Wneath the bluo skin. Ordered to coDtinuo the mcdioiuo ; to UM 
passive motion. 

10th.— The cicatiiz has got hard ; the hcahng in quite sound, and the 
join! onjoya ]torfect freedom of motion, except that ho cannot quite 
straighteD the fiugcr by the musclen of the j>art, although there is no 
obstruotiou when it ia straightened by another hand. 

Case XIIL — Qoorge Balster, stat S3, tailor, came among my ont-patienU 
to the Charing-CnwvK HoHpituI, 32iul Juno. I SAO. 

A companion had, in fun, stabbed at him with a needle in the knee, on 
the 20th. He thought nothing of it, but the part ia now patofuL 
' The joint is shghtly swelled, and ho has a good deal of fever : he was 
reoommendod to comu into tho hospital, but would not \ aayn he can be 
nursed at home, and will ccmo in a cab : the little puncture may just b« 
seeu as a dark si>ot on the iimido of the {latelU. Ordered 8 leechee; to 
he followed by hot (loultioo; splint: calomel and opium pilta, 2 grains; 
and J gi-aiii iiigbt and morning. 

24il). — Cmut) back: thi) Hrab in not better, rather worHO ; ban much 
)iaiii, and it is more swollen, more hot, and the skin is ix-d : tried in vuu 
to persuade liim to como in : to ountinue the pills. 

To take the following draught three times a day :— 

■ 9 Potassa> Nitratis .. .. gr. xv. 

Spt. ^theris Nitrici . . nr^il. 
Mist, Camphono .. .. Jj. M. 

20th. — His wife came to ask mo to see him, a^ bo is ver}' ill ; found 
him in gi-eat pun ; the joint much more swollen, uot merely from fluid in 
the cavity, but from ocxlcma ; the iiprface ro«l and hot. It seems that od 
the S7th, about midnight, he hnd two or three shivering^, and could not 
be made to feel warm ; he afterwards was restless and in great pain : last 
night wondered a good deal, and slept hardly at oU. Tongue, brovm ; 
piilsi', low and quick. 

Ordered the following drought throe times a day : — 

1^. Ammonite CarlKmatis .. gr. v. 

Tiw. Opii niiv. 

Deouoli Oinohonn) .. j^. M. 



CflAp. II. CASES. 63 

A grain of opium, as a pill, at night ; brandy, four ounces a daj ; the 
joint to be covered by a large poxUtice. 

30th.— Worse ; hardly knew what was said to him ; or, at least, could 
liardlj- answer ; delirious, and talked, not loudly, a good deal in the night ; 
erea now, wanders a little. Made a long incision, down to the joint, on 
Mch Bide, and in ftvnt of hamstring tendons ; about three ounces of pus, 
altogether, came away, with fiocculi in it. To go on in the same way. One 
Teasel was tied : lost very little blood. 

iai July. — He was a little better yesterday ; the tongue was cleaner, 
ud his manner less oppressed ; he bad a dose of castor oil ; to-day ho is 
endeotly better ; tongue cleaner ; and he says he is easy : slept well last 
ni^t without wandering. The wounds discharge freely. 

Stii.— He may now be reckoned out of danger. 

IOUl— Still goes on well ; wounds granulating : substitute two pinta of 
■tout for brandy. 

The end of this case was tedious. It soon became evident that the best 
that could be hoped for was a partially anchylosed joint. The treatment, 
at last, became limited to passive motion, rubbing, &c. ; and he recovered, 
nhioutely, with some very fair power of moving the limb. 



H 



ACUTE HHEDMATISM. 



ciur. n: 



C H A PTEU II I. 
Acute Rheumatism. 



Patholoqy. 

ALTHorou ftcute rheumatism is a discaeo belonging to physi- 
ciaiw 1 feel it necesaary to cater Bomewhat minutely iiiHin 
certain points oonnecte*! witJi its j)atb()lo^, bocausc we shall 
then be ftblc to tmre tlierofi-oni this ft<'tions which take pluco in 
the chronii: Ibrrn of the disease, and bt?causo a very hiyh authority 
has recorded liis opinion that the local affection of the joints is 
not inflammalor}'. 

The order in which the symptoms of rheumatic fever occur is 
nnt always the same, but whatever it be they are genemny pre- 
ceded by a cttrtain foeling of malatse and vague wandering 
pains in the Um1>8, such as are usual before the actual iuvafuon 
of any febrile diseiim?. After a certain period of thin incitUition 
there eonms on ashivoriug fit, aecompaiued or followed by great 
heat of skin and perspirations, and by the whole train of symp- 
toms which constitute the perfect disease, a great part of which 
is puin Hud swelling in one or more jointa. The affected joints 
are very painful, enlarged, hot, and red, and when first swollen 
fluctuate ; but the most remarkable part of tlieir condition is, 
that a joint thus suHering and exquisitely painful shall iu a few 
hours lose these signs of inflammation, which are transferred to 
another and distAnt Articulation. 

A most important part also of the malady is the tendency 
exhibited by int^^mal and vital or<^iiH to assume an iiiflHmmar 
tory condition; thus, not only tliu ^>L>ri- and eudocaitlimu, but 
tite pIoursB, peritoneum, and the lungs themselves, become 
involved, moreover in tlip larger number of instances the inflam- 
mation proceeds rapidly to the deposition of lymph, producing 
tliiekcniiig, adhesion, or consolidation, as the case may be. 

Now, tiie wlmle clinical history of this disease clearly demou- 
Bb%te9 it to be a speciiie fever pixxlncf^nl by st>me jHjison in the 



ftir. ni. 



A B£XX)D-DIS1'U81S. 



65 



I'M, liko typhus fever or the oxautbemata, and, like U»eso, 

dieimititism, besides {injductng the general symptuius wliicb 

RBStttnte it by their very nature a fever, also sets up actions 

M particular partd or textures of the body. The poison pro- 

Jncing typhna, or any one of the eruptive fevers, 18 nmro 

Wnjilicftt^^d than is prfibably that whicli produces rheumatism, 

uisQot to be defiued by any chemical Ittiigiuige or tcst>, and is 

lolraluoed into the body from without. On the contrary, the 

dieainatic poison is m all probability lactic acid, and owes its 

Jiraeence in eo jo^eat excess either to u check on its excretion, or 

tvits gu{>crabunduut formation in the Ixxly, or to Ixjtli;* and 

it may well be that one cause shall give rise to, or rather a 

itun of circumstances shall act as a cause determiuing, Itoth 

tiis cxceeeivo prodnction and diminished excretion of lactic 

>eid. Although external circumstances may and do produce 

aatism. the poison itaeU of the disease in elaborated 

f and not out of, the body. Dr. Todd obscncs that, " These 

] GBiises must be admitted to bo imperfect assimilation and vi(-i»> 

latades of bi-miierature, aud heuce the ill-clad tiud l«idly fed 

lebfldTen of the {XK)r are tlio most frofjucnt victims of rhouinatism. 

iHord work, exposure to cold and wet, bad food, are strongly 

Iciintrasted with the ease, comfort, and excess, which give rise to 

the analogous one of gout. If, now, we remember, that the skia 

18 the great emunctory of lactic acid, and that bod or too little 

kfood may pivo rise to its imduo development as well as too much 

llotKl, it is no wonder tJiut as lactic acid is imperfectly excreted 

Ithrongli its natnnU channel in conaequenco of the influence of 

Icold iu chocking perspirations, aud is too freely developed in the 

laltmojitary canal, it sliould accumulate iu the blood. Moreover 

Itho long continuance of the causes which produce the <lofectivo 

_ I secretion and the demuged gastric one, will give rise 

tthenndne development of the lactic acid in the secondary 

Mcstniclive assiniilativo processes, tlins infecting the blood from 

every source, aud lending to periwtuate the diat}iesi8."t ^V^len 

lliewfi processes talic place quickly, the system becomes do- 

llijged with the acid, and rheumatic fever is the result, with ita 



* The expeiimootfl of Dr. GattocI, ro- 1 
prtcd in llie- Mwl CUir. i'roiw., vol. 1 
ISM, axi' intontlcU to prove Itint { 
Vii mi i)k> lAUiAii iir riii-ii- ' 



matism. 

t Todil, oti Gout luid Blioumntism, 
|i. li.i. I^iiKlun. 1S43. 



F 




Aa atievpt hM bno BftdA ^ Dr. TaU, 

Aeavieior Ih: Phmt, to espluD Ob Mtioo of tite 
on theie tiaan tfaos— " Aad it is not nnimc 
Ast an tbiM times bdoo^ to tlie 
jjlpi-i^i^ n dMM% aad mre cSueflr eonposed of those | 
ekntettli bom the deeonpontioQ of which, in the 
tear of tbo wyelem, thow gmt Moondaiy otgaiuo com} 
nre« aoil lithic acid and bhctic add are ivodooed. It is 
fectlj oonaiatciit with bouikI theory to suppoas thai 
tianes are capable of exerttng a ^ecal attraction on the j 
or ihenmntit^ dement and this quite iiTespectiv«ly of any i 
mical explanation whirh might be offered." t 

Dr. Fuller says — "It b worthy of note that the 
meet commntily implicated in rheumatism are all examples 
the albuminoofi ami gelatinous tissues from the rlt>(x)mpogitioci i 
which in the wear and tear of the boily are formed 
secondary organic comiwimda, the lilhio and lactic acid, 
ivhich gout and rbeumatism arc intimately oonuccted. 
as it is but consistent with our knowledge respecting the 
cesses of nutrition and assimilation to suppose tluit each 
selects from the blood and appropriates to it^lf such matters 1 
correspond to its chemical constitution, we may readily 
ceive that some peculiar attraction may be exerted by 
fihmuH and fibro-serous texture for cx)mpound8 9uch as lithic i 
lactic ftcid, to wliich they bear 90 strong an affinity. "+ 

These two quotations express a similar, or ])erhap rather aa 
idouticjil theory — indeeil it is difticnlt to avoid being impreaaed 
by a remarkable similarity in the wrbiage even of the p«» 
sages ; and they have been tlius placed in juxtaposition 



difldatkMM of tlda Uhuv. 
t Todd, ou Bout and RbeumatiMu, 



p. HI. London, 1&I8. 

I Fuller, 00 BheomAtJam, Oont, 
BciaUoa, p. 49. LondOD. 1856. 



Cttif.m. 



GELATINE AND LACTIC ACID. 



67 



oertAtD objections to the theory may simultaneously apply to 
iMth MQtiiors. We will admit, without further qm>6tiou iu thin 
ji^ioe, the theory of |inmarv and nc'coudary assimilation, with 
kll ha wide-spread romificatioDs ; stiLl it docs not app^^ar to 
aw consistent eithor " witli sound theory,** or ** with our know- 
WgB," that a substance whose decomposition would produce 
>fiatain mot^iriul shuuhl therafore atlxm^t tliat material. What 
theory of oi^nic chemistry would teach that any substance 
ias an afiBuity for a product of its own decomposition ? 
XiveoTer if tissues contaiuiug much grdatiun should have, by 
Tirtne of tliat uirouuistauccs a strong aflimty fur lactic acid» 
tbe fikia would bo especially alfected, and we know that this 
Rgan is seldom attacked in rheumatism, and then only by a 
aC^ and generally a transient eruption. The acid perspiration 
il not to be looked upon as an affection of the skin, but 
iDn[Jy as excretion by the integument of a morbid principle, 
lictie acid- Surely it is safer to accept fact simply an fact, until 
W8 can find a more correct explaimtion than one bm'lt on a false 
diemical a^umption. Indeed if it be necessary to explain 
jilieniicaUy the relation l)etween the ailection of gelatinous 
and the presence of lactic acid, the theory ought to run 
in tho contrary direction : that the action in those parts was 
the cause o(y and not Uie consequcfnce of, the acid in tlie blood 
— sinco the decomposition of thoBc tissues will produce that 
B acid they therefore have do diemical alBnity for it 
" The condition of parts attacked in rheumatic fever is, as I 
hope clearly to sliow, intlammation ; on the state of the mem- 
branes of the heart or other internal tissues afiected, there is 
no doubt; bnt some disbplief has l>een thn»wn upon the inHam- 
I in«tory nature of tho joint aJ^cction, and as that subject chiefly 
Bconcems us^ it is ri^ht to go over carefully the reasons for or 
^kHin^ such opinions. Tlie reasons against tlie iidlammatory 
^^Bore of the joint affection in rheumatic fever are summed up 
■b)- I>r. Todd, in that part of his Croonian Lectures wliich is 
" df-voted to proving that ** rheumatic fever is not symptomatic 
of local disorder ;"* and if that eminent physician had confined 
liimself simply to proving this point, no word could with justice 
hire been raised against his conclusions ; but in doing this he 

* Gout nml KhiMinuitiiiii, p. 134 et tcq. 

F 2 



68 



ACUTE KUEUMATISM. 



Chap. ITT. 



lias also endeavoured to show Ibe non-iuilaimnatoTy conditiou of 
the joint affcotioii, and in tliat he has, I think, failed. In order 
to trcAt such an authority witli all tho resjtect that his opinions 
merit, it is necessary to quote Iiis I'easuuii in full, even at the 
risk uf appearing tedious, so that uouu of his argumeattf may 
loae tlieir duo weight and signiticance, and that the criticisms, 
which I shall have to offer, may bo duly contrasted with hia 
propositions. 

" And now let me eay a few vords in rofarenoG to the faypothesia, which 
some have advocated, that tho rheumatic fovcr is merely aymptnmatic of 
a local ioflammatioa, afTecting one or nioru juiiiln. Suc)i nii hyjKithMia u 
very fur from affording a satisfactory expl&uation of tho phenomena. 

" 1. It will uot cxplaiu the peculiar dialhcaia, nor tho UmitatioD to a 
X>couliar period of life. Iii the diathesis the conatitiiUoiial diaturbanoe is 
ofU)D, beyond all proportion, greator than the local afTcclioa ; so that, ib 
acme inatauces, the latter ia overlooked, or attributed to a wrong caosB^ 
in the anxiety which is excited by the altered apitearanco, imperfect 
nutrition of the patient ]. or until aome vital part ia touched, as the heart, 
tho funcUooH of which liecome impaired. And, in tlie paroxysm of rheu- 
matic fovor, the conbtituiional diaturbauce ia fur (pruater than can be 
accounto<t for hy the local miaohief, and, aa Dr. Qravee has shown, may 
eiiHt without aiiy affection of the ji>itita at all. 

"S. It will not account fur the affection of tho heart. It is true that wo 
meet with iustauccii whore a local malady \nll give rise to aSoction of 
aome diataut part ; but, when this is the case, the secondary affection is 
similar to the primary one. Thus cancer at one part will produce 
cancer in another. But in rheumatism, on this hypotheais, we ahould 
find an affection of tho heart, which essentially consists in tlie effusion of 
ooagulahle lymph, produced by an articular affectiou ahowiiig no aucJi 
Bigu. 

" 3. I repeat that we liave no Batisfaotoiy evidence that the arttoular 
affections are truly of tho uaturo of ordinary inflammation. The parts are 
certainly swollen, jiainful, and there is a cotiHiderablf! How of blood to 
them ; but they do not aiiffor, oven from tho effusion of coagulabte lymph ; 
much loss are they the subject of thone destructive and disorganizing pro- 
coKHoei, which so often follow in the wako of a truo inttammaUon. Nor is 
it the nature of a true inflammation to desert, quickly, one part, leaving it 
unimpaired, and to fasten upon another ; and, after making a short 
sojourn there, to revisit tt8 old abode, or to fly to some new region. It is 
true that, in some instances, the jointa do not OMape unharmed ; bat a 
slow derangement of their nutrition is ioducod — which may go on for 
years and years — nhicli altem the textures, and even allows them to near 
away; and which rcaiitta those remedies that usually check an inflammatory 
prooeea. This, although often called inflammation of chronic kind, is 
surely more like tho alow and insidious worlcing of a canker, which drioa 
up, or impaiitt, the matter destined for the nourishment of tho tiasitta. 



dur.IIL 



DR. TODD'S VIEWS. 



69 



'I do not» however, wish to be undoratood as dooTing tlmt iho ordiniry 

(0ect« of intlanuQfttion do iakd place in rhennialic juintit. I am boond to 

vlmit tbftt some omaeft are on record which seem to p«.rUke of this nature ; 

tol such instaacea are extrarooly rare ; and their occurreuce does uot 

ianlidate my argimient ; on the ooiiti-ary, here exreptio prtAat reffnlam. In 

tbsM cases the poison has been more strongly attracted to a partionlar 

jdat or joints and others have consequently sulfered leea; and Uie 

Nmarkable diapoution which rhounrntiam hoa tu ahifl from joint to joint 

iiabaeat. 

" 4. Lot na compare with the rhoumatio paroxysm the ooustitaiional dis- 
tortaooe, which an undoubted iufliiinmutiou of urdtuary kind, affecting a 
jnnt, oroatoa, when not connected with a oonstitutioual taint. 

** In the latter case, the fever is always directly proportioned to the local 
dstorbance. The pain of the joint, .md the iUfficutty of uJting it, mo the 
finat nod chief objects of the {Atient's attention ; and it ia uot until the 

Idestrnctive inSanunation has proceeded to a great length, that his consti- 
tutioo begioA to suffer, and the febrile diaturbanc^ begins to wear him 
oat. The amputating- knife, by removing the source of tlio irritation, 
^^■oedily pata a «tnp to the fever; and it often tiappfrmt, that the night 
*ft«r an oiwralion of this kind proves the first one of rest and rofreHhing 
ibpp which the patient has enjoj'ed for many weeks. How different is 
thiadaacHptionfroni tliatof the irrilHtivo fuveruf the rheumatic paroxysm I 
Wen a rheumatic hmb to be amputated, how diff'erent would be the 
•vrgoou's account of hiti fiatient I 
"A. But it may be said, you cannot deny that inflammation of the heart 
Ittzista, for there you have the jiroducta of iuflainmatiun in abuiuluiice. 
I Maj we not tnfur that, because the heart is inflamed the jointa muet be 
[»> likowise, and that lymph is effused in them also, whitdi eubeequontly 
I absorbwl? To tide I reply, that the heart ia VRpy difforentty 
Qcvd from the joints ; these aru rendered absolutely incapablo of 
motion, wbiM thai ia moving with even more vigour and rapidity than 
usual, contracting with energy, and occasioning a eonfiiderable amount of 
friotioo between the opposed sur&cea of its serous membrane- Surely 
Uwee are conditions more likely to excite inllammation, eRi)ecially if on 
irritant fluid be in contact, thim the absolute rest, to which the joints are 
of Decettity coDdomncd. Doubtless, if the joints could be freely used 
fdiuing the paroxysm, they would more frequently exhibit marks of 
' dattnictivD inflammation as a consequence of the rheumatic paroxysm.* 
Voreover, the heiirt may be said to bo bathed in blood ; for not only are 
Its earitieii 6Ued with (he liuid^ but its exterior is surrounded by moist^tre 
derived from the serum ; which, doubtless, contains tho oesonee of any 
I mortiid eltiment tho latter may hold in sohition ; and, besides all this, the 
■ubstoiice of the tiuart is permeated by blood- vcesels, which ramify 
I of minuteness of which no one can form an aduqimte conccp- 
t has not bad the opportunity of examining a minutely injected 
' tipeviuten with the aid of the microscope. 

** t«stty, it bos been said that this is an inflammation of the fibrous 



* Bee Dr. Corrigiui'v Piiper in tho Dublin iouinal, vat xvL" — Note by Dr. Todil. 



70 



ACUTE RUEUMATISM. 



Chap. lU. 



system, and the weight and authority of the great name of Bichot havo 
tended greatly to propagate this error. 13ut bo little satia&otory is thU 
theory, that some practical pbysioiutw have endeavoured to make a dis- 
Unution hetwcen what they call syuuvial, or bursal rheomatiam, and 
fibrous rhoumatiam. The natural hietory of the diseaee, however, does not 
warrant this distinction, for in no instance of rheomatto fever are the 
membnnea free from irritation, as evinced by the existence of effusions, 
and the synovial mombmnoB caq scarcely be afi'ected nithout involving 
the Bbroua ttasuea which surround, support, and connect the blood-TeSMlB 
to them." 

I. On the paragraph numbered 1. there is little to obeenre, 
for 1 do not intend to show that rbemnutio fever Ib simply 8ynii>- 
tomatic of joint inflammation, but that to a diathetic fover 
an inilummation of the joints is sujM?radded. If under ordiaaiy 
ciroumKtances, i.e., if wbilu the couiititution were iu no way 
affected, wo could prwluco such a joint attack, it wt)uld be 
accompanied with symptomatic fevor ; but any such action is in 
acuto rheumatism completoly masked ; yet none (^an deny that 
the intense pain and tenderness of tlie joints may mid con- 
siderably to the irritability of the patient. 

II. It is quite certain that the joint afiTcction does not produce 
the heart afiection ; they are both brought alK>ut by the same 
causes, viz. the constitutional state, and therefore it is ri^ht to 
suppose that the same diathetic condition would produce the 
same local derangement : it is inflammation in the heart — why 
mu-st it be another condition of the Juintti ? It is quustiouabto 
whether they are so dissimilar, as Dr. Tofld supposes, as will be 
seen in proposition V. ; and in making use of the disease cancer 
to demonstrate that, if u local affection produce a distant one, 
both diseases are Bimilar, Dr. Toihl has chosen (I presume 
accidentally) a remtirkablyilltistrative example. Primary cancer, 
although it be schirrhus, is nearly always followed by enccpba- 
loid : tlio two thseases are essentially tlie same, but their morbid 
anatomy slightly different. 

in. Concerning the presence of coagulable lymph, I must 
refer the reader to No. V., but I may here sny that thou^ usually is 
in the joints some inilammntory exsudatiou. " That it is nut the 
nature of true iuHammatiou to desert quickly one |)art and 
fasten uixin another." is a phriwe with an amount of ambignity 
about it, owuig to a want of dctiiiition of the word "true." If 



f, m. 



11*8 INFLAMMATORY ORIGIN. 



71 



I 



I 



OTsqielas bo a trao iuflammation, then metaAtasis is the nnture 
of some Bach afifpotions. Thpre have been rocordcci several casee 
of orchitis with sudden metastasis to the parotid or to tlie brain. 
The refusal of the jiiiot malady to yield to the ordiaary remodiee 
of inflammation does not prove that it is not inflammation, hut 
simply that tliere is something whieh aet« as ft constant irritant, 
ra^ the diatheius. We ahoulil not expect to ciin^ a oonjunc- 
driliK as long as there were a piwf of fjiiiek lime under the eye- 
lid. The slow derangement of nutrition, to which Dr. Todd 
rrfera, is not merely wear of the joint surfaces ; there is actual 
ftUorptiou in some parta, and dejMDsitiou of now matter in others. 
Honce it is to my mind more like a true (rlm>ulc iuUammation 
to any otlier morbid process or to any '' canker." 
V. Dr. Todd's fourth paragraph refers only to the idiopathic 
oatnre of the fever. 

V. The stress which Dr. Todd lays upon the different circum- 
ftenoea, us to the necessity or non-necessity of motion in which 
the heart and joints are placed, would lead one to infer that 
these ccmld make the difference between tlie possibility of the 
organs to become inflamed. Very little eonsidenition, however, 
will show that rach is not the case. In a normal condition both 
the heart wid the joints move readily without pain or incon- 
venience ; hot there suddenly arises a morbid state of the system 
which renders first the movement of eert^iin joints so j»aiuful 
that the patient, except on urgent necessity, ket^w them still ; 
and then the motions of the heart, also become painful, but must 
go on tinlesa the patient is to die ; hut in neither case is the 
racirbid state produced by movem4*nt ; the joints, indeed, which 
move Itiss than, are generally affected before the heart. The 
winstant movement of the heart, then, can only ai^gruvnte the 
tion, not produce it. If then, in itfi t^gravatod state, as in 
heart, it is inflammation, wliat else is the unaggnivated 
disease of the joints? wbat is it that produces the swelling and 
effusion, the hent, &c ? In regard to the heart being bathed 
in blood internally and externally, the actual presence of Idood 
in the cavity is ibe only difference between it and the joints ; 
and even here tlie blood is intravascular, the fluid of Uie peri- 
cardium being i|nite comparable to thi- synovial. 

The above (quotation I'rmn Dr. Todd's admirable lectures, and 




ACUTE RHEUMATISK. 



Chat. m. 



audi answers as X liave been able to give to his oouctusions^ 
appeared to me desirable tii^m tho great weight which any 
opinion of such an authority must carry with it ; yet the quce- 
tion is not to Ijc <lecided by logic, but by morbid anatomy. 

Tho superabundaut Hynovia secreted into the joints during 
acnto rhoumatifim is quite at first of entirely normal confiistence 
and colour, but in a number of days, which vnnca, and the 
limits of whose tinctuation I am as yet unable to define, this 
fluid changes colour, and becomee first of A greenish hue, then 
slightly opftlescout flocculi appear in it, and then, in tho most 
advanct'^d stage, it becomes more ne-arly opaque and whitish. 
At this time tho synovial membrane is reddened, either in broad 
patches or isolated sjxpts, and several arboresc<*nt vessels apiH^ar ; 
soon after, the inner siuiiico of tho membrane becomes granular, 
and shreds of soft gelatinous false membrane are seen adlioring 
to it, and it gradually becomes thicker, hi the mean time the 
fibrous textures around tho joint at first lose more and more 
their lustre and pearly appearance, and soon after become 
bathed in a yellowish effusion which has an acid reaction. 

Case XtV. — Denaia Loughlin divd \u the Cb&ring<CroS8 nospital dunng 
muItarticulAT rheumatism, and tho body was examined. 

There vos both pori and ondo-oorditia. The pericardium coutained 
much fluid, and waa atudded with false membranes and shreda of lymph. 

I examined tho lefb luieo and ankle ; the latter bod only been lately 
affeoted. 

Kntt. — The periarticular tissuea contain a good deal of ofiiiAod yoUow 
serum. The subayaovial tlsauo is awollcn and thickened ; the synovial 
membnuie i^ itself thickened \ ita iimer rturfoco is redder than normal, 
and aome long braunchiug vossoU are to be aeen runoiog acroas it. In 
two plaooe, one at the outsido of tho patella, the other at the inner nido 
above the interarticul&r cartilagoa, are false membranes ; tho former 
nearly oa big aa a ahilliug, but oval ; the latter smaller, which adhere 
pretty closely to the nunnbraiie. The {\md in the joint is large in quantity, 
probablj between Uiree and four ounoea ; it is turbid, opolesoeut, and four 
ebruds are floating in it ; one of theao, the largest, ia a white (Wcculuti, half 
on inch long ; two of them are quito transparent on'l golatifomi ; a gela- 
tinous concretion rests cu the inner condyle of the femur ; it was not 
originally adherent, but merely uggtutinntod. When this jelly voa removed 
the cartilage beneath it was quite normal, as aleo were the oariUagta 
throughout, 

AfMc.—Tiio aheatbea of the tendons, particularly those in troai of the 
joint, contained a good deal of yellow, straw-coloured, thready fluid. Tlio 
periarticular tiseuon contained also fluid ; the ajrnovial membrane alightly 



Csi/.UL 



POST-MORTEM APPEARANCES. 



73 



tUekoMl, Jta ioner surface nxl ; ftborescent Teesels veiy visible ; at ib« 
tuck were two small spots of extniTosAtioD beneath tho basement mom- 
bnue. No adherent &Ue membrooca. A good deal of yollowiah green 
tnoflpareDt fluid in the joint ; two amall gelatinoas ahreda were floating 

in it. 

CiOS XV.— From a paper by J. Cosaoy^ in the ' Archives G6n6nloa * 
bt Stfarcfa, IBS-t. 

J. Comey deecribca, nt length, two caaes of acato rheumatiam, with 
osKbnl afTectioii, of which ilm patients died. At the poat morttim tlio 
joAti were examiued, 4pd de»crikecl as follows : — 

Artitui*Uitmt. — All those which have bevn the seat of rheumatic affeo- 
fioB nre cxazniucd with care. Extomallj, these jotnta showed no external 
dinoLoaratioa. and acarcelj any swelliag. 

Ifff tOumldtr.'-BynoviiL, limpid, yellowish, and filantc in tolerable 
tbondance ; articular surfaces and synovial membrane perfectly nonoiU. 

Shtwa.—Th^ right was healthy, but the left has Buffered. Synovia 
BHre abundant than in the right, of a gieeniah yellow, opoleaccnt^ and 
(Kotaina eomo albuniisous shreds ; nevertheless, it remaioa ropy (iwf 
lH(rwr9 hien filinU). Synovial membrane markedly injected, particularly 
itit» mb-oIecranoD i>ouch ; there \a do perceptible thickening ; cartilages 
bMlthy. 

Wri$U, — ^The carttlogOB and aynovio] membranes, of both joints, were 
kalthy. Synovia jilmtc, opali?sceut, rather doficiout in the left, but 
itiU the joint was not dry. The ieudinous sheathe.*;, and the cellular 
time arauod the joint, in the normal condition, 

Knfta. — The right contained two large tabltapoonfula of synovia, which 
tia ropy, transparent, yellow verging into green, and in which floated 
fndy aome albuminous ahreds. Synovial membrane somdwhat injected 
Ihrooghoat, but more particularly in ita aabcrurcal pouch, and on tlio 
folds which this membrane forma at the side of the ligamontum patella)* 
It preaouted no evident thickening. Cnrtilagos healthy. 

Left knee, a tablospoonfiil of tranHporont, threading synovia, without 
■ay jellow-groen Inatre, and containing but one albuminous ahred, small, 
tnmaporont, and gctatinoua in oouaistcnoe. The synovial membrane con- 
tnatod by ita ]>aI]or with that of the op[H>site aide. Cartibgcs healthy. 

tn the two ankles the synovial membrane and cartilages were healthy ; 
tlus synovia, normal, both in quantity and quality. One of the articuja- 
timM oontained a little transparent, gektiuotis shred. 

The fibroua tisaues around the jointa above dcscriliod were healthy, and 
in aomo othcn they only presented rather more moisture than they do in 
health, but there was no trace of piis. 

. Can XV]., from J. Coasay. 

' JljAouM#rs. — ^The right is healthy, in the left is a tablospoonful of ropy 
■piovia, which is opalcaoeut, slightly groen, and contains shreds. Tbe 
•Tnovial roembnuie in not perceptibly injected, but comiKU-tson with tliat 
tf the other aide sho\^-if it to be slightly thickened ; oartdages healthy ; 
pwtt healthy in every way : wriste a Uttle puffy externally, but lees so 



74 



ACUTE RHBUMATISM. 



cbat. in. 



than durmg life. The left one oonUiDS a litUe ropy aynoriii, opelosMnt, 
and of a grMuish yellow colour. The membrane iUelf ia, od its £ree sur- 
{aoe, alightljr granular, and has <m it a few irregularly disposed ml patcbi^ 
The articular Bor&ces perfectly healthy. Tho euboutaaooua (xUtUar 1 
around the joint is infiUmted vriLh limpid iBmou-coIoured acrum witbd 
a trace of pus. The right wrist is healthy ; the stuToanding cellular tissue 
is, like that ou the left side, slightly iofiltrstcd, aod the synovia in the 
oxtcosor sheathoa is opalescent without other alteration. Hips healthy. 
Kuees still a little swoD^n, tho right more so than the left. In the right 
was a rather large quantity of synona, which was ropy, greenish yellow, 
turbid, and conUuDfl shreds. The rynovial tuembrahe, where it lined the 
tendon uf tho rectus fcmoris, was pale and smooth, but at the sides of the 
patella, about tho crucifurm ligament, and in the subcrureol pouch (cul-de- 
sac sus-rotulieu) its surrocc is tincly grauulated, and of an irregular red 
hue. The suUsyaorial tissuea&re not |>erceptibly altered in any way ; and 
the membrane itself, at those parts where it is granular, is thickened, but 
so slig^y that the thickening is only [lorceptiblo when comjiared with a 
similar memLmue taken frora a hesltliy subject. In tlie left knee, except 
that it coutaiua rather less sj-novia, there are just the same apjHjanuioea 
as in the right. Ankles quite healthy^ both as regards the synovia, mem- 
brane, and cartilages — there were no ahaoemeB nor any purulent or sao- 
guineous infiltrations. 

It is to be observed in both these cases that the first di«! 
on tlio eighteenth d^y of the disease, thv secontl on tbe ninth ; 
that tho joiuts, iu which was most pain, and which bad been 
longest attacked, wore £i>und most injured. 

Oaab XVII., from A. Bonnet, of Lyons,' fumiahed him by M. RodcL— 
Tho patient was a woman, aged A2, of a good constitution. She waa 
admitted into tho UOtcl Dion on tbe 3rd August, eight days after having 
been attadced with rheumatism, iu consequence of a chill, and she died on 
the :iOth of August, on the twonty-Gfth day of the diseiuio. The paina of 
acute rbeumattam had invaded suooesAively nearly all the joints of the 
upper and lower limbs. Several of them bad become red and swollen. 
Death seemed owing to cerebral symptoms, which mode their appeanuico 
five days before death. The patient was attacked with violent delirium, 
accom[Muicd !>y very severe paius in the head, eichangcd during the k»t 
two days for profound ooma. The i>aticut had been treated by somowfaat 
aii};ht measurun — two bleedings, leeches, amall doacfl of camphor aud nitre, 
MiHtura on tho joints, &c. 

Tho autopsy was made forty houra after death, when deoompoaition was 
far advanced. 

Both knees contained three or four tablo-spoonfuls of a transparent saro- 
aity, all tho mtMubrano was red, (edematous, aud studded with little fringes 
that were muoh Injeoted. Ite Teasels were prolonged over the cireun^ 



* HuUdiet dea Artirulntiens, p. 329. 



OlAP. III. 



POST MORTEM ArPEAHANCKS. 



75 



ftmoe of the cariflage, which vraa ulcerated and grooved in several spotn 
or the ortMulxtiDg sar&oeH of the tibin, femur mid ti^-l-f^Ua. Several nimU 
cf the cartilage, more particularly of this latUr boue, were velvety, and 
tmuibrmed into fibres six or seven miUim^trcs long, and more or Iosh 
iaolatod from oos aoothei*. It appeared as though the juxtaposed fibres, 
■fasivof oartihgtt is composed, had been sopsu-atcd one from the other, 
■ad tiiAt they were tdightlj hypertropliied. 

The mxa& alteratioDs were present in the left elbow. The leoion of tho 
Dvtilage «rna farthest adv&nccd upon the articular aurfaoe of the ulna. 

There wab no aJt«ratioD of carti1ju;eti in the two tibio-tonial, in the lintl 
tuaal, in either hip, nor iu the rij^ht wrist^joint — tho synovial mombraoo 
BMrely wae injected and contained Boiiie Heroua efltiition. 

Tbe ahoulder-joints and right wrtul (siV) had undergone no chiogB. 
There wma no alteration in the fibrous structure of auy juiut. 

Tbe heart, the lungs, and the brain wera examined, but no, change waa 
{nmd which might not be attributed Ui decomposition. 

Cabv XYiri.— Acute Itfaeumatiam. — This account ia kindly furnished mo 
by my friend Dr. Bristowc. ' 

William UiUs, 40, eugiueer, admitted into St. Thomas's Iloepital, Luke's 
Ward, under care of Dr. Barker, September 15, 1859. 

The man had hail acute rheumatism for eight days before admission, 
wiUiout much joint aftection. The heart was doily examined without tbe 
detflction of any abnormal sound. Tho pntiiitit was noticed to be very 
lulky and short in his answers. On tliu 23rd of .September, when con- 
nlesceni and walking about tho want, he fell down dead without faa^nng 
exhibited any signs of distress whatever. He was treated with lai^gc doties 
of nitrate of potash. 

Fbat-mortem by Dr. Bristowe, September 24th, 1869. 

limd. — Brain and its membranes healthy. 

CA«t.^lAi7ax and trachea healthy. There were numerous fibrinous 
idtiirinnn throughout both pleuroy. Tho luugs were of the usual size, 
crepitant throughout, but congested. The apices were punctured, and 
there was considerable emphyBema at tho apices along the anterior cdgeH, 
ind at th« bases of the organs. Broncliial tubes healthy. The pericar- 
ilium wsA adherent throughout the greater part of its extent by a layer of 
Moiewhat recently efl'used lymph. The a<lheeioiis were not complete on 
U)o right aide, and the cavity l^ft contained alxmt an ounce of nlightly 
taririd Mmim. The heart was large. Tho walls of tho left Tcntricle were 
thiflk, firm, and healthy-looking; they wore contracted, and tho cavity was 
MSply. The valves wore healthy. 'ITie walls of the right vontriclo wore 
oooaidanbly tliicker tbau uaturol, the carity was dilated and filled with 
OOaguhuQ. The co&gulum was partly fibnno\is, oiid partly black -currant- 
^i^T'lLke. The Utter was in cuiitact with the walls of the ventriclu, and 
was [ffolongvd up tJie comus arteriosus along the pulmonary artery and 
j its first brauchcM, was moulded to the orgau.^, and was so thick that it 
■Mppearvd actually to fill them. On opuiiiug this clot a mass of librinuus 
ooagulum, about as large as u walnut, was frnind in its Interior, from 
vhidi aeveral cylindrical procesM-^ wore ymlougcd in various dirootions, 



76 



ACUTE RHEUMATISM. 



CnAT. m. 



TliG Urgent, about as thick as the Httte finger, ooetipicd the axis of tho 
clot ID the conius artoriceua and cotDmi^ncemunt of tJio pulmoiuiry 
artery, but the others were smaller, about tho aiae of goose quills, were 
coDVoIuted and twisted in various directions, and did not, so far as cntild 
be Been, correspond to any vessel, although thej looked as if they had 
1>een moulded therein. The fibrinous masses wore yellonish, dose-grained, 
lough, and uniform throughout, eaaily sejiarable, and apparently distinct 
ft-om tho coloured cloti! surrounding them. The right auricle waa dis- 
tended hke tho ventricle by coagulum, the outer part of which was dull and 
soft, tho inner fibrinous, and presenting curling cvUndrical cast-like fibrina- 
tiona, which, altliough they looked as if they had been formed in vessels, 
were oontaiued wholly in the coloured dot, and did not extend into any 
of the veins. Valves on right side healthy. .^i!vA<mcri-peritoiieum healthy : 
liver, spleen, i^ancroos, stomach and intestines healthy. One of the kidneys 
was about half as long ^aiu as usual, about one-third of it beisg p;irtiaUy 
separated from the rouaiuder by a deep fissure : kidueya otherwise healthy. 
Aorta healthy. 

AWe.^The iwlient had been suffering from rheumatism, and the left 
knee-joint wem laid open in order to ascertain its condition : a few drachma 
of a thin straw-coloured fluid ooKcd away. Tlierc was fibrous degenoratioa 
of tho cartilages of the inner side of tho patella, the surface of the ^no- 
vial mcmhrano was somewhat redder than usual, especially along the 
margins of tho cnrtiiagcs, and it proscntod a shghtly granular ap]>(>iLraiice 
in many parts. There did not appear to be any disease of tho siirroniiding 
tiaaues. The fibrous part of the cartilage presented the usual character 
of that form of degeneration. Tho synovial mumhriinu presented tinder 
the microscope a large number of tortuous congceted vessels, and tho sur- 
face itself was studded \s*ith papilLp and small pedunculatod proceaaos, 
consisting apparently chiufly of nucleated cells. Thoy were the proceasaa 
recently observed upon the stuface of these membranes. 

P.S. — Tho muscular tissue of the heart was examined nnder the micro- 
soo|)e, and apiH^ircd healthy ; and tliis was the case with that portioa 
even which was in immediate contact with the inflamed pericardium. 

Those coses giiflico not only to pn:ive timt the disease in the 
joiuU is iiifliimraation ; but also to illustrate ita morbid anatomy, 
viz., inflammation of, and effuaion into, tiic synovial membrane, 
and the periarticular tissues, followed by thickening of those 
parts. In scv(-*re cases tlie ufTusiou becomes opalesccntt even 
purifonu, and tbo cartilages partjiko in tho inflamnnitory oction. 
The met»istic quality of tliis inflammation is very remarkable, 
but the description given of tbo sudden disappearance of all 
morbid symptoms is upnally exaggemtcd; for although there 
can be no doubt that the inflammation itself clmoges places with 
extreme rapidity, it is not true that tlie |wrt Iut*r!y aOected is 
left ill a ^mrfectiy hfaltby eoiKlitiou ; on the euuir&ry, oan- 



Ghat. III. 



I'OST MORTEM AETEARANCEa. 



77 



ddorablo swelling still n^maiiis, anH disnppoArs luoro or less 
■owly ucconlmg to tiie jr»-i'«ter or less amoaut of effusion hthI 
thiokeaing. (>n tho syraptoms of this disease I ahull not enter, 
as it belong to tho physiciiin ; hnt it ij> well to observe that the 
siirfa«'o of tlu' )nmU an' redder than in any other form of arthritis, 
abowinpT thnt the areolar tissue is more widqly iuvolvwl, so tlmt 
even the snbcntaneous Ijiyfra are inflamed and the effeets do not 
always dIi>uppoar with tlie fever ; but nometimofl u joint, gent^ 
rally a largo one, na tlie kneo or the elbow, is altered and re<)nirei» 
ciinjiidorrtblf' att('ntion ami care; sometimes, even in spite of all 
Uuit art cun du, the limb can never be recovered. 

Tlw? following is a ease in which, after rheumatic fever, an 
air<M7ted joint did not reoover. It serves to show a close eon- 
n«*ctioa between ^oiit and rhcunuitinm, or at least possibility of 
ihi6 one changing to the other. 

Casb XtX — Uiss B^ mtat 19, daughtor of a modicul practitionor 
residing ■ little way from town, stout and healthy-lookiDg, bad rhoumatio 
feTer fourt«3«n yetra ago, from wbich she recovered without further lesion 
Ibao lanuucsBaudonlart^Eacatof tho right knee-joint: this affoction, in»tciul 
of geittng better slowly, bccuinu wonio. Dtiritig the wholo of tho summer of 
IH."*? she raSered much pain, and theru was very distinct and audible 

|cn-pilu>) between tho femur and tibia, which Uttor bono was vory looso, 
ami oonld \te tvistod (laitiiilly round ; tito patella wan fixed — all movemeut 
and pmaure punful. Every meani* was resorted to in order to save pain 
and roduce sweUing ; but everything failed, and at last it waa determined, 
in a (xnumltation between Sir. Hancock and Ur. Henty Qeorge Johnson, 
lliat it waa better to rvmove tho Umb. 

<)u the Mh NoremlMr, li*57, tberoforo, 1 accomiwniod Mr. Hancock to 

. where, aaainted also by Mr. Ilird and Mr. H. G. John^ou, Mr. 

Haucock rctnoved tho Hmb above tho knee. I took the part home and 
oaaiainod it tho same evening. 

'Htiera was a good deal of healthy fat arouud the joint. ^Vhen the 
flbruua tiuHuea around the sheathes uf tendons and tho Ugameuta were 
reaobed, th«7 were fonnd infiltrated or occupied by a soft creUceoua 
matter, in great abundance ; in some places, aa about and in tho iutemal 
lat«««] ligament, tho aocnuiulati'jn of tliiti material was ao oonsideraUa 
that tbe ligament aoemed stretched out and to cover it in like a cyal. 

On opening the joint a quantity of thin railk-liko fluid, containing a 
gritty matter in susiwnaioD. flowed away. Tho whole cavity was filled 
wjlb a similar chalky matter to that above described, ajul which, when 
placed under the microeoope, was seen to contain crystals of urate of soda 
Every almcture of the joint iteelf, exceiit a sac like a thin fascia, and 
which was probably thickened synovial membrane, had disappeared : car- 
tilagva, oruoial ligaments, and joint surfaces of bone, were aU absent. Tho 



78 ACUTE BHEUMATISM. Chap. III. 

Dew bone Bur&oea were veiy irregular, having uneven rounded eminences 
and depresaiona that fitted rudely into one another ; the patella was firmly 
anchylosed high up on the femur.* 

This case shows a singular connection between rheumatism 
and gout, and should certainly be of much pathological interest 
in aiding to clear up some of the yery difficult questions con- 
nected with the subject; but such a termination to a rheu- 
matic attack is, I conceive, extremely rare. The more usual 
alteration to be found in joints, as a result of the chronic inflam- 
mation left behind by rheumatic fever, is thickening of the 
fibrous structures, such as will be described in a future chapter. 

* I put this joint into spirit, and it I kindljr allowed by Mi. Hancock to pre- 
iB Btill in my poBseseion, I having been | servo it 



ft IV. 



FY ARTHROSIS. 



79 



¥ 



h 



CHAPTEB IV. 

PYARTHROBia 

It ■ ft remarkable fart that any otie disease shmiM, like the 
one now umler consideration, produoo in one form such a typhoid 
condition as to Yte ahurmt invariably fatal, and in aiiuthor shmdd 
na»9 as its prominent symptom merely sweiliug and inllam- 
mntion of the joints so liko sub-acnte rhmunntism as very 
fh-quently to \w mistaken for that disease. Indeed one form of 
m-oalled rheumatism (the gonorrheal) is but a mild fonu of 
parultmt infection, and certain other cases happening in puep- 
pCTnl women belong to the same category. 

The coarse of the severep form of the attack may bo thus 
(Uted in tlio briefi^t miuinor. l)uring a snppnratiou in some 
part of the body, there supervenes a low form of fever, generally 
ptvceijed by shiverings, and aocom[)anied by great norvoua 
dc])tu$siuu ; tlie discliarge changes in character, or may stop 
altogether ; abscesses are developed in various parts of the body, 
a joints among the deep musck-s, in the lung, liver, &c. After 
dttlh veitis leading from tho seat of suppuration will generally, 
aocDr aflinu always, be found inHanieil, sometimes containing 
pitN, and broken down coagula. 

ITie milder form of the malady takes a diiferent course. 
r>anng tho healing of a small wound, during a purulent dis- 
diai^i from a mucous membrane, and sometimt«, though rarely, 
wliilo no fiouriH! of suppuration can bo discovered, tho patient 
lull be attacked by shiverings followed by pain in a joint, sub- 
sequently perha[»8 in several joint^i ; soon swelling of those j)art« 
oomes on, and tho pain w generally very severe. Tho ptmers 

the patient are depressed, and the tongue is brown and dry ; 
bnt Uie eympt^ims are scarcely typhoid. The swelling may 
iHandor from one joint to another, although there is great pre- 

Dce for the Imee ; sometimes, though not constantly, when 

attack goes to another articulation, it leaves tlie one tirst 

iectMl quite free, eubsequeutly the patient may get perfectly 



80 



PYARTRROSIS. 



CnAP. IV. 



well ; bat generally one or more of the affected joints is per- 
manently injured, and Uie ])ationt mil probably believo tliat ho 
has had a rheumatic attack. 

It is only when a large number of cases have been seen, and 
when connecting Iuik» between the first form of this disease 
and the second have been supplied, that our view of the whole 
malady becomes broad enough to allow our perceiving tho rela- 
tionship between its different manifestatiomi. Its pathology is, 
however, extremely obscure, as may bo gathered from the 
number of names applied to the malady, each name having 
some tendency to denote a eertaiti theory of production. Puru- 
lent absorption, purulent infection, pycemia, ichorhocmio, septi- 
cemia, are a few only of its dosiji^niationB. 

Tlio first of tliest^ names, purulent absorption, is on oxpone*it 
of one mode of aceoimting for the origin of the disease ; namely, 
by tlie simphr bodily absorption of |)ur iuto the circulation, whose 
corpuscles, it is uIlinmHl, oiiiy bo seen in tho blood (Sedillot, 
Do rinfeetinn Punitente), and which are supposed to produce 
mechanical closing of some small vessel or vessels, as happens 
with iuinJuble jwwders injected iuto tho veins. These pus cor- 
puscles are imagined as being subsequently deposited in the 
tissues, thus forming abscesses. Another theory of the ill effects, 
said to be produced by pus in tho blood, is that it causes tluit 
fluid to coagulate, and thus renders it imiit for cin.'ulation.* 

Now, in the first place, pus caimot be absorbed by a vein 
whose coats are intact, and if au opening be mode and remain 
in such a vessel, or if it bo cut tliruugh lis iu amputations, it 
never pomaius pervious from the oi)ening or cut end upwards, 
but is closed by coagulum which would prevent tho simple 
and bodily flow of pus from a suppurating wound into the blood. 

Then tho blood normally contains certain white cells which 
cannot l>e digtinguishtd from pus-eells, and though there are in 
this disease raon- white corpntscles tlmu uuual, the sime )iaj>ix*U8 
in very many maladies, and I believe in every depressed state of 
system ; hence the mere pn^senoe of an increased number of such 
bodies could by no means waiTout the conclusion^ that some of 
them were pus-ecllit. As these normal wliite cells are in mze 
and form exactly lite pus-cells, no vessel that would allow one 

• Hunry I<«e, P.B.8^ Oo Phlebitia. 



ftup.rr. 



THE ABRORPTION THEORY. 



61 



*t to pass conld be obstructed by the other. Tliirtily, the 
ftirraatiou of the secondary abseesses is not merely a passive 
infiltration of the tiKSues with piu ; but is always pronoded by 
the deveJopment of foei of inflammation, some of which do not 
npparate. and those which do form their piis from the tissue, as 
m overy oilier case ; even if a pus corpuscle could get into the 
litood tlirough any nrtificinl opening in ii vessel, it could only get 
out again through the same or another artificial opening, or by 
maldug an o{)ening for itself. Lastly and chiefly, pure pus, if 
proper precautions in its introduction bo observed, produces 
neither coagulation of the blood, nor any symptom of purulent 
tolection. Mr. Henry Lee, whose experiments upon this subject 
are so well known, must have been unfortunately betrayed into 
an error by the method us<^ in injecting the pus. Yircbow has 
shown* tbat most of Sedillot*s experiments were vitiated by 

I the mode in which the wound was made, and the nozzle of tlio 
inje>cting-tul»e thrust in; for blood must have formml ooagula 
around these parts, which afterwards were earned into the 
circulation. Mr. H. Lee's experiments l>eing performed on a 
BJmilar method, are clearly as open to the same sources of fallacy. 
In the vast majority of instances, when sufficient care has been 
taken in the method of injection, and in the selection of a piu'e 
pas, no symptoms have followed the oi)oration. A commission 
repeating these experiments, twice found negative results in 
both instances. Beck found in fourteen injectiona that not one 
was followed by symjitoms of purulent infection. 

In the *Prim Essay on Inflammation or the Teioa," by Mr. HoDry liee, 
jtut referred to, that surgeon gives an account of throe RX|)enmeut8 
performed on oaacB of different ages, by the injection of pure pua itito a 
vetn. 

In nch case the vein thus treatod became immediately hard and corded, 

in one M violently thai, •' Evm /oreihU prc^tire tvas not aujgierient to overcome 

iht nttuloner offerrd to the rrtuni vf liivni." Every one of the oniuials waa 

wuab^ afffloted viihiu 'J} hours : the first died od the third day ; the 

•eooud, on the foiu-th day ; and the last was, ou the second day, in great 

J danger of death, but recovered, eo that he waa kiUed on the tenth day aft«r 

Htlii* operaiion. In all the aaimab wore found, after death, more or leae 

H phtebitiii and abfUeewR. 

H Shiortfy after the appearance of this eieellenl essay, a committee was 
' appointod by the Edtuliurgb l^ysioloigical Society to repeat the«e experi- 



* Ueber EmtioUe mid lufvklion Geiommclte Abhandloagao,' p. 64S. 

O 



82 



PTARTIIR09TS. 



Ohap. rv. 



montB. lliey fUniiabod tboir Report on the 6th Janoixy, 18fi3 ; it may 
be saoD at length in the * Edinburgh Monthly Jourual,* voL viL, p. S72. 

Report of a committoe appointed to repeat Mr. U. Lee'a 
experimonte on an ass, with a view of determining local efTects 
of pns on tlie bloDd : — 

" EsTERiMEKT I. — ^Tbo Hpheiw Vein of an asa was exposed, and a tube 
introdnced, confined by a Hgotura. Fresh and healthy pne was then slowly 
injeoted, uptmrds, towards the heart, from a syrioge holding an ounoe. A 
slight obstruction was now [jcrceived, and the vein above the ligature 
could bo aeon to bo aomewhht swoUon. This swelUng, on being felt, wu 
very soft; and, on pressing the vein from below upwards, the miied blood 
and poB was roodtly pu8he<l before the finger ; when all obHtruction to the 
pUBSgo of pus from the syringe was removed, the syringe wss again filled, 
and another ounce of pus injoctfd without oocMsioning any further local 
efTectA. T!io animal was then allowed to get up, and exhibited no change 
in ita normal condition. 

" ExPKAncENT II.— The same aaa was the stibjeot of another experiment, 
having; been perfectly well in tht* interval. Six inches of the jugular vein, 
in the neck, were carefully dissected and exposed, and a minute aperture 
was then made in the upper end of the exposed vein, and the bent tube 
of a syringe introduced without a ligature. The coats of the vein were so 
transparent that the flowing blood could be seen through them ; an ounce 
of fresh and perfectly healthy pus was then slowly injeoted (foirnwmndi 
towards the heart, and, owing to the transparency of the vein, the yellow 
opaque fluid oould be seen to join the blood, to oontinuo a few momenta 
running side by aide with the crimson current, until, at length, the vein 
became full of pus. On removing the syringe to obtain a fresh supply, the 
blood from above oould bo seen to join the pus, to continue side by side 
with that Buid, presenting a streaked red and white appearance, without 
any coagulation, until all the pns was carried forward and downwanl 
towards the heart, and the vein became a^in full of blood. Another 
ayringe full of pus was then injected, which could once more be seon to 
fiow with the blood, then, as its quantity increased, to talte the place of 
tho blood; and then, on the syringe being exhausted, to receive bbod 
from above, the two mixing togclhor and continuing their course, without 
coagulating, until once more the vein contained nothing but blood ; the 
wound was now closed, and the sniuial allowed to rise, which he did 
without H[iiHirant nufTeHiig. Ho prenented no unusual Bymptoma during 
the next few days, when he was killed, and the parte carefully dlssooted. 
The vein was pervious, presenting no thickening, nor cording, nor abscaosei^ 
and the external wound was nearly healed." 

Thus the evidence is u]u)gothcr against the idea that pus can 
in ita totality be absorbed, and that even if this cotild take plac*^ 
tliat it wonld produce tho disease under consideration. ITence 
the name purulent absorption, iuosmuch as it tends to fix upon 



Cbap. EV. 



PUTBESOENT PUfl. 



83 



the dbeaae the mmple absorption of pus as its canae, is inadmis- 
nfcJe, and pycenua is equally objectionablo. Purulent infection 
•]^)ears to me more a(lmiasihle,8inc<! it denotes, tliat the system 

■ 18 vitiAtecl by an ii^ecting pus w-itliout deiiuijig tht; inodo of in- 
fectaon, nor the coudition of the purulent fluid. 

Icborromia and septiciemia occupy at once a different ground, 
and aasert, the ^nt, that the blood contains unhealthy, putrid 
pni at ichor ; the other, that the blood is rendered putrid by the 
iiiBnence of decaying matter. Experiments have of course been 
tried for the sake of proving the Brat position by injecting 
(lutrid pus into the veins, precautions having been ust'd to pro- 
TMit solid portions being injected with it The results of such 
experiments are extremeJy unsatisfnctory, and do not go far to 
prove anytliing, except the intense dliliculty of all such research. 
|H The mode chosen for experiment, namely, injecting putrid pus 
I into ft vein, does not imitate nature sufficiently closely to render 
thefesulta very reliable, fur such pus cannot bo absorbed en masse 
ia nature, and the rapid introduction of putrid material into the 
tR)dy is a very diffVrent thitig from the gradual vitiation of the 
ayateiD by the same miLteriul ; and tiien again the same source 
of fallacy by coagulation of the blood is still more apt to occur. 
As to results we have only the pro<Ifiction of secondary al>!}ces8 in 
I porceutal higher ratio, than when pure pus is used ; but there 
ii in tho«e iust-auces tbe remarkable fact that such abscesses have 
always the same smell and <pialities as the pus injected In by 
Ur the larger number of cases, about seventy-five per cent,, the 
ipnptoms produced are those of a tN'phoid fever with diarrhoia, 
tbo stools being horribly fetid, and the intestines are afterwards 
^ found to be ulcerated. 

B Nov. as wo see tliat tlio injection of putrid pus into the blood 

ii much more apt to coagidate portions of that fluid than if pure 

[tOB be used, it may well bo doubted whether the percental 

I difference iu the fonnation of secondary abst^ess be not al- 

H together owing to that cause. Tlie fact, tliat the secondary 

H tbecess* when they form, smell like the injected fluid, does not 

W prove that the pus of the abscess is a iH>rtiou of that injected ; 

since it would certaiidy liappen, tlmt tlie sidpburetted hydrogen, 

nr olhr't ill-odorouB muterial wliich gave the putrid rliuracter to 

Uic putf, would impart a similar, but diluted evil savour to the 

o 2 



84 



PTARTHROSIS. 



Ohap. IV. 



whole cireaUting fluid, and would come out in the secrotione ; 
hence the intestinal evacuations hare the Rame odour. The 
injection of a quantity of such pns, producing so often a different 
set of symptotm*. ami partifulurly diurrUoea, sliows that the raode 
of experimentation is inapplicable, the poison finding its own 
emnnctory acts as its own antidote, — just as an ignorant mono- 
maniac will,take such a dose of oxalic acid that the stomach re- 
jects it, and the poison cannot take duo effect The experiments^ 
though they prove nothing whatever, would lead us to consider 
it prohahlc that the putrescence of the material is the cause of 
the evil ; but whether by direct absorption into the blood, or by 
an indirect action on tlmt fluid, is very duubtful. Dr. Julius 
Vogel (Virchow'e * Handbnch der Pathologic und Thonipie ') 
leans very strongly to this latter opinion, and to him the name 
Septicaemia is due. He affirms that tho blood in this disoaae 
may be variciuidy afleeted by the development tlierein of lactic 
and hydro-sulphuric acid, of carlxinato of ammonia^ of abnor- 
mal quantities, and several morbid forms of extractive matter, 
&c. &c. These statements require, however, further confirmar 
tion ; but in HUpf>ort of tlie Be]>tica!niic theory, it must be ac- 
knowledged, that the blood has a power of multiplying any 
organic morbid jmison introdnred into it from without (hence I 
believe the term zjTnosis) ; and whether the blood bo poisoned 
by the absorption of the fetid gas, or of the putrid pus, it scenifl 
probable that this jioison is multiplied in the blood, as is the 
case with the pus of small-pox, or of glanders, when inoculated. 

All the experiments hitherto performed, however, throw only 
a negative and doubtful light upon this subject ; and their 
sources of fallacy are still further increased, if it be considered 
that in many instances a phlebitis is found to stand in some 
relationship of cause to the disease. Such a relationship allows 
us to doubt whether, even in the inst&nces when secondary 
abscess followed the injection of pns, the phenomena may not 
have been caused by irritation and inflammation of the vein, 
and not by the mixture of the pna injected with the blood. In 
such a mode of accounting for tho pheuomeua, the injecting pipe 
would be regarded as the irritating body, and tho in6uence of 
pure pus, local and general, miLst he ronaiderod null. The 
grt^ter frequency of secondary abscess, when foul pus is injected, 



f. IV. 



CONCLUSIONS FROM EXPKRIMKNTS. 



85 



may well be attributed to ita local irritant action. One conse- 
qaence of tlie phlebitis is suppuration of the inner coat of tlie 
vein ; another is tho furmatiou of a clot, which sulweqtiently 
Bappurattis, sol'teus, and [>orIiaps putrifios ; hence the admixture 
of pus, of putrid matters, and of portions of solid coagula with tho 
Uood. From this fact Virchow argues plausibly enough, but 
peihaps with a little too much bias, tlmt many cases of supposed 
•baorptiou of, and infection by, pus. originate in embolism, that 
B, the stoppage of aome veRseht by the coagula ; and this view is 
flertainly 8wpporte*l by tlie occurrence of many instauccs of 
apparent purulent infection, in which no primary deposit of pua 
can be found. 

Thus the result ef all these experiments upon tlie ])hyBical 
aose of pundent infection leads to the following very unstitts- 
fiu!tory conclusions. 

Infection of pttre pus into tfie blood produceB in the great 
najority of iustaucos no evil remdt whatever ; when such occurs, 
it may arise, Ist, either &om the mere presence of pus iu the 
blood : * 2nd, from tho formation of clots on the nozzle of the 
iaJHOting pi|te, which, being carried into the circulation, give 
rise to i-mboliKm: 3rd, from phlebitis set up by the mechanical 
bjury of tho vein. 

Ii^ection. of putrid pus into tJu hlood causes, in a larger per^ 
(entige of cases, secondary abscess, but generally a set of morbid 
^ous entirely different from those of purulent infection. Ttie 
krger numl>er of instances ui wliich this experiment is followed 
by pyaemia, may 1h* justly ascribed: Istly, To the coagulating 
effect whic-h certain products of pntrefaction exercise on the 
Uood. 2nd, The irritnling effect of putrid matter coming un- 
diluted into immediate contact with the coats of the vein, 
causing phlebitis. 

The disease ts oeoasionaUy set up where no primary injlamma- 
Han can be found, and yet it is doubtful whether it can arise 
^tboat a phlebitis, or at lea=it the fonnation of clots somowhore 
in the circulation. Hence it may be due simply to embolism. 

In ttpite of theao exti-emely nugatory conclusions from all ex- 
Verimente 1 have had a strong desire to undertake a fresh series, 



* Thti Ant of tiicM cMibeK ia alutwt I puro piu iu the ciicuLitUm witWat di«> 
piofcd ifflpoMibl* \jy tho eudtuanou of | tuibaLcc. 



60 



PYARTUROSIS. 



QOAW. IV. 



and yielded in some meoaure to tlio temptatioii. My deeire was 
to place pus in different conditions, from the perfectly pnre and 
healthy to the nioBt putrescent, not in a vein, but Bimply in 
contact with it,* thou of employing other snbstauceB, lactic and 
hydro-sulphuric acid, carbonate of ammonia, &a, in tlio same 
way, and carefully analysing the blood in each cose, whether any 
secondary abscesses were produced or not ; but I have been de- 
terred by cousidering the niunber of experiments necessary to 
produce any decisive results, the great quantity of time that 
must be employed, and the vast amount of cruelty to be involved. 
These experiments wore the more readily abandoned because 
a careful observation of cases yields results which lead, if 
not to decisive conclusionis nt loiist very near to absolute 
truth, and reveals that a certain condition exist«t which has not 
been noticed hitherto, and which is not pruducible artiliciidly 
in the body of any animal. This condition is a certain state 
of system rendering it susceptible to the influence, whatever 
it may be, that produces the disease in question. 

Every student knows that at times a (Ussecting wound proves 
dangerous, producing absorbent inflammation and abscesses, 
wliile at other times uo evil results whatever follow. Every hos- 
pital surgeon knows, that while under usual circumstances he may 
operate on deep [xirte of ihe body — resect portions of bones, Ac — 
there come certain periods in which he avoids opening the akin 
a^ much as possible for fear of purulent infection, or erjsipelua. 
Such occasional pronouess to the malady is not only exhibited 
by a case hero and there in. one hospital at a time, but it may 
be in all hospitals at once, not only in London but b\bo in the 
province** ; and at the same time a low fonn of fever spreads 
among the students ; and in private prnctice we And the same 
condition. Such a state is an element of the disease, which in 
experimentation cannot be disregarded, and no doctrine can be 
correct which refuses to acknowledge the circnmstances, wliieh 
render at one time the system prune to such maladies, or which 
at another protect it entir«ly. 

The iuiluence is evidently of the epidemic, or zymotic class : 
it affects a lai^ number of people, and a large district; and 



* Viroliow, Op, I'it., p. Hiti, produced I bj? plooing a pLoccof putrid fibrio in the 
nil (lie uooilitioiu of puniloul iofectiou | ja^Ux veiu uf a dog. 



At. IV. 



SYMPTOMS. 



87 



Iborois pnwont, at Uu- same time, erysipelas, diptheria, typhoid 
"Ini^or other of the lower forms of zyiDoai& Uenoe, it caimot 
be doubted that a large portion of thia malady consists in a cer- 
tain epidemic, afl'ucting the blood in a peculiar manner. 

Hicroscopio examination of tho blood in purulent infection 
showB it to contain on abnormally large number of white cor- 
pusrJos, which it &iu hardly be doubted wore mistaken by 
SedUlot for pUflHSirpuHolea. At tho Komc time, tho Bplecu ia 
tttOftliy found enlarged, and either greatly hardened or softened. 
Tho blood has a particular tendency to fonn clots, which appear 
to oonnst rather of cou^lomeratious of the white colls than of 
Striuuus concretions; but wbetlier tliis etato of blood be 
produced by a local condition, or whether lliat state pro- 
daoe the whole disoase, geucrul and local, is a question of some 
difficulty, althongh the epidemic tendency of the malady 
would lead to the latter conclusion. At all events, in those 
cases where purulent infection has followed a wound the an- 
nexed conditions will, I believe, be constantly found. A 
collection of unhealthy pus surrounding a vein, tlie inner coat 
of the vein inflamed, and coutoiuing a clot broken down, appa- 
reoUy suppurating, the pus inside Iwjing in a similar state to that 
outside the vein. 

It has been asserted that the pus of secondary abscess does not 
caotoin perfect corpuscles, but that they are oil broken donni. 
I Itare examined pus from scyeral secondary abscesses, and 
$aaaA that when it is putrescent, or very oflensive, the pus- 
cells am, iin a rule, broken down and imperfect, as tho cells are 
fonnd to bo in any CAvity containing sucJi matter ; but when tho 
pus is not offewfiive, uor dark in colour, its colls are perlwt 

LooaIj Symptoms. — The pain in joints aflected by pyarthroeis 
is A severe aching, with sense of fulness and distension ; it is 
•^nvated by motion. Tho swelling docs not, like that of 
flunple acute ^novitis, follow the ehA(>o of tho synovial mem- 
brane; on the contrary, the tumefaction is more general, and 
has no distinct outline of commencement. The colour is nearly 
always white ; whiter than tho normal hue of the skin ; it has a 
sickly sodden appearance. In one case reported, tliat of Louisa 
Stonely, Ca.se XXItL, the skin was red ; but there were other 
ttnomidic's also prL«cut that render this a doubtful instance : for 



88 



PYAHTHROSIS. 



Chap. IV. 



example, there was no discoverable seat of Ruppiiratton. The 
subcutaneous tissues feel quaggy and sodden ; late in the malady 
ikey pit. A practised hand soou distinguishes that a great deal, 
in some coses nearly all, uf the swelling is oxttTaal to the joints; 
sometimes the articular cavity contains, however, a great deal of 
fluid. In that form of disease called Gonorrhteal Rheumatism^ 
the case often docs not advance to the actual formation of pus 
in joints. The Huid effused into tlie cellular tissue is probably 
amply serum ; at least we may so conclude from its subsequent 
absorption, but the joints are, in these coses more partitMilarly, 
extremely white, which offers a strong contrast to the true 
rhemuatic disease, in which they are red. 

The surface over the affected part is hot, sometimes very 
much so if the case be rapid ; but in the slower form which 
accompanies a gonorrhcea the temperature is often not perceptibly 
increased. 

Treatment. — Upon the method of treating purulent infection 
from a wound, it is hardly desirable to enter, for it may hardly 
be considered as coming within the scope of this TroAtise ; but 
the differences of opinion reganling gonorrheal rheumatism, as 
it is called, render its mode of treatment very various. As this 
variety arises from diversity of opinion in putlioh^y, it appeared 
to me desirable to place it in juxtaposition with the malady 
with which I believe it to bo identical 

Some surgeons, conceiving that tliis is a peculiar metastasis 
of the gonorrhosal discharge from the uretlira to the joints, treat 
the disease vdih largo doses of nojmilm, anfl in the theory of such 
treatment lie two errors: firstly, in the patholc^y ; secondly, in the 
idea that the balsam is a specific fur such discharge. Othen 
give colchicum, in the belief that the disotisu is a rheumatisnu 

Firmly assured as I am of its nattm?, I would recommend a 
Btimulaut and tonic general treatment, and locally mere sooth- 
ing applications unless a<Jtual abscess be formed. Slercury and 
other lowering means are to be strongly deprecated. Purges 
are to be avoided, except one at the outset, paitly on account of 
their depre^ug influence, partly because we do not want to 
hasten absor|)tion uf tlie morbid matter, whatever it may be ; the 
action of tlie bowels must of course bti njgiilated. 

Quinine is the remedy on which I chiefly rely in this disease ; 



CW.I7. 



TUEATMENT. 



89 



not merely the ordinary grain, or two grain doses, but lai^ 
<{[uuititje« : five, eveu ten grains at a time. It is hardly neces- 
Bwy to enter into certaiu other cases in which I have found 
tltroe or four such doi»e« act very beneficially, apparently by 
jfodoeing &n action which is wanted in this disease. At all 
sreuta, in two or three instances I have found it very valuable. 
One cannot talk with any pro]>riety of curint/ a disease like tluK ; 
tlus poison is actually in tlie blood; oil ttiat wu can do is to 
support the system and prevent mischief while the morbid 
tutttT iH being eliminated, and in some instances we can pre> 
Ttat the formation of more poison. 

Ammonia and other diffusible stimuli ore of great value. 
Wine, brandy, and diet may all be used to the same pur|X)3e. 

tydatircs, chiefly opium, niUKt be employed, if merely to 
imreut pain and irritation killing the patient. It is well, how- 
^n, to wat/'h the action rather jcalonsly, for it must be allowed 
wither to depress the system nor to check secretion, by whose 
i&wis the poifon is to be got rid of. 

lulljree cases of purulent infection I liave tried (he intental 

'Klmiiiifltration of cldorine ; twice in the form of the liquor sods9 

<^iiriuAtJE ; once in the form of chlorinated water. I um not 

siffe of their action or inaction; two of the cases got well ratlicr 

*pieUy, the other died. It requires more experiments and 

howledge to fix their value or their want of value ; my own 

i'»'lJr«iiion is, that they are useful and liave a decided action. 

^Wben thu disease commences, its origin, unless clear and 

ahould bo sought If it arise &om a small wound or 

Kture, an incision that shall lay it widely open should bo made, 

^^ chloride of lime or B0<la lotion should be inserted upon lint, 

^^ a poultice appli<.Hl over tliis. The joint should bo placed 

"t'eu a splint ; one that is as light and little annoying to the 

/"Client as possible ; soothing application, poultices or lint dipped 

" >rann water, and covered with oil silk, or cotton wool, are* 

'^^9t comforting to the patient When abscesses form, it is 

|'*tter not to open them while the jwitient's health continues in 
'^ery low deprestsed state, unltrss absolutely necessary. I have 
'^'^Ji the bad «ympt*ims greatly increase after such an operation. 
^**<b pus in them is often in u very peculiar state, and the least 
'^^^'utasiuu of air causes rapid putrefaction. If an abs(>i'£S muKt, 



uu 



PYARTIIBOSIS. 



Chap. IV. 



however, be opened, the wound should bo closed as soon as Uie 
|)iii) has cvaaed ilowiug, aud pressure by means of a bandage is 
t<) bo applied. Wlien, however, the pus is in a jomt cjivity, the 
earliest possible opporttmity which tlio condition of health per- 
mits should be taken to evacuate the matter by a wide inciBiou 
in the most depending part Chlurinatcd soda lotion upon lint 
may be inserted into the wountl, or iudee<! the cavity may be 
rinsed every day with that fluid by means of a gum elastic tube 
and syringe. 

Case XX. — E. B., aged 46, ft hettUhy woman of nerroua temperament, 
woa admitted into St. Thomas'H Hospital, Ulth December, m47, with « 
small anouriflin of the ri>;ht carotid ortorj about ita blfuroation, and the 
common carotid was tied b^ JVlr. Green on the 20th. 

She went on very well for a week ; the head Bymptoms merely amounted 
to a seDBntion ; the woiuid Buppumtod freoly ; tho pus was observed on 
the 28Lh to be rather dark in colour. 

January let. — Mr. Qroon saw her, and himself drossod tho wound ;*tbere 
was flomo discharge of pus, which, dTjing of a dark colour on the skin, led 
to tho supposition that it was blood; but a closer inspection corrects that 
error. She coniplainod of a sense of stiffness between the wound and tbo 
angle of tho jaw, and this tract is tender. 

Bowels confincd^ordered to take at night V'H. Colocynth comp. gr. z* 

Hvd. — There is a rather copious diiicharge of a brownish coloured pus, 
but the wound is closing slowly by gnuiulation. Although she complains 
of no [lain, has had nothing to disturb !ier mentally, no shiTeringS, qo 
bowel complaint or indigestion, yet there is eomothiug that renders her 
uneasy, morose, and discontented in nuutnor. She rej>eated the cirfocyntb 
pills last night, but the bowels have not yet been opened. Tongue while 
and dry. Ordered the following draught at bed time ; — 

Mist. SennsB comp. ^as. 

(ith. — Mr. Greon dressed the wound, and could find no pulsation in the 

artery, either above or below the wound. Pulse 85, feeble. — E^ daily. 

6th. — Is very uneasy and dismal, her manner is quite peculiarly 
miserable. I'ulso 90 ; tongue white ; bowels still conBucd. 

Mist. ScnoflO comp. jjsa. at bed time. 

7th. — The medicine acted rather violently. The granulationa of the 
wound are 6abby, and the edgea are rod and swollen, aud the pus is of a 
liolc brnn-n hue. Sho complains bitterly of pain in her left knoe, but it 
in neither red nor swollen. 

10th.— Id the same state ; tongue, brown and dry ; has very little appe- 
tite, aud easily tires of any one aort of food ; the ligature has lengthened 
irom the wound ; but, according to &lr. Green's dirootiona, I did not pull 
the silk out. 

13th. — Yesterday Mr. Green withdrew the ligature, which offered no 
rtifiistauoc ; it had cvideuUy, therefore, divided the artery on or before the 



ClAT. IT. 



OASES. 



91 



lOCh. thai ia, twenty-one days odor the operation. She is to have a glau 
of porter doily. 

I^Ul — She 19 restleaa and tuwaay ; complaina of her knoe, but of no other 
pain ; aajs that &he (eeU oon^iscd and unable to lliink or control her 
mind ; is rety low apirited. The knee somewhat ewollen ; to be 
pooHioed. 

ItiUi. — sun iu the same utato of mhiJ. Wound healthy and discharging 
freely. Pulse 95, fueble. Sho coustantly bears an exprottslon of cooDto- 
DSDoe hardly to be called piuchcd, though it is something approaching 
that form. The mouth is puckered up, tbo lips compressed into an 
cnxiou expnesion ; about the upper part nf tho foco ie a half frown, half 
meer, either of psiu or of discouUint, or buth. Pulse 95, feeble ; voice 
weak and querulous, 

tZSrd.— Shti ia in the same low, desponding state. False 100, weaker. 
29th. — Mr. Green saw hor with Dr. Lecaon ; they did not form any con- 
okaioii aa to what actually ailed her. but they agreed she was in a proca- 
riflW condition. Fulse suudl, weak, and rapid ; tongue, white. She 
bdgged that she might hare treacle and brown paper applied to the kneo, 
■id it was allowed. 

Tebruary 2nd. —Dr. Lccson baa examined the urinu, and found it loaded 
with Uthate of ammonia and hthic acid. Tho kneo is more awoUcu, otherwiHe 
sheia in tho same condition. 1 took some paiai to see a relative of the 
patient to inquire about hor peculiar nuiitiier. It appears that it has 
•hnys been rather querulous and morose, but not, of oounw, to the some 
digree. The knee is more swollen and painfuL She is to have two ounces 
of brandy, and, as diet, almost what she likes. 

5th. — There was found accidentally to-day a small abscess over tho 
nur condyle of the humerus — she berHulf had not complained. There 
*■ likewise found fluctuation at the outur side of the left thigh ; viscera 
<iftba thorax examined, were found healthy. 

7Ul— Opened the abticess iu the arm and let out an ounce of pua, which 
^examined by Mr. Simon and reiK>rt«d healthy. 

9th. — Four ounces of pus taken from the outaido of the thigh ; a little 
ttotv came away during tho day, 
1 1th. — ^The leg not much decreased in siM, nor is there leaa pun. Sho 
^B ^ Veiry luw. Pulse 120, feeble ; tongue, white or slightly brown. 

^f Wine Aiv, iustcad of bmudy. 

l3th. — Complains of pain in the head, also in tho affected leg and arm. 
^*>«oeaa oo the arm smaller, and discharges; very little pus eflcapea tivm 
^« abacesa on the thigh. 

^ 1.6th. — Pulse 1 10, irregular ; tongue, white at edgoa, brown la the oontro, 
^*^, roagh ; akin, hot dry. 

^^^ i7th.— The last two days she apiware a Little better; but is now weaker 
r**^in ever. Pulse 1 1 5, irregular, intermittent ; touguc, as before, but 
^^'^niuJous ; voice, verj- fueble. 

loth and 20th. — Lower atill ; pulse fluttering, and not to be counted. 

'32nd. — She sank, and died at twelve A.u, 

^M, — ^There was in the neighbourhood of tho wound a disseotiug absooss 



92 



PTARTHRUSIS. 



Chap. 1Y. 



Tkith which the divided ends of the artei? commuiiicated by opea 
orificea. 

The arto)7 remained open below the aeat of ligature to within half ui 
inch of its origin, where it was Bi?aled by a plug of ooaguhun. Above th« 
TQBiwI renMined open aa f iir aa the bifurcation, where it was closed by th« 
ooogulum, which filled the coBtrocted oneurismal sac. The portion of 
artery below the ligature contained pus mixed with what appeared to be 
broken down coiigixlum, while the port above the ligature was empty, 
llio vein was closed at a point even with the aneurism by a thiu plug of 
a bright golden-coloured lymph, while it was phiggod IwltTw by ooagulum. 
The inner membraue of the vessel was covered by lymph of various colours, 
in diHerout Hioges of decompoaitiou. The vein between the two plugs of 
coagulum was filled with thick pus. On the iimer and posterior port of 
the veto, on a level with the hgature of the ai'tery, was au oval upeuing 
oomnmnicatii)g with the abscess. This abscess extended duwiiwanls be~ 
twecn the muscles to the pleura, In the reflected portion of which was oa 
ulcerated opening about the size of a shilling, whose edges were adhereot 
to the pulmonary pleura at the apex of the tight lung. 

f7j^.t(.— Heart and great voasels healthy. No appearaooe of geoerftl 
plouritis. In the upper lobe of the right lung were uumeroufiUtkl* deposits 
of pus, about the size of a millet seed, which might bo called miliary vomios'. 

Uead. — ^The ventricles of the brain contained perhaps a httle more aenim 
than in health. No diflurcnco could bo found in the size of the two caro- 
tids ; in foot, all else healthy. 

Abdomen. — On cutting into the abdomen the only observable abnoruuU 
appearance was a fatty and somewhat enlarged Uver. 

Lc^.- — On cutting into the thigh and leg a very largu quantity of <lark- 
coloured and very fetid pus esca|>ed in a jet. This came fcaai a diffuse 
ftbsoeaa, which bad separated, in51trated, and partly destroyed all the 
nniaoles of the thigh ami upper part of the leg. I'hia abscess also comtnu- 
nicated with the knoe-Joint, where the oartilagee wore alt swollen and soft, 
and in many places eaten away, iiarticularly at the posterior surface of the 
patella, which was nearly bare. 

This caso, at least all thai portion which relates to the sup- 
purutiou of the woiunJ, and to its consequences, is copied in full 
from nn old case book of ray own, and is described simply as it 
Btruck ODC who had uever eeen such a malady btifore; it is 
perhaps the more interesting on account of the very siniplicity 
and absence of all arrihrt pentt^ in the narrative. The i)eculiup 
manner, and the dcprcesion of spiritfi, art? remarked upon and 
kept ill view with a feeling of doubt, whetlier they wert^ some- 
tiling peculiar to the woman, or were symptomatic of chan^ 
in cerebral circulation, or were due to the disease. The wliole 
caae^ more particularly the autojwy, is most interesting, and 
should be tlius summed up. 



CBAf . rv. 



CASES. 



93 



A fibrous sheathe contaiaing artcrr and v«in is opened, and 
a UgBtnrc put round the orteiy ; tlie position of tho patient, 
Ijnnji on Oie back with the head raised, 18 such as to prevent a 
free exit of pus, which was secreted at the bottom of the wound in 
the sheathe of the vessels, probably remained there, or burrowed 
in the eJieatbe ; and eight days afttir the operation the pus is dark 
in colour. On the tenth day the bowels are confined, and on 
the nineteenth is an observation of the peculiarly depressed and 
discontented manner, which never left her. It is remarkable 
that she had no rigors. Abscess in the thigh and ann formed 
daring life. 

The vein is found inflamed ; the lymph whieh lines it is in 
various states of decomposition. Some pus which it contains is 
pruvented mingling freely with the blood by plugs of lymph, but 
even these have undergone a certain form of decompasitiou, 
which renders them oraiigi* in colour, and soft in (■oxturc. The 
odour of the pus in tlie femoral abscess is the same as, though 
leas powerfiil than, tliat of the decomposed lymj>h in the vein. 
It is not jHx*il>Io to conceit that there were any local conditions 
in thisco^e diflVrent to most ligature of arteries, in whose sheathe 
the vein also is included ; but gome condition of the sj'stem evi- 
dently permitted the vein to become inflamed, and the clot con- 
tained therein to suppurate and putrify, and to infect the blood. 

Casm XXI. — Robert H«ath, of^ed 16, had a Btnall piece chopped off 
the end of his Utile finger Mith a Imifc ; tho bone was uot laid bare. He 
euna to tbe ChariDg-Cro53 llospital IGth June, 1859, to bo dressed. 

30tb. — CuDB oompl&iniDg of pain in the lefb kaee, and »aid be felt very 
iU ; Iiad paio in the bock and IuIds and head ; bad a shivering fit when he 
woke about three o'clock on tbe preWous morniog, and waa sick ooce or 
twice ; hardly slept at all lost oight ; has no appetite ; bowela coaAoed ; 
TCB taken into tbe hoaso uudcr the caro of Mr. U&ucock ; tlio limb wta 
|rat oa a spHnt, and he had ton leeches apphed to the kneo. Mr. Hancock 
aav tiiiu in the middle of tho day ; ordered the foUovriug pill three times 
a day: — 

R. Hydrorg. o. Crotll ., .. gr. iij. 
Quinie diaulph ., .. gr. j. M. 

July 4th. — The tongae is brown ; the piilse small; skin, hot; he i^er- 
■pircts ; has no appetito. Ordered four ounces of wine, two eggs, daily. 

Ttii. — Leg more airollon ; tbe swelling extends above and below the 
koe« ; there is fluid, not only in the joint, but in the periarticular tissues, 
and beneath the Coacia ; modiciue purges him a little. Add to each pill 

Opii pulv. gr. |. 




94 



PYABTnH03I8. 



Chip. IV. 



18th. — ^Tho whole left limb ia swollen to a very greKb degrw, ao much 
RO that it looks, in ooraporison to the other, gigiuitic ; it is quaggy ; pita. 
On t)io outside is deep fluctuation ; an indition made through the /'wuz 
iat'i, about thre« iDches above the koae ; a fprea.i deal of pus etfcaiHul ; 
urine loaded with litbatoe ; tongue white, dry ; he perepires profusely and 
wutea; pulse 110, thready. To tako throe times a day: — 

ft. Truj. Opii n\iij. 

Amnion, carb gr. iij. 

Decoot Ciochoiin .. .. ^. M. 

Eight ouuooa of wine ; ^(gs ; chops. 

Aug. 12th.— The boy is getting weaker and weaker : Mr. Htnoook deter* 
mined to give him a chance of liTe by amputation. Oi^ration performed 
thin day. 

I examiood the Hmb minutely and will give a dcutoription of its ap[)ear- 
ancea ; it will bo hardly dosirablo to follow tlie case further. Tlie boy was 
hanging between life and d«ath for a month after the operation ; at laat 
reoovered. A eurious circuuutance occurred before he left: he had 
phimosis, and the pema wan iioiuful from irritation ; had swelled once or 
tmoe; on examination some substance was found inside the prepuce. Oo 
slitting up tho part there came out two lithic acid calculi, one about the 
sixe of a pea, the other a little Hnialler: it^])r<i)>al>te thatduring the time 
he was in such a dangerous conditiou, then formed from the loaded urino 
in the plaoe where they wore foimd. 

EoMvUuation o/ JAriib, Axigaat 12th, 185!). — At the amputation a large ab> 
■oeoB was opened, which was under and around the extensor mnaclea. and 
which reached two-tlmxis up the thigh. This a>3ace^ did not oommtuii- 
cate with the joint, but it extended quite round the thigh, lying among 
and dissecting out the muscles; all the p(u^ with which the pus came in 
contact were covered by a soft pultaceous pink tissue (a pyoyenio mem* 
braiie), which, however, did not bind them together so oa to form walb 
for the abucess. 

The periarticular tissues could hardly be c&Sed thickened; they were 
corered, or partly convortcd into a soft material, such a.H above described. 
The joint contained a thick, greenish pus, hero and there dark In colour, 
without any shreds, and not offensive. The synovial membrane was red, 
in some spots claret coloured ; its surface waa covered, in great iiart, by a 
soft pultaceous tiasue like that above described ; this waa moat abutidmnt 
in the Bubcrureal sac, next about the alar ligaments ; over the crucial liga- 
ments there was very little, and hero the membrane was mo«t vivid in 
colour. The patella was much encroached on by this material. 

The cartili^ of femur was ulcerated in a deep broad groove over the 
outer condyle ; the cdgos of the ulcer were sharp in one i»art, where bone 
was laid bare ; the sod tissue 61led up the apace. The patella had a bixxKl 
groove of ulcer down to the bone, running transversely aorOBS it : many 
spots of oartilago on the tibia were discolourcfl, but no others were ulcerat«d : 
the new tissue could be easily pushed back from all p:irtM not eroded. 
Other parts of cartilage and the iutorarticular tibro-cartilage healthy. 



IIT. 



CASES. 



95 



TImi inner ooata of uieriea ftod Teins were carcfullj examined ; not a 
trace of intlamniAtuni could be found. A little clot taken from the 
[lopIiLeal veiu contaiDcd many white oeUa ; it was, to the naked eye, nther 
pde and colourtea. The poR, both in the knoo-joint and in the Bub&scial 
ifaaoeeit, cmitaiufid perfectly well-formod and normal cells. The soft tiwnio, 
both wiUiiu and without the kuoe*joint, consisted of nuclei, round, oval, 
and « few fiuuform cells, among which meandered some tine Btniotureleaa 
DembraDO : the common fonn of new funuatiuiis from connective tiasow. 

I The next case is one in which a slough was eatahlishod over a 
Tcin ; pnnilcnt infection 8^t in, from which the patient partially 
recorered, and no exaniinatiou of tho j>art« tliereforc could bo 
made : bnt as the immediate cause of the disease the same con- 
dilion of vein in all probability existed. 

Cask XXII.— Bebeooa Caawell, aged fi2, bad a spot on tho right leg 
«Ueh vaa inflamed, and which she feared would ulcerate ; she came, 
iberefore, on the 2nd March, IS5U, to the Cliaring-OroKi Hospital, and 
Ur. CaotoD rsoommendcd that some varicose veins on the leg should be 
«hlitenU«d. 

She waa a healthy, muBoular woman, above middle height, and said 
her health haa always been remarkably good ; complexion dark ; rather 
I bilious. 

She was admitted on the 7th March, and on the 9th and throe following 
' diya, four issnea were made with potasita fiiaa, over as many veaous 
Waocheo ; at tho same time she was ordered t« take, three times a day, 

itist. Quinm ^j. 

S3nl. — The slougha are Beparaling, and she seemed doing well, but was 

' lut Qt^t seized with eevcral severe rigore, followed by lioat. To-day the 

tongue is brown aud coated ; pulse lOO. hard ; there are red lines numing 

up the thigh to tho groin ; great pain in the right knoe, which she 

described as coming on oa though it had been struck. 

Pil. Calomel c. Colocynlh gr, v. 
to be taken at bedtime, and tho following draught to-morrow :— 
Bauat. Cathart ^. 
Eight leeobos to be applied to the knoe. 

S4th, — The {lain in the knee cocUnued ; it is swollen and Hliglitly fluo- 
^^iMing ; is very hot. To take the following draught every four hours : — 
9. Potaasse Carbonatis . . gr. xv. 
Potaasii iodidi .. .. gr. vij. 

Vini Colchici ni.v. 

Int Quassiic ^'. H. 

3^— Tho kneo has becomo less painful, bat the right shoulder is now 
***"<:ked in a similar way, but leas Bcveroly. 

^th April. — Tlie pain in the Icf^. knee Iiaa ceased, and the awDlling nearly 
""i but the right shoulder is woi-se, and tho right wrist is painful. 



96 



PYAnTHROSIS. 



Chap. W. 



13t]i. — Has been in muoh the samo condition; t-ongue still furred; 
pulse weak, llO. To take the foUoinring draught throe timea a day :— 
Q. Amnionioi carboaatia .. gr. iv. 

£thona ohlorici .. .. "ixx. 

Decoct Cinchona) . . . . ^". M. 

&(ercuria] plaiater to the shoulder. 
16th. — The wrint more swollen. 

Repeat the pill as on the 23rd. 
ISih. — Fain keeps her ver^ rtstlcsa. Add to the draught 

Tr. HyoBoyami jk. 

To take one grain of Opium at uight. 

S3rd. — ^The left kuae became very painful and awellod. Apply six 
leeches. 

26tb. — The knee rery painful, swollen, hot ; the shoulder only now stiff. 
The right wrist swoUeii, painful, iinniuveable ; no alteration in oolour of 
any joint. Tongue still browu ; eyen dull. 

30th. — In the same general condition. Right wrist is, she says, more 
swollen and painful ; she complains to-day of the right knee, which, she 
nays, is very tender. At a sput ou the outer side examination Hhowed 
that the tibio- peroneal joint was the seat of pain, and I think, alao, of 
HwelliDg. 

4th May. — The pain at the outer side of the knee bos di&appoared, but 
that at the wriat continues, and it remains swollen; toi^c still browm 
and dry. 

9th. — In the same condition ; alcops but very Uitle ; tongue less browo ; 
pulae 90, a little stronger. 

11th. — Both luiecB are again p&infiil ; I cannot find, howeveri that they 
are swollen, though they are hot. 

13tti. — Knees still hot and painful ; right wrist better ; left wriat 
swollen, hot, painful ; tuiiguu lirown ; no appetiiu ; very low apirita. The 
saphena Tcin, absorbents of the glands of groin, have all regained their 
Duiural state. 

I4th. — I suggested to Mr. Canton the use of large doses of quinine. 

SOth. — Has taken five grains of quinine thrice a day ; is now up, and 
nya she fools much better ; doea cot look ho lugubrious ; tongue not 
brown, hut still white ; knees well ; ankle better ; pulse firmer. 

S3rd. — Ilaa gone on with the quinine, and is much improved ; the 
oounteoance is no longer depreiiaed and dull, but clearer iu colour, mad 
brtghtar in expression. The wrist is still a little swollod ; but this seems 
only the remains of inQamnmtion. 

SOth. — Tlie pama in the wriat and hand are better, and the toiigue is 
cleaner, apitetite better; ahe was, at her own request, dischaiged to go 
into the country. 

30th. — ^She goes to-day ; I examined the wrist and hand, there is but 
alight swelling about them ; movement of the wrist is painful, and there 
is ahght crepitus ; the knees seem recovered, except that there is a feeling 
of atiffncsa, chiefly iu the right une. 



Cskf. IV. 



CASES. 



»r 



In thiB caflt^ are the samo set of symptoms, thnugh lets miirked ; 
ttie foci of inflammation did not form any abi*opf«ea, but are 
metastatic; there is the name dt-prw^ion of tho vital powerH.'' 
The eflfect of quinine in latj^i' drwes is especially noteworthy. 

The cauae of this state is pretty eWdeut A sloiiRh {h formed 
over a vein, of suflicient depth to caiiae iiiflHmmatkin of tlutt 
reaeel : tlie alouglif* have not yet flopamt<'d, but there is a slight 
iliBcharge, and suddenly arise rigors, followed by the oonstitii- 
tioiukl sviuptoiuti ^f purulent iiifection, and accompanied by 
absorbent inflammatiun, which hitter fact murks the I'xistence 
of a poison nat«idc tiie vessels. 'J'he catte, if compared^ as to its 
caoiteis with the other, will be seen to be very analogous ; inflam- 
mation of a vein surrounded by u morbid decomposed pufl, 
18 in both instances the primary cause. 

The next case is lesa clear. 

CAitB XXIII.— Louifta Stonelj, aged 17, unmarried, a short, ulight girl of 
liighhr nervous temperiiueut; nhe is a miUiuer, working in aii airy room, 
bat ftt the rate or twelve houra a day. 

]u ike bcgituiiiig of FobruAiy. IB-'id, ehe was exposed to a heavy »t]owcr 
of tmin, caught a severe cold, aud waa aoon aftc^rwartls 8i>i2ed with 
OMudderable rigors ; her teeth chattorcd frequently, oiid abu hod, alter- 
nsieJj, a sense of beat and chilliness ; she had exhaimting swoatA and 
aching of her limbs and loina, with hcadochu and glddiueas, groat proatra- 
tioD of strength, and muscular jiains over all her body. These symptoms 
ooatioiied for several days, when there commenced pain, with great atifF- 
seas, in the right knee; this went off in about three days ; she then gob a 
bwl sore throat which, she suys, arose from swelHu;; of the right side of 
the oeck, which pressed on her (MiJate, this state lasted a week ; and 
then the right elbow-joint became extremely painful and swollen, and gut 
OODtannaUj worse for three or four days, and at last so painful that she 
oarae to the hospital on 

Friday, Ilth March. — I saw her at that time and found the countonauoe 
anxioos and flushed, the eyes Buflu:«ed, unnaturally brilliant and rostleas ; 
the poise was rapid and feeble ; the general surDace cold ; tongue fiirrcd, 
brown» and much marked by the teeth ; she seemed in great pain. 

The elbow was swollen ; diseased 11] ; sound 6| inches; and ro<I; very 
hot indeed, oontrasting strongly with the chiltineits of the nutt of the sur- 
fftoe. T sent her up stairs to the ward, and she fell under the care of Mr. 
Cuiton. 

12th. — To take the following every four hours : — 

H. PotaassD carb gr. xr. 

Putos^ii iodid. ,. .. gr. viij. 

Vini Colchioi .. .. tiflx. 

Inf. Quassia) 5j. M. 



98 



PYAKTHROSIH. 



CBAP. IV. 



16tli. — Continuea in much the aame feverish sUte — ^is^ bowerver, weaker, 

aod altogether is vorse. 

Fish ; rioe to be added to diet, 

23rd. — Worse, more feeble, and with oa much fever ; tongue brown, 
ptrticiJiirly far back ; elbow moro paiuful. I Buggeated to Mr. C&uton 
large doses of quinine, wbicli voro thus prescribed, to be takea three times 
a day : — 

9. Quinse disnlpb gr. t. 

Mist. Aeacio .. q. s. U. 

jK97th.^PtiIsc better; coiintouaneo leas amicus; she says horaolf that 
' BM is better and stronger ; but the anii ia the eaxtfB. Five leeches were 
ordered to be applied. 

30th.— Oenorol boalth improved ; but the elbow is, if anything, mora 
swollen uiid pitflfy ; tongue cleaner. 

April 2ud.— The Umb atAtrta now much at night, and she cannot bear it 
moved nor touched ; tongue much cleaner ; appetite improved. 

13th. — The atarting of the Umb has increased ; also the tondenwa* of 
the bones, both above and below the joint. 

Empl. Lj-ttffl outside joint. 
16th, — Empl. Lyttw inside joint. 

lOtli. — The pain in the joint is less and the starting has much decreased. 
She Itaa caught a cold : to leave off the quinine. To take, every fbnr 
hours, 

Mist. Pot. chlorai. jj. 

17tb. — A point above the outer oondvlo has boon more red for some 
time past, and now fluctuation may tic distinguished in it. 

SOth. — Flucluattou being now sufficiently distinct, a small incision waa 
made, ami a rather brownish-looking piifl evacuated. 

£2nd.— The wound has discharged a thin pu.s, and the {Mun is relieved. 

SSth. — The swelling diminished and the pain much less ; no starting of 
the limK To take »ix graiiiB of the iodide of Potassium and infiiaion of 
Quaaria every four hours. 

From this time she gradually got stronger, and the swelling subsided. 
She left on the nth May, in the following condition : — 

Tho aldn over the elbow still rather red and the joint shapclora : no 
heat nor tenderness. Tho forearm is still bent in the angle of the splint, 
namely, a right angle, and although it can bo slightly moved from this 
{Kisition either way, the least bit lieyond suoh slight motion is extremely 
imiufiil, and causes contraotion of the muBcles ; this limitation of move- 
ment is probably more due to muscular action and fibrous contraction 
that! any cliange in the shape of the joint ; there is no fjratiug. 

May, IS60. — I saw this girl again ; she hail quite recovered the use of 
her arm, but seemed in a feeble condition which, however, she says, is her 
usual state of health. 

In all these reports, except the luat, we lliid a wound which* 
suppuration, ffjlIowHl by pnmlfnt infertion. The last case is not 



CBAr. IV. 



UTEIIINK SnpPUnATIOK. 



09 



so dear, because thfrp is tio evidence of suppnratioa ftuy where 
in the body except at the elbow, whicli secme*! swrondarUy 
affected. In Uie first two we find distinctly a rein bathed iu 
putrescent, or at least in coiiflnetl, pus. 

There are a set of cnsos well known to the aceouehenr, 
vhicb Vr. R. hee has taken muoli pains in investigating, and 
the following account is taken from his book on the mbjcct :^ 
•*ln women who liave enjoyed fi^ood lienltli during pregnancy, 
and in whom the process of [jarturitiun has been easily accom- 
plished, uterine phlelritjs (x-casionally commences within twenty- 
four hours after delivery ; with pain more or less acute iu the 
region of the ntems, accompanied or followed by a severe rigor 
or a succession of rigors, suppression of milk, and loehiiil dis- 
cfaaT^gGf acceleration of thf3 jmlye, ccphalalgiu or slight inco- 
berence, with moet distressing sensation of general uneasinesB, 
and Bometimus by nausea, vomiting, and diarrha3a. These 
syrnptoiuA, after short duration, are followv^l by increased heat 
and tremors of the muscles (if the face and extremities, rapid 
feeble pulse, anxious and hurried respiration, great thirst, with 
brown dry tongue, and fre<pient vomiting of green-coloured 
matter. Tlie sensorial functions usually become much affei'ted, 
axkd tliere is a state of drowsy insensibility or violent delirium 
and Agitation, which is soon followed by extreme exliunstion^ 
Tlie wiiole surface of the btidy not ui»fn'<|uently asHunies a deep 
and peculiar sallow or yellow colour, or a petechial or vesicular 
jffoption appears on different parts of the body. The abdomen 
IiIbo soxnetimeB becomes swollen and t}iu|>anitic, and some of 
the remote organs of tlie body, such as lungs, heart, brain, liver 
and spleen, or tlie articulations and cellular mcrabrano and 
tousclcs of the extremiticii, wnfler disorganization, from a rapid 
Mid destructive congestion and intlammation." 

The following ease from the same vroTk is a good illustration 
of the disease : — ' 

Cask XXIV.— Mrs. U%y, aged 38, was delirered in the British Lying-in 
Boniutal, 2nd March, 1639, after an Muy mid naiui-al labour. The 
jjJbmitii was expelled in m few minutes after the inliuit, and her situation 
BMCMd favourable untJl the thirtt day after deliver}*, when a considprahla 
4iBofaar^ of bUxMl from the utents took ploco. From the Cth to tbe 20th 
of March idie made no complaint of imea^ine^ in any part of the body 
tfaoagh h«r strength rapidly declined. The conutenanoo waa of a duKky 

U 2 



100 



PYARTHROSIS. 



Chap. IV. 



yellow tinge ; the heat of the fturrace (tlightly increased ; the reapiraiion 
waa hurried, pftrticularlj on bodily exertion, and the pulse was abore 130, 
and feeble ; the tongue pale and glossy, with total Uhu of appetite, though 
at no period was thoro aoy nausea or vomiting ; bowels o{)cn ; the ut«ruB 
gradually receded into the pelvis, and prfissure over the hypogastrinm 
produced no eensible uneosine^i's. The milk was Becr^ted sparingly ; the 
locbl:d discharge had a peculiarly offensive ameU. From the 20th to the 
28th, whuu she died, the prostration of strength increased, and the pulse 
bpcamo still more feeble aud frequent. The respiration was uxti-emely 
hurried, and she was incessantly ham^sed with a backing cough, and tha 
exi>cotoration of Frothy mucus. The abdomen oontinuod soft, flaccid, and 
not affected by pressure. She, however, during this period complained of 
excruciating pains in all tbo joints of the right superior extremity and m 
the right knra-jointf which was obaorved to be considerably swollen, but 
not diaooloured, 

Ditwcctioa. —On laying open the abdomen the tntestines and otlier 
viBCem presented a perfectly faeotlhy appearance, and the uterus was found 
reduced to its usual airs a mouth after delivery. On careful examination 
of the peritoneal coat of the titenis, a {flight adhesion was obacrved be- 
tween it and the rectum on the left side. 'I'he uterus being removed^ 
and its cavity laid open, a portion of what appeared to be placenta, 
about the size of a nutmeg, in a putrid state, was founvi adhering to its 
inner turface at a point corresponding to the adhesion between the perito- 
neal coat and the rectum. The muscular tisaue of the uterus around this 
was of a dark colour, approaching to block, and as soft as a sponge ; on 
cutting into it about a tcajtpoonful of purulent matter encaped from the 
veins, and a small additional quantity was forced out of them by prewnire ; 
Mmall coagida of blood and lyruph plugged up the surruunding veins, and 
the spermatic and other alKJominal vt>ins presented no morbid appearance, 
and the uterine ajipeiulagas were healthy. 

On opeuiug the L^psular ligam»ut of the knee-joint, where a fluctuation 
was perceived, about six ounces of tliin |>uruU>nt fluid eaoaped, and the 
cartilages of the joint were found sofbenod and considerably eroded. Tliere 
was no appearance, however, of inflammation external to the capsular ligft- 
meiit, and the femoral vein M^aa healthy. The right wrist was swollen, 
but the structure of the joint was not affected ; the ceUular membraiw 
around it was unusually vascular aud infiltrated with serum. 

Here again we have a caae, aad no lUfficuUy would be found 
in quoting a series of such, where, aft*'r parturition, there is 
left behind u piece uf plarenta, whose putrefuction is followed 
by a low fomi of inflammation and suppuration in the ut«ru&, 
In the pecnlinr eondition of the part at the time the pus very 
readily piitrellea, the veins inflame and (•xhale a simihir matter, 
and nil the »ym])tumii of pnnilont infection, pueq>oral fever or 
puerperal rluMiraatiam are produced. 

By a enrions analc^y such disease i» peculiarly liable to 



CitAP. fV. 



GONOHKUiEAl,. 



101 



fiiJlow opcmtiuns uliont the male periumuni, urotlira, and pros- 
fate. It foUowr* tho opemtion for stone, rutting Btrii'liirca 
from the j>erina?um, and eveu sometimos the violent and incau- 
tuMH iutroductiou of a Imugie. It is evident that tlm largti 
Tona which gtirround tho common cement of the nrcthra and 
the prostate gland, also those which surround the uterus, are 
very liable to this furm of iuflamiuatioiu either on a<wount of 
llie dejilii at which they lie and thf action of nrine on h>chia or 
piu, or the tortuous arid sinuous formation of the veins tliem- 
If then suppmTition in this portio]! uf the hody be no 
to produce purulent iniection, and more especially tlia 
artictilAr form of that disease, can it be wondered at tluit suppura- 
tion of the male urethra is occaiiionaUy accompanied or followed 
b)' piiius and swellings of the jointji, which have been, ami often 
are still, mistaken for rheumatism ? Indeed this disease goes by 
the oauie of gouorrhceal rheumatism, while it is in reality a slower 
form than ordinary of purulent infection produced by inflam- 
mation of the |in)static veins. I have no coses of dissection to 
prove this pwition ; persons do not die under gonoirhceal rheu- 
matism ; but all the cases I have seen or read of go far to show 
the true origin of the disease ; their course is not rheumatic ; 
indued the simultaneous afl'ection of many joints is the only 
iymptom common to this malady and rheumatic fever. 

For one case of this dtsscripticju I must refer boi^ik to p. 31. 

Cam XXV- — <a'orga Uooley, aged 25, came to me at the Charing- 
Crnos Hospital Much 5th, 18fi6, fur a gonorrhcca. He had a good deal 
of inflammatiou, tbe orifice of the urethra lookiug very red. lie had 
Ditnie of potash, nitric wlher, aud byoacyaiaus ; in a week tho inflitiuwa- 
Vit; symptoms were so fiu checked that I ordered Llm ou injection of 
nltp'hattf of alum, two graina to tho ounoe. He ^vent on -veiy well ; thu 
diMhuge had ntarly ceased. 

S&th Haroh, — Complains of pain in the knee, which ia awelled. Two 
^7* tga, he iuforms mu, he bad a very bod beaduchu and could not work, 
bil Uid down ou bia bed ; shivered end felt chilly, aiid be hiix been very 
lowind dt^preawd ; has do ap)>etite; is restless and has bad dreams wbeu 
^ "leepa ; tongiie brown and dry ; pulse quick, suiall, and low ; bowels 
^OBfitud. He wu ordered a done of castor oil, and the same Boline 
»»«Uire u before. 

9I«t — Much tbe same, except that the ot^cr knuo ia now swelled ; both 
J^oW are very painftil : they are not hot — are white; aouie fluid in tho 
Jovial cavity, but moat of the Bwolliog is due to oedema of tho periarti- 



102 



PYAUTUKOSIS. 



Cq«p. IV. 



Ordered poultioee to the kD«ea; to keep in bed ; to (*ke the folloviug 
tbree times a day :— 

9t QuUuB dusulpb. 
Aoidt Sulph. dil. .. 
Spt. -fflthoria chlor. 
TVtt. Auroutii 
Aqum 3i' ^' 

April -lih.— FecU loaa depressed and has less pain iu the jaiota ; to take 
four oimctM of gi» in the day and one grain npiuin at night. 

7th. — His koeos are both better, but the right wrist ia now swollen ; ho 
com|i1aiim of a heailaclm aiul KidiUnesa^ diia, apitarvutly, to the (juiaine ; 
the tongue is atil] brown ; the pulse is 90, small, aud conipnawiblo. The 
following ia orderud to be taken every four hwunt : — 

Uiat. Ammonite sesquicarb. effervcae. Siae. 

Hill. — Tlio hwclling of the kuee« luiich leas ; the right kriec, that last 
aSeotetd, has etiiefly dimiiiitthed ; thu wrist the aarae ; iongae rather 
cleaner. 

Itith,— Ho ia altogether better; thu pulse is stroegur; but he oow 
complains of paiu iu the left uikle. 

T2nA ^Ho has oomo into the hospital. 

I wofl unable to follow the miuutiee of this caae further : he ultimately 
got well, with a oortAin araouut of stifihasa in the left knee, which had 
njuiained luotd ubtitinntoly affocted; the same tonic and stimiilaat form 
of treatment being continued. 



i-. V. 



«TUUMUUS SYNOVITIS. 



103 



OHAPTEU V. 
t*T8UMou« Synovitis, 



PATHOHHiY. 

X&TiBE is mitl to abhor a Tacuiim ; but her abhorri'iico for a 

durp l^oiimiary Hue in more violent ; thus, thuu^'h in aoolujry, 

Wuny, or auy oilier natiirul wiencc, the iypical examplcfl 

(rf fiut-H may be strongly markcil, the legs choice iuBtnuee« loee 

tlk'if distinctive clearueus, till itt laat, iii the luwest sjjeeimeiis, 

tlir deninrcutiuDS become more and more ohhterated, ho that 

liie .suvant hardly knows whether the namelegs thing he is 

examining ijelong to his own subject or to his neighbour's. 

Bius it hi with differeut forma of diiiicuse : an inflammation of any 

part may be evidently simple, or evidently gtrnnious ; or what 

is (|uit6 as common, it may lie ou the vergetn of both. We have 

already lieeu that simple chrouie synovitis is a slower fonu of 

the acute; we will now follow out the history of the strumona 

furm, pointing out those signs whicE most powerfully mark its 

cooslitutiouHl origin. 

A pationt scarcely, if ever, dies juM as a chronic intlummation 
is beginning iu an important joint, 60 that wo very rarely get 
tlie oppoitimity of examining the synovial membrane, under the 
first attacks of such a malady ; bnt octtnsionully it happens, that 
» limb must be amputated for diseatied ankle, or wrist, and we 
fujiy then find among the tarsal or carjml jointy, one or more 
'<iboutdug mider early stages of disease ; and again, by compar- 
>ug symptoms with what wo know of the later stjiges, it is not 
<liffi'Tdt to obtain a reliable hiatory of the comi^luint from begin- 
ning to end. 

A rlironic synovitis may be an oft-recurring sequel of a pre- 
vious acut<? attacJc, or it may commence at once as a chronic 
•ii^lanimation. The cases in their pathological anatomy difl'er 
iittle ; but one has rather the start of the otiicr, as it commences 
*" a part already thickened and weiikened by disi*ase ; yet, ou 



104 



STKIJM0U8 SYNOVlTia 



ClUP. V. 



the other liaiul, any inflammation which commences without 
adequate local cause, in a chronic form, in some deep part of the 
body huvinj^ no commiuucation with the extorior, is alwnys of a 
constitutional clianictcr, and is tmn* tbureforc to be more difficult 
to deal with, more deeply-rooted than an inflammation owing 
its origin to some mere fortuitous circumstance. 

At first the very same processes, which take place in an acute 
inflammation, are found also to go on in the chronic, but mach 
more slowly, viz. hypercemia of the synovial membrane, and a 
secretion into the joint, of a fluid, wliich bttcomcs more or less 
fibrinous; then arise grannlations from the synovial membrane, 
thickening of the subsyuovial tissue, and inflammation, &c,, of 
the airtiliigea. 

When we hare au opportunity of examioiug a joint, which bos 
for some time been uflfected with Btrumous synovitis, we liud^ 
and are principally struck with, a [tfjculiar thickening of the 
synovial mcmbmue. The canity of the joint shall be much 
encroached upon, shall have almost disappeared, the synovial 
membrane Ix^iug tliickencd, both internally and externally, by 
a gelatinous, soft, pulpy material, of a light brown or rose colour, 
which, in the lowest forms of the disease, has a greenish look in 
the sliadows, and where the light comes through its tranalucent 
substance. 'I'he amount of this growth is not always the same: 
sometimes it is not more than half an inch in thickness, and the 
joint cavity, still large, is full of badly-concocted pus ; in such 
cases a ditfcrent, a piuTilent form of inflammation has snccec-ded 
to the action which cau:^ed the thickening, 1 have had mituy 
opportunities of examining typical eases of tliis strumous disease, 
and will n^lato one of its mu^t striking instances, that have 
fulliMi under my notice. 

Cahe XXVI. — Phoebe Hope, aged 8, waa admitted, uuder Mr. Haiicodc'li 
cure, into the Chart rig-Crutui IloH|iital 32iiil April, 1856, with a farwlTaiicod 
M^rumous iltKea^e of the kuee. Owing to the Miat^j oFthu patient's htjolth 
aud other c&usw, the Umb was oaipatated vn |he 3rd May. 

3rd May.— I cxauiiiied the limb. On disttec-ting up the patella and 
opening tlie joint no cavity cmild bo seen, except two soiall apaoee^ whose 
position and Hize will be dencribed i mined iati>ly. The whole space between 
the akin and these cantiea appeared convei-ted into a light browu jelly, 
intersected hero and there by thin, white, fibrous, glistening bands, 
marked by small wary vesseb, and spotted by specks of eftrtvassted 
blood, of a hue suiacuhat durkor than thai ut ttie veins. The intent 



Ciur. 7. 



GELATINOUS THICKENING. 



105 



timUar mrtilages soald not be found : the exterua.1 ligamentfl of the joint 
Ktia ouly vi.iible as scattered white librillfa separated from each other by 
the gt'UtiuouB tiaauo ; the crucial ItgamuutA urere in a similar coadition. 
On each aide of these latter structures, and of the masa of jellj which 
coolOMd lh«m, was a piriform cavity ; the I&r^r part, which would admit 
tlie finger, being situated in front, some distance from the patella, the 
siDiIler end ntoning backward and a littlo outward ; they wcro u ahape 
files the lateral veutriclea of tlie brain without the descending oomua ; 
tbey contained pus, and the smaller end communicated with abscesses, 
uQdar the corresponding heads of the gastrocnemius muscle. There 
^ipeanul to be no com muni cation between the cavities, nor between the 
■hMxese*. The gelatiuouH matter was in placoa immediately under the 
tkm, and was generally about two inches thick ; not so much at the back, 
ak)R at the aide of the patella. Tliere was no trace of articular cartilage 
oa any uf the joiat-surfaoea ; but the jelly-like material appeared to ariaa 
ttjoilly from the synovial membrane and from the otherwiHe bare cancoUi 
of the femur, tibia, and patella. A section across the ligamentum patellin 
pTBWDtcd the out ends of the fibres separated from each other by the 
aame gelatinous tissue ; they seemed swollen and sodden. Examined by 
the mieroMoo]>e, this substance was found to consist of a number of 
DtKleoted oella, round, ovaL and fusiform ; of bare- nuclei, and of granules. 
Most of the fusiform cells were arranged in lines, throe or four coUa 
Inroad ; the cells lying end to end, or, rather, with their thin ends juat 
OTerU}>piDg the similar extremities of their neighhount to the right and 
Mt. These lines of cells crossed and rccrossttd each cither, forming 
tnegalar spaces, iu which the round cells and other constituents of the 
tinoa were stored. The white bauds presented simply a fibrous ap[)ear- 
■Dcs, and were much tougher than any other part of the tissue.* 

H was explained In Chapter II., timt besides mere liquid aud 
filisiiioaji pflii&ion into the joint, thore takes jdace au actiou even 
in icote synovitis, which cuiil'l only bo compared to that of 
B»nuUtion- The jelly-like material just described, results from 
"•e earn** process ; but, in an acute and healthy iiillaminaliou, 
"K tissue oi^nizes itself more fully, and is developed into a 
^nrm or imi»erfect areolar tissue, which, if the person entirely 
'^Wver, will, after some months, become more pnrfi'ct, until it 
""•ild not be distinguishable from hc-iJthy, but thick, tissue. In 
■ tyiiical case of stnimous joint disease, the newly-formed 
"latter reraaiua always in the state of granulation ; it doe* not 
•^tuict; it does not fonn fibres ; it never advances beyond the 
^'*l fonn of urude ccU -structure, such as hits jn.st been described, 
"*t«tcii tlieae two conditions innumerable gradations may bo 

*W NO kcooant of a mioroecopical I Dr. Hundtiuld Jones in * Putliologiual 
^"""■Aho of a itoiibu vnnditiuii, Ace | Transaction^' vol. iv. 



lUtf 



iiTRL MuUS SYNOVITIS. 



GKat. V. 



found Freoeli authors, Vclpcao,* UonDet,t Kichet,* mod 
others, describe this stnimoiw disease aa "tunttur foM^uttue ;" 
the Uflt author divides s^rnovial iDflammatioDH mto Pseudomem- 
brooense^ and FongiKOses. Sir B. Brodit^ § tenncd tikis l&tter 
** a morbid change of the synoviftl membrane ;" the only real 
difference in in tlie degree of development, which the granula- 
tion undergoes, and an inflammutiou, marked by more or less 
foil development of the intlammotory prodncta, may take on 
tlic fuuguua form ; or a disease of this latter sort may assume ■ 
pow'(»r of development, and become •* psendomi'mbmntiiise-** 
Thus, a scrofulous ulcer, or a large wound, may, after going on 
well fur some time, throw out large flabby granulatioiu, which 
wiU not lianlou, nor form a sound tissue, but wliicii, after 
another interval, may, mor*) or less suddenly, oontmct into small 
florid granulatione, encceeded by development of tiasiie and 
cicatrizatiuu. It will be well to remark, that these changes 
follow vanntioiis iu tlte health of the puticnt. Thus, as said 
above, innumerable gradations will occur in joint diseases, not 
only in different cases, moro or les^ decidedly ^tnmious, but also 
in the same case, as the health of the patient may vary. 

The granulations arise, both trom the free sur£Ace of the 
synovial mcmbriiuo, and fn^m the subsynovial and periarticular 
tissues. Those which arise from the free siu-face commence by 
a slight increase in the villous roughening of the membrane^ 
rendering it like the mucous coat of the small intestines, or like 
the palpebral conjunctiva, when it is slightly granulur.|j These 
villous or gruuular jirocesses iucroasu in size, and iu this form of 
{lisease assume a conical shape, with broad bases, and but slight 
projection, tho bases unite, as do the granulations of an ulcer, 
and constant growth ttiickens tlie mombrano in the couceutriti 
dirotlion. Like the hyperaemia, this tissue is most developed, 
where the menibranu is loosrst; and as iu all jointa very loose 
folds overhang the cartilages, it is here that the greatest growth 
takes place, and overlaps tiioso stmcturee ; may oven creep over 
them, and unite across tliem, covering them with a reticulatiou 
of new tissue. At first, and until the cartilages become diseased, 

* Volpeau, Bictiorinairp, en XXX I M^nobx^s do I'AoAddmie, lame xrfi. 
v^iId. Art, 'Articiiliitioiu.' $ Pitteiuce of Joints. 

t ' MiiUdu'tt ilcH ArUcbiiiUoiu.' || TliU IttUt-r c'vui{Mrii*oa U iuiult.< bjr 

X Hli'lul 'Sur U^'rainounBtuucliM.* ' M. Uielwt, Op. oit 



Ciju-.r. 



'nOKUE VEtiETATKtN. 



107 



» 



theft uew formatioua may be piishe<l away with the feather of a 
{WD, or the tip of the finger, and beneath them the cartilagini>iia 
sur&oes are foimd in paii^ quit*; heaithy* in parU o|in([ii<> Hnd 
jAead white, iu parts aclimily grooved. The new list^ue lias been 
nip^ioeed to absorb the cartilage;* we shall (M'c iu tlie |>ro|»er 
place in what the action really exists. 

The eteeuoe of tliis growth is a cliange in the mode of de- 
relt^KDent of the epitiiflial cells. Under tJie irritation of the 
disease these bodies fall off, and there are developed instead, 
from the basement membrane cells, which have not, like the 
•fithelial, lost their geucrutive |)Ower, and which, thi'tefore, 
iroustantly produce new cytoblusts. By tikis moans many of the 
rillotis-Iike prt^toessos and their secondar}' sacculi bcKiome matted 
tflgether, wliile some grow and shuit out a<-ross the joint ; at 
irrt, iu a reticulated form, supported od the cartilage ; subso- 
qoeotly,, bs tbey iucroaso iu breadth, they lunte liiteruUy, Hud 
become layem of lal^ niembntue. Thiki, by the eonbtant t'unua- 
tioD of new cell-layers, internal to ihom? previously dcvelojxid, 
the cavity of the joint is more and more diminished. Under 
ocLioD the basement membrane loses its peculiarity, of 
uo vessel to [diss, and minute tortuous capillaries are 
prolonged into the older layers of the tissue. The newer parts 
have leas colour, are les» firm tlum the older, and contain only 
runnd and oval (no fusiform) coJls, nuclei and granules. Many 
of Uiesc bodies are shed into the joint as pus-cells, where, con- 
tioioing to multiply, they render the lluid more iind more pari* 
Uma. 

'rhia species of actiou, m it takes place upon serous mem- 
litue^ Is despril>ed by liokitaiif^ky, under tho name of Tissue- 
Vfigilation {GeJCeb>tvegetation). Sulijoiued is hi8 account of the 

(■ODMa 

"A accond portion of the products of the inflamed tissues 
i.*Wa membranes), the *' Oewebsvegetatiou " {Tv^ue-vegeta- 
^\ most be distinguished from exsudatioo, and arises tu 
'waeijueooe of eSiisiou into the subserous tisHue. It coDsists 
** A growth from the basement membrane of masses of cells, 
u & vf^>tation of round, oval, and fusiform eells which 
**'*jI»6 themselves iutct a hyaline masci, and become areolar 
AiliKi Kry 0(1 ( 'U'tirtitioo of C^l^^lllKt■.■ McL Chir. Truiui., vol. xix. 




108 



STBCMOUS SYNOVITIS. 



Ctiup. V. 



fibriUee. Examination of this matcnal on serous membranes 
offers the mo6t and richest explanations on the origin and 
dsTelopment of Uiis TegetatJoo. On the serona membranes 
&ri»? hiyer^ of round, oval, and fiuuform cells of ^ nuUemetnw 
in diameter, with nuclei of ^q millcmetrc. They grow ont of 
the membrane in the form of a delicate villous covering, papilla- 
like granulationH. or of branching; and anastomosing folds, and 
give to the eurface its well-known dnll volvotty oppoaraneew 
At the same time the serous membrane loees its fibrous texture, 
and assumes a hyaline gelatinous cunsijitenoe. The vegetation 
forms itself into a simple or an intemipted lamella, or into a 
netWOTk. and these again give origin to new masses of celK of 
fringes, papillae or baiiils. \u this way are piU-<l up simple or 
looped lamellfE or network ; thes*^ lost int<.^nningle freely, 
whereby a change into tibrous connective tissue wlvanees from 
the older to the newer strata. Tlie nutriment for this continu- 
ous vegetation is derived chiefly from the vessels advancing into 
it from the serous membrane ; bnt some portion of it may be 
borrowed from the exsudation contained iu the cavity within the 
growing formation. The growth, when the blastema (histo- 
genetic matciial) dissolves, is reduced into a serous fluid." — 
'Lehrbuch der Pathologischeii Anatomie,' Bond I., s. 13(5. 

Besides this vegetation on the surface of the synovial mem- 
brane, there t^kes place in the subsynoriul areolar tissue an 
action, whieb is in reality the same occurring under somewhat 
different circunistunccs. Tliis similar action on the subsynovial 
textures is a vegetaDon of cells in the meslies of the areolar 
tissue ; it takes place in every mesh around tlte 8\'novia] mem- 
brane, beginning at first in the parts close to the ba.«ement-*!truc- 
ture, and sjireuding gradually outwards, centrifogally ; it tills the 
areolffi with, and at last converts the tissue into, a translucent 
and gelatinous mass. The growth tabes its origin from the 
areolar-cells (tfee Chap. I.), and is similar to the process whereby 
loss of substance, oj^en wounds, fractures of bones, divided 
tendons, &c., are repaired — similar therefore to granulation, 
which can only take place by the agency of connective tissue, 
and in the places where it abounds. 

Mr. Paget has given an account of the glaxing of the surface 
(if upon wouudB. "Blood gradually ireasing to flow from the 



C^AP. V. 



PRUT ARTICULAR ORANIH.ATION. 



100 



BOrfaco of hucIi a wound, one may still see some blood-tinged, 
serous-look iiig fluid •x>ziiig from it alovrly ; as this bccomeH paler, 
some of it rollects like a whitish film or glazing on tho surface ; 
and this, if it be examined >vith tlie microscope, will be found 
to contain an abuudanco of the white corpuscloB of the blood 
imbedded apparently in a fibrinous film. Tlie collection of 
tlicsc corpuscles on tho surface of tlic wound, rspecially on 
wounded muscles and fascia;, appears to depend only on their 
pecidiur adhesiveness. One seeu them adhering much more 
firmly than ever the red corpuscles do to the walls of the minnto 
blood-vessels, and to the glass on wtiinh they are examined ; and 
80 on cut surfaces, while tlie other constituents of the blood fluw 
away, the white corpuscles, and probably also some of the 
fibrinc, quickly congulaling, adlierc." • 

These ceUs> which are supjxised by Mr. Paget to be white 
blood corpuscles, are. I believe, formed by and from the areolar 
cells — bodies which we know to possess nuclei, aud to have a 
generative power. If we have an opportunity, which frequently 
occiu^s in a hospital, of examining a wound inflict*Ml a few days 

, hefoit) death wo shall find tlie areolar cells in the neighbour- 
enlarged, filled with granules, aud if acetic acid be added 
their nuclei will be found evident aud large. This is not tlie 
pUice to give a full account of this pnwcss, as it occurs in all 
the connective tissues throughout the body. I must refer the 
reader to my paper in Beale's Archives of Medicine, 'On 
GranuUtion,' &c. ; but it may bo said here, that these areolar 
cells enlarge, till themselves with nuclei, aud granules which 
through the cell membrane, and escape into tho areolar 

'meshes, and there go on moltiplying until each mesh is filled 
by tliem and their progeny. This view gains great support 
ftom the actions which take place in bone cells under infiam- 
matory diseiise, actions which can be followed with much more 
rf^adiucKs than in the areolar tissue ; the cell-changes in ulcera- 
tion of cartilage also support this principle, since the three 

Ltissues and species of cell all belong to the same class — to the 
onnective- tissues (Donders* * Biudegewebe *). 
As this process goes on, the basement membrane disappears, 
tile fibrous structure of the areolar tissue itaelf changes, aud 

* Pagot'A 'Surgicul Putholo^y,' vol. L, p. 2DI. 



no 



STRLMorS SfSOVITlS. 



Ohak V. 



all the textnres involred become suaply a jelly-like maat. Tho 
ceUs» in which the growth takes or^n, lose their existence ; ae 
do all snch bfxlies when they prodore a plentiful progeny, and 
the flbruiis (iutercellnlar) piirti* ttf iho tiiwne are eaten wp. and 
abaorbcd into this fnt}x?mljundunt growth, as is the law in all 
long continaed inflammations of tlie connective tissnea. The 
more recent parts of this growth, that Is both the inner and 
ontrr layer, consist entirely of round and oval cells, and bare 
nnclei. The older portions poR^CAS also a numhor of faMfiirm 
Pells, which arrange themselves in linos intersecting each 
other. BO as to form a network. This is a corameneement to 
the regeneration of areolar tissue; the lines of fusiform csella 
may bo ser^n in diflen?nt Btaf^os ; in some ihosff liodie* vary btit 
slightly from the oval form, having still a considerable circum- 
ference in proportion to their length ; in others the cells lM>coroG 
longer at the expense of their breadth, acquire taper ends, and 
at last become mere cell-fibres. If the process be tolerably 
healthy, tlio formative action goes on until a real, but clumsy, 
areolar tissue is formed comparable to the cicatrix of a wound ; 
but if the m:tiou be modified by Btnima, or indeed by any 
advanced debility, the granulation does not advance beyond its 
crude gelatinous condition. Between these two many grada- 
tions exwt, creating differences in the more or less marked 
scrofulous !y[»f; nf the jwrticular eaae. 

While this inflammatory action on the synovial membrane is 
proceeding tlie cartilages l>ecorae diseased. The subject of 
ulceration in tlicse structures has been already in jMirt discussed 
(Chap. II.) ; and it was aflirmed that the changes therein are, 
like the changes in the other structures of the joint, due to 
intlammatiou — it is true that tho cartilaginous iuflahimation 
is a secondftiy action ; bnt it is not true that its ulceration 
is due simply to passive erosion of the cartilage, as the growth 
of certain mosses and lichen may eat away the stone from 
which they sprout. Tho course of the morbid action is as 
follows : — 

As granulations form on the intomal surface of the synovial 
membrane, they, lying thickly on tlie spiovial fringes, overlap 
the cartilage more or less. About this time appear in that stjuc- 
lure some slightly elevated spots, which Iiave lost their tirilliant 



CHir. X. 



mXTSRATION OP CARTILAGES. 



in 



poluh and tnuisluoent appearance, ami liuvn Iwoome of u dcail, 
dirty-yellow isJi hue. These specks may be in any part of the car» 
til^e, under the thickened fold of Rvnovial menibrane, or At its 
wlgy, or in the centre of the juiut-siirfuee, wliere no false mem- 
httne 08 yot oiista. If n Sfjctiuu l>e made perpend icnhirly 
througli one of thc«c spots, it will be found to be conical in 
shifWi, the Uwe being at the free surfaee, tho iipex deep in the 
•tnw'lure of the cartilugo. The depth, at whieh tht^ ap<?x may 
la. increases with the age of the disease ; sometimes there is 
perceptible breadth of apiKirt- ntly healthy cartilage Ih?- 
I H and the attnolied snrfnco ; later, the cone is truncated 
hf the bone* 

If tJie swtion be exAmined by the microsco[H*, it will be seen 

tiutf at the diseased part, the cjirtihigp eorpusdes liuve become 

h»^r, and the cells contained in them hare also greatly 

^nneaaed both in size and number, each one beinp provided with 

anunbcr of nuclei, and haWujj; become more or less granular; 

time of them aleo contain oil-globules. 

This dibiurbance of the nsnal condition commences bolow the 
part which looks to the naked 
ew diseased; but l)ecome8 
more and more marked towards 
Ihe (rea edge of tlie section, 
fflwre many of the swollen cor- 

pnaclee lea© their distinctness ^ ,-^ / 

of outline, and even coalesce. 
IV indistinctueaB of outline ih 
owing^ according to KokitAun- 

[aoA Weber, to the^ gela- 
Du of tlie hyaline sul>- 
■^m, but tliis assertion re- 
^•iiv« proof: it in wrtain, how- 
*^, that during and in con- 
"cqueoce of tliis alteration of 
** celK the hyaline substance 
t*«omp« oiiscurely granular, striated, and fibrous ; it also assumes 
' yeflowish colour. 

Tk' free smrfaoe of these unhealthy sjmt*. examined by the 
wioToeoope, prej^eut^ a n>ngh uneven aspect, full of irregular 



A 



SmUom tf SiramoUA Clnr of CwtlUKc nugnlfnt 



112 



8TKUM0US SYNOVmS. 



CUAP. V. 



depresaious and equally irregular elevations. The depressuMifl 
are formed by the rupture of Bwolleu corpuscles, and the 
elevations, whicii are fibrous or velvetty, by the projection of 
the altered hyaline substance, h>cattored over this eurface are 
many celK witli severul nuclei, and more or Icrb granular, some 
of which are undergoing further changes, becoming fusiform or 
even stellate. 

These Hj»uts may occur in any part of the cartilage, either at 
the edge overlapped by the false tissue or in the middle of the 
joint, where two surfaces of cartilage are in actual contact, no 
false tissue intervening, or in any |>art of tlic cncnistiug material 
which granulation has not yet reached ; again under this tissue 
the cartilage uniy remain for the meet part healthy, and in 
these places Mm whole zone of falsB tissue, with itrf ramifications 
and its plexus of vessels, con be lifted entirely from the carti- 
li^e, wherf^ver that structure ha** remained sound : but, wherever 
it has undergone the alterations alretuly described, there occurs 
a peeuliar adhesion between the two tissues in a manner now 
to bo exjilaitied. As the ulceration continiies it approaches 
more and more the attached surface, the hyaline sub-jtuuce be- 
comes JibrouB over a greater area and in greater depth, the coi^ 
pnscles increase id size and bur^t, discharging the cells into the 
surrounding structure, in which mauy apjmreutly empty rifts 
and chasms are perceptible. The direction of these cracks 
appears peculiarly arbitrary ; some of them run with the fibres^ 
others directly, otiiers obliquely, across them ; many of thorn 
terminate at either end more or less abruptly; but some of 
them, and this of course depends upon a fortunate position of 
the section, are seen to diverge from a centre larger than any 
one of the branches, which are themselves larger near the centre 
than towards tlieir termination ; the whole sbajio is Uko that c^ 
a crack or star in a {Mine of glass, produced by striking it with 
any small objtjctv On examining this st<>] late rift more chjeely, 
it wUl be seen to be granular throngliont ; on appl}'ing dilute 
acetic acid the granules fade, and in the centre of tlie star one 
or more nuclei will become evident* In fact, this appareotlv 
empty space is not empty at all, nor is it a series of cracks in 
the hyaline substance, whose directions are accidontaL It is a 
stelhkto cell developed from one of the c^irtilago cells, that fawl 



Our.V. 



TRAXSFOKMATION OF CARTILAGE. 



113 



'Uci^V^. 






iieea leatttired from a rupturetl corpuBclp, and which is in form 

aod size exaoily like one of the ceWa so charucton'dtic uf nreulur 

tianiR. In fa*-t, tho cartilapt? has &!owly uudergouo a tnmuformtt- 

tioii into a form of granulation, or into 

nascent areolar ti&sue, and at the same 

lime there has occurred, between the 

«nirtiirt' thus formed and tho similar 

iiiitcrial ^jrowing^ from tho synovial 

Biembrane, an adhesion or inter»eav- 

ing which bt.'ciimt'S more and muro inti- 

■iUl* iiuti] at la^ it is mere contiunity. 

It ill this condition \s liich led Mr. ^Vnton 

Key* to ascribe the iilo^'ration of car- 
tilage to the motion of a rodent tissue 

powing frota tho inner surface of the 
membraae. which gradually 
the caitilage, supptwod in this 

instance to be perfectly ])assiTe.t A 

olmrer knowle*lge, however, and a ^ ,j "J 

dfiAcr .study of the phouomena lead 

rtrnth that the cartilage is ulcerated by an action or 
actions of its own, and thua we come back as nearly aa possible 

»ijif II Brodie's opinion. This celebrated surgeon so clearly 
that this was the case, that m order to explain its pos- 
nbility he bad to insist on the presence of vessels, because 
Don-Tascnlar parts were supposed incapable of intlammntion. 
Aa, however, it can now be certainly aflimied that any jiart 
which is capable of uatriti<m is also ca^nble of inllaininatiuii, 
it can. I snbuiit, be no longer denied that cartilage is liable to 



Sv 



M ' ' ■' ■ Tniris.. vol. six. 

i 'iIiiT bow iH;riiii»cioiijJy 

luiVt- clmi^ lo lln! vifW 

Kt cumlnKi; ts a mori--ly T«t«4iv(t Tiiato- 

iL in fl|iitu uf Mr. (JtMxUtr'a uul 

lir, BwUith'b iiiV(^tii:iitiiii] iiili* their 

kiiir<^. Aa Into w ^H^^ m. itii^ht-t, 

■ IJJi'pital ]1 -- :h, |)iiI>)iH)i(i) a 

■f'li W(, ; ill il„ M«- 

nU'l A'^i' ij 1 .rioli.. inwliich 

"tlut ttu* iiiiiy dirctt Diniiiier of 

tlml ntrtilni^w art* fntnoiiHtilc 

a.uiiimtitin WfniUI Im- !■ > *ii'liioii«tnit'- 

iU 111 tin- MUbHUnr-i' itM.-)r." It in 

U) nifuU' ait itriouiufil 



which W'urs its riilliicy so op(:riIy, TliP 
Ony'» 8rh<.M>] uf Fatliuloiy t'ollnw. li-nw- 
cu:r. M. Hielirl in lliiii iiistanci*. uud 
eTi^ii in itA liuft prMlni>tion i^rr; the 
MiiH! iirf^timmt furthnr. Mr. Br>'aat 
oiiyM '* they " >' tin- cHrtiluK*-''" " t^*}' "U- 
iWrgii hifperiraphg otitl atnfptiy. lliinK 
llitT lutU-r in its bimplir u'luto. IiiJIiuqci 
and nlct^niU' U» y ciuitiol. tia Ihi' prf- 
ecncL'' of vtiMN'U ill the tisHQH in gem:* 
niliy (■uiiflidt^ri'i) iitML'iuairj for sui^h jini- 
(•tM«f>L*)f." Thut if, llii'V i:iiiy undtrgo ull 
tilt! nilitiiiii ttf iiillunmmtiuli, but tliey 
t'ftunot influinc. 



I 



114 



STRUMOUS SYN'OVITIS. 



Chap. V. 



bo inflamed, anrl consoqaently ulcerated, whenercr an iuflaiiii 
Xiiry discaae attacka tlie other stnictures of the joint.* 

It luis been said that during tins process many eartilaf»e p-ot^ 
puscles buret on or mair the surfaee, discharging tlie cells amuuf; 
the fibres of the altered hyaline tnihstauoe, and into the joint 
cavity. Wc liavo in the present chapter traced what becomes 
of them in the former situation. In Chapter IL, wo found that 
the cella which are set free into tlio joint cavity continue to 
multiply tltere as they did in tlieir natural situation, and contH' 
buto to the formation of pus. 

The cartilaginous intliunmation is accompanied by a hyi»er- 
icmia of the vessels beneath the articular himclhi, which any 
one may determine for himself who will take the trouble to 
split several bonei*. over whuse extremities the cnrtila^^s are 
ulcerating. Thus although it is certain tlmt wliat is colled not- 
eularity of a tiasiie is not necessary to confer on it a power of 
becoming inflamed, it is equally certain, tlmt when a tiiwne 
makes increjisnd nutritive demantU, incre^tsed supply will be 
brought to it. Uence the vessels supplying an iudamed part 
will become hyix'ncmic, wlietbcr they be situated actually in 
the [lart or at some distance from it 

If the whole cartilage, as well as the sjTiovial membrane, 
were thus changed into granulation tissue, and they became 
united together as just described, the joint would be obtiterateii 
and if the new material shonhl then contract into a tough 
fibrous substance, the disease would terminate in what is ctdlud 
false-anchylosis. But it very rarely, if ever, liappeus, that the 
cartilage over tlie whole suiface is thus iinifomily altered ; on 
the contrary, it is usually affectetl very deeply in certain [tarts, 
before it begins to be diseased in others; hence the iuilumma- 
tion spreads at these points more rapidly to the bono, whicli in 
its turn beeomes intlatni':(L Inflammation of bone is the same 
action, whether it begin primarily in tlmt tissue or spread to it 
from another structure, and in the chapter ou osteitis these 
actions will he fully handled. It must, therefore, suffice to say 
here, tlmt a^ bone is a connective tissue, having cells ami inter- 
cellular Kubstauco, and tis it im a tissue which once was cartilage, 

* 6t»e pai>cre ot naioe 'Oq tho Arti- I Quarterly. Oct ISA^, nii<1 in Kdiiiburifh 
mlar Ciuttliigca ' iu the TIrit. and Fur. | Monthly Jdintuil. Peh. 1860. 



Ciuf.V. 



nONE BRCOMF..S AFFECTED. 



115 



it8iu'iioQ9 wcmld be presumtxl, on a prwri reasoning alone, to bo 
awilar to those of like etrnctnres. Indeed wc fiml, in cnries 
l«ppiiration of this material, thai the colls in the lacMinm 
' ftod generate at the expense of the intercellular parta. By 
litis prueeas the cancellar plat^^, wliich supjiort the articular 
liUetla, aftfir a certain time give way. This, of course, occurs 
fooaest at those parts which have first become inflamed, nameiy, 
itlhe spots, whence the curtilage has been ulcerated. There- 
fi>re, very eoou after guch ulceration has reached the bone sur^ 
fiioe. the lamella powders away in little prisms. 

But the brine intlaminatton, having once been sot up, spreads 
tnlenUly so as to be going on beneath portions of cartilage, wliiVh 
luTo not beeu eniil*Ki on their free suriace. In such sjx)ts, 
also, tlie articular luniellu, after a time, gives way^ i^ud the car- 
ItbigG becomes detiichcd not from, hut with, that »itructuro. 

Ry these actions the cancellous cavities are laid bare to the 
joint, and from their lining membrane, as well us from the bone 
cells themselves, sprout up gi*anulation8, which imite with those 
from the syuOTial membrane, wherever they come in coutoot 
with them. Wherever, on the other hand, the lamella aud car- 
tilage have been detached complete, these two lurm a barrier 
between the new tissues from bone and synovial membrane. In 
tbe examination of joints tliat have long beeu the subject of 
I rtnniwus synovitis, such detached pieces of cftrtilago are fre- 
K qttantly found in a more or less advanced stage of fatty degen- 
^^|imti(m. Till! <leep surface (formerly attached) of these pieces 
^^^ cartilage is rough and gritty, lilce sand-pajH-r, from the 
■ idnaius of the articular lamella, now dissolved by loosening of 
I tlie Ulbolar structure into a series of prisms, one of whose ends 
nnuins adherent to the cartilage. The fatty degeneration (a . 
ponstant accompaniment in connective tissues of iusulficient 

t nutrition) which the cartilage cells of theserfrngmcnts undergo 
*»nieg iJie interceUuhir material to Lecome tibRms; but this 
■> H rory difiercnt librifieation to tlmt described as a result of 
"^tlamraatory disease, and the fibres never commingle with those 
"• the granuUtions from the t^-novial membrane ; tbe dcgcne- 
'^Uti curtilage always n^nmins uiu^ttached. 
^ 'tnviiig nuw followed up these three processes, viz., gronula- 
I *"* of tlic synovial membrnne, alteration of the cartilage into 

I 2 



116 



STRUMOUS SYNOVITIS. 



CH*f. V. 



nascent areolar tit«ue, aud sprouting of grannlntions from the 
boae, w© must continno to trace them iu theii* further develop- 
ment, totli progrctaivo and retrogressive, i'he eondUion to 
which we have brought all tliese |wrts is an follows: — The 
synovial membrane, inclnding much subsynovial tissue^ is over- 
grouD by a mass of granulations, ]>erhftps two or three inches 
thick, the (^artila^:!s and articular lamella have dit^ppearod, 
aud from the cnncelli p^rows out a similar gnuuilalinf^ Ktnieture. 
These two masses of granulation matter, nnitefl at the edjfs, 
enclose a mvity, eoritaiainn? pus of a more or less perfect sort, 
which in all probability fimls exit alon;; one or more sinuses 
traversuip; the tissue. Now this condition is simply that of 
an abscess which is becomiufr filled np. It w cvide-ut that when 
once the joint as a frietiouloss apparatus has Im'cu di'stroywl, 
nature aims at obliterating the now useless or rather injurious 
caTity : she does this by just the same pnwpits, when*by she 
fills up any other cavity, accidental or diseased — by granulatiou 
aud cicatrization. Dnt this false tissue may act in several ways : 
firstly, it may simply cfHitiiiue to grow iu circumference centri- 
fugally mthuut increasing centripctally, more and more of tlie 
periarticular tissues l>i>coraes involved, but the cavity remaining 
open and suppurating ; secondly, it may degi-'uemte iu several 
parts, causing fresh suppurations ill the cavity and abscesses in 
the substauce itself of tho false tissue; thirtlly, it may both 
grow and contract towards tho centre, fill up the cavity, and 
unite the bones. Uf the first of these there is [mthologirally 
nothing further to say ; it is simply u continuation of a pi-ocesa 
already doscriUxL The second set of actions are degenerative. 
The transition from a nxiud granulation cell to a pus cell is 
very small, aud such cliange frequently takes place iu this new 
tissue ; the same ultimate end also is produced by the fatty 
degeneration which large portions of the mass may nnderxo. 
By either process abscesses ar« pnMliifnd* which increase con- 
stantly iu size, destroying more and more of the material wherebv 
ultimate union might otherwise be obtained. It is a gr^at emir 

• It would occupy Vm miicli aimcc to 1 how thv ct-lk fononl oa tiw ww mw 
diow Iif»w A imun iif P..IK liecoming | (aee thiw prtxlncod full nito the ol 
ffttty. (U'liiim-Kci. tiiwi k-iivt* a nivitv I luul beM>mo nni cell*. 
IMurtiaUy filU-ii wild ni]y mntlera. nn/i ' 



na*r. V. 



DKOENERATION OF NEW TISSITE. 



117 



U) lank npon pus as the destructivo roateriul ; it is the result* 

not Ihe cause of tissue-solution ; how otherwise could an ubscess 

gr*limliy oontnict, squeezing out more and more of the fluid 

nutil its walls can come in contact and unite? Tlie rooaon why 

it is necessary to let out pus is that tho walls may oomo together ; 

Inraaloitgas the granulation represents Hurfaco not in contact 

"ith a similar texture many r)f tlie cells which grow from tliat snr- 

fiitswill form into pus cells, whereas they might othurwitwi unite 

with the opposite wall and ftfnn tissue. Hence, after o[>ening 

M fibeceSB we put on a compress to keep the sides of the CAvity 

iatdotact The proportion between the amount of pus and the 

amount of granulation is very variable, in different and even in 

the some case. In very cachectic coses the tissue has nut 

[jower to remain, but the inner cells melt away into pus, and 

thus we have a larger abscess and cavity, and less fungous tissue 

than in Case XXVF. An examination of such a joint is given 

at the end of this Chapter (see Case XXXY). 

Fatty degeu'smtion is not infrequent, and may last long 

before it produce abscess. In examinations of gelatinous tissue 

tkit yet suppurating there may be found many sjwtii where the 

nucroscojH! clearly reveals this retrograde action. Such spots 

H are generally lighter in colour than the rest of the tissue, ore 

^L <niw-coluurcd, and it may be a question whether a diffuse sup- 

^P^pBrution at these places have not already begun ; certainly in 

spots with a light greenish tinge, which I have once or twice 

leen in the substance of the gelatinous tissue, a very large pro- 

- I^ntion of the cells had more the appearance of the pus cell 

H than any such bodies in other parts of the growth — possessed 

n aurenl highly refractive nuclei. 

n It occasionally, though rarely, happens, and then only when 

H the strength of the patleut has been very much reduced, that 
" the whole tissue at once suffers from fatty degeneration. There 

I then occurs a wide-spread unhealthy suppuration, great loosen- 
ing of the joint, and necrosis of the cancellous Iwno structure, 
Oceasionally, in the midst of this new granulation tissue, little 
spots of tubercle (miliary tubercle) will be found, but these 
foftnations are rare. Some misconception generally prevails as 
^ the intlumirt! of tuhi.rcular nmtter u]Km disense. au<l it He*)ms 
^ *>e frequently considered as the cause of the iutlammatiuu. 



118 



STRUMOUS SYNOVITIS. 



OHAr. V. 



awl of the secondary changes. I am by my own obsenratioiis 
conrinced that Virchow is right in looking upon tubfirrlc aA one 
form of cell degcnpriition.* This is, however, hnrflly (lie place to 
enter into tlie miuute pathology of tubercle ; sudiee it to say that 
it is produced in these new tissues from the cells, that it is 
only one form of the alterations they will after a time undergo, 
and tlwt it does not produce the granulatioas, but is formed 
from them. They are therefore not a cans©, but one of tlie jmv 
ducts, of strumous synovitis. The'tubercle is simply one of the 
degencrationH which the new tissue may undergo. 

The third procc&s is tlic mcun.s whert^jy union between the 
bones is protluccd. The mosses of granulation from the osseous, 
synovial and anbsynovial tissues, having intermingled, enclose a 
cavity which contains pus. In the weaker states of system this 
cavity does hot decrease ; it ratlier increases, because many of 
the new cells formed on the inner surface become pus cells ; but 
when a littJu more power is acquired, these bodies remain and 
assist in tho filling up of the space, until tliey grow across the 
cavity and unite with its opposite neighbours ; at the Riiinc time 
and also in consequein^e of increased ]Jower, the whole mass of 
gronidatious undergoing fiulher development becomes more 
fibrous and contracts centripetolly. By the^o meiuis the pus 
is squeezed out of the cavity, which becomes oblitemted, and tho 
bones are now joined together by a solid Uefihy mass wliich, as 
it consolidates, contracts mure and more, after the maimer of all 
cicatrices, anfl draws into closer contact, not only tho bones 
themselves, but the skin over them. This is the reason why 
a joint auchylosal after a stnimnns s^movitis is often smaller 
in circumference than its healthy fellow. 

In course of time, when tbo limb has been kept perftu'tly 
still, the fibrous tissue, which sprouts from the cancellar walls, 
begins to be studded with minute points of phosphate of lime, 
and so become gradually bony. The prf>ces8 radiates along tho 
fibrous growtlis from each boue : in fact, they grow along tho tissue 
until the process at one end comes in enntiu^t with tliat at the 
other. Thns all tlie intersecting net-like fibrous elementx 
are converted into bone ; tho whole forming a meshwork of 
thin oeeeous platc?( enclosing cavities, then^fore a stmcti^ per- 

* *Ot'llulur Pnlholugie,' p. 4ti. 



C«AP.V. 



PAl&E AND TRUE ANCHYLOSIS. 



UU 



iidlf similar to the cancellous portion of bone.^ Indeed the 
tion between the one bone and the other bei'umes 
oHtterat(>d ; ercu whv.a Ibe coustiliJiitcd mass Ih Kplit, no lino nf 
JBOctioQ can be fonnd — llie two uro fused. ^Vbcu the wliule 
libn>ct*Uu]ar mass baa been thus oysilied, the anchylosis is 
rnllod a true one. SometimeH |H)rtiouH of tlie iahc tiat^ue will 
be cuavctled into cartilage previous to 08sitication ; but this in u 
mere arc'idental condition, ia not essential to ita couvenuon into 
bone, and mruly takea [)lace in atxumoua diseaae. 



Symptoms. 

Among these we must include not only the local signs of 

inSmmiiation, but aUo that general condition which would lead 

itt tu proiiounro the diiicaao scrofulous or otherwise. It must 

Iw remembered tliat we Imvc to deal with a state which may be 

(hmly tixed iii, and produced by. a highly depraved lutbit of 

Ifody, or witb ((nr whieh, comtneuciug in some exciting cause, 

jiiits on just siifticic'iit tsIownet« of action and other generic signs 

to warrant its uicluHion imder the head of strumous indomoia- 

lions. In making this distinction at the bed-eide, we are guided 

Hot by local signs and histor>' of the cose alone, but alao by the 

graeial ap{>earance and conformation of the patient. 

The ftrumoug diathe^U baa been the subject of much tliought 

ud care ; many writ<'r?i and lecturers detail certain complexions 

nd other aigns whereby they believe themselves capable 

ol dftMiing this tuiiit, that is to euy, of detecting a tendency 

U» oerl4un forms of malady. Many of these signs are, I believe, 

bllscioiia, and the rest are not diagnostic of the constitution, but 

of Ktnimous disease actually commenced, and then present. 

Fine light hoir and blue eyes are said to be marks of the 

'^'vnoQs diathesis, but quite us much and mure iiitructablo 

wnas of stnima occur in individuals with thick swarthy com- 

plexioDH and coarse dark hair. I know some families, one more 

J*"ifiilarly, all of whose members have remarkably fine Uglit 

*""' *nd light-coloured eyes, yet in whieli no scrofulous disease 

«ui be traced for generations back. The mode of growth of 

'*^ **iatt(jred far forward ou the temijle, low down on the 



120 



STUUMOUS SYNOVITIS. 



CBAf. V. 



napo of tho ncok, and coding in a eo(t colourless down, is said by 
some to bo B sign of the stnimoiis taint. I conceive tbig notion 
rests upon far too slipbt a I>a8i8 to be seriously foiisidere^l 08 a 
nifMins of diagnosis. Again it haa been aQirmcd tbut tltickeued 
finger ends and hooke<l nails is a marked sign of strumous dis- 
ease, but careful obsorvatioii has comriiiced mc thnt any malady 
producing violent protrnct-tyl cough will impress this form upon 
tho nails. Phthisis produces it, and therefore this i<lea of its 
Btnimous origin has tecome prevalent ; but asthma will also 
cause it, and I watohed for many mouths a jmtient who was suf- 
fering from abscess of tho liver oj>ening into tho long, whoae 
nailH became mon? hooked and finger-ends more elultbed as tlie 
cough continued uud iiicrwi.st*<l in violence. Tht* j)ntient has 
recovered, and has for some yoare coughed hardly more tlrnn 
any healthy person, and tho nails have gradually resumed 
their former shape. 

Other appearances, to be immediately specified, are not so 
much evidences of a strumous constitution as of a malady then 
present. Struma cou^ist^ in a state of biul nutrition, and of this 
evil action tho appearances are the outward signs ; the symptoms 
of a morbid Eiction then going on, rather than of one about to 
begin. 

Such defective nutrition gives rise to two ecto of appearances, 
i^acb remarkable for itflclf and for its distinct separation from 
tho other. The former is marked by a |>eculiarly large and 
sluggish pu[iil, most ubKervablu when, as is often the ca^, it is 
combined with a light-coloured iris; we know that an iris of 
such hne should be extremely rapid in it« action, because the 
small amount of pigment renders the eye more sensitive to 
light,* The white of the eye is in these cascs of a bluish pearly 
hue, marked by tlic px-SHago of one or two wavy vessels. The 
skin is often remarkably clear, with a cold bluish lone in the 
very transparent shadows that makes it look translucent. 
There is often a pearly tint about the upper lip and comers of 
the mouth, which beauties of tlie old Frencli court tried to 
imitate with powder. Tho veins, in certain porta on tho upper 
eyelid, about the temple, and across the lower jaw near its 

• Hiifolauil. * Uebf-r <!!« Nutnr dor I Uiie pc-cdtiarity of eyo to id children an 
Skrufelkrankbtil,' haa remarkrd that { uv-ompwiimont of oieaenleriu <Uwaae. 



Cbr.r. 



SYMPTOMS OF SCROFULA. 



121 



visiblr, making purple markings under the mk'm. 
'Tht tompfes are thin and clear; the cdieeke, defined in outline, 
We a soft bloom upon tliem, while red and brilliantly tinted 
^ odd to the whole richness and delicacy of eolouriug. 
Bredow,* a Rusfiian phyeieiau, observes on the great beauty of 
tha aspect, and at tJie same time un tlie trauqiiillitr, almost 
imfwwiTeneai, of riHWt "part* of the face, whieh Uikos its fre- 
<|iioatly spiritiml expression chiefly from the eyes." It ia beauty, 
Mof a peculiar sort, which, toft-elher with the tranquillity and 
fitdtneffi of the fm^e, reminds one of that bloom, whiclt we know 
I oAen rvTuits for a few moments the fe-atures of the dead. 

Another ty^jo brings with it ugliness of the coarsest deserip- 
The head is large and angular, bigger behind than in 
tlie ears arc big, puffy, shapeless, and projiwt from the 
botd ; the jowB arc prominent ; the noiw swollen, and it* carti- 
l^ieA ill-^lefinei] ; the lips thick and sliapeless; the hair coarse, 
dslL eithf-r dark or of a disagreeuljle red ; the conjunctiva of a 
dirty-yellow and muddy appearance ; the eyelids thick, swelleti, 
ndrcd, even when fn-e of infljimmntiLm ; the lash ill-developed 
and scattpred ; the complexion dnll and o|>inpie; the skin 
oonne, unctuous, and marked with largo orifices of sebaeeuus 
dwts. The figure is ungainly; the limbs unwieldy; the j<iint- 
■ds t>f the bone^, the liands, and feet are large ; the belly pro- 
niupnt.'f" 

Kow in both these cases Uio morbid appearance is not one of 
mere complexion — both forms may be cither dark or light ; it ia 
"iftfi *f defective nutrition. In the former all the connective 
t*»Qfii* ore too thin and fine, their powers of nutriment are inmiffi" 
*^<^t; thus the coats of the vosaclB are so thin that the bluod is 
"^n through thern ; luid in jiersona thus constituted, hemorrhages 
^ar from the mucous mendiranc without the presence of any 
Qweratiou, but simply because they are not strong enough to I'esist 
™ft presaore from within. In the latter case we have a clumsy, 
^iclc set of connective tissues ; they posaesa sufficient nutritive 
^•1 Imt little formative power; hence the fibrous, cartilaginous. 



l'rM'>w 'Ou Bi-FofiUa »nJ its do- 

^^J^'-Ttgin, \ 'Cmnmcntade VitiuScro- 

?^''>« ctttckiiig *>{ Ihe uiip<-r ivml 
^*' »!• lu Um modton Ui>e, and of th« 



fomiw over the mter-maxinnry jmic- 
tutt--: uiid if tliifl be combiui'd witli Uic 
■■ullliit.-Mt ubuvu moatii.in(.->i U tauy uho 
bf ciiuiuL-ruted as mldiUoniJ t-Tiik<iiL-u. 
but ncitbcr its pnwenoc nor its abuiivo 
uoriinportaiict'. 



122 



STRUMOUS SYNOVITia. 



Chap. V. 



and other iutercellular parts, are (instead of being Ux) fine or de- 
ficient) too large; but they are at the same time iU-conoocled, 
eoft, flabby, and »»ddeu, refusing or abiggishly accepting the last 
and L'ompietiug act*) of tlieir developmunt. 

The descriptions are of course taken from the strongest exam- 
ple of each type ; but obsen-ation will, I am confident, show 
tliat one or the other form is always a prevailing mark of struma. 
The«o appearances are in reality signs of stmmouB disease 
then going on, and t'oiisistiiig, iw tliut malady always dot;*, of 
defective nutrition in tlio connective tissues. Such a state pro- 
duces a tendency to chronic indammations of tlie parts it afiecta ; 
bnt it dot^s not merely produce inflammations, it modities tham 
also, rendering them very slow, insidious, very obstinate, and 
very liable to end in suppuration or in degeneration of tissue. 
This is in u<^!cnrdance with our ideas of a constitutional disease ; 
and if struma be a defect of tJie whole nutrient system, 
causing ill- performance of interstitial nutrition, it follows that 
an inflammation, wliich is an exoneration of this latter process, 
miLft be impressed, even in an exaggerated degree, by those 
functional faults. 

When, therefore, a patient with a swollen joint presents 
himself to oiir notici', an<i we find the nlwve-nained signs of 
actually present strumous disease, we may fairly conclude that 
the inllamimitiou also, if oJiromc, is strumous ; but we have no 
right to form that conclnsion simply because the hair may grow 
far forward on the forehead or low down on tlie nape of ibe 
neck, or bi^cause the i^atlent has light hair and blue eyes. 

The history of the cose will aid us very much in forming a 
correct judgment A chronic synovitis may be the residuum of 
an acute attack, ur it may be a rela|tsc after the pntacnt have 
appeared well. The former of these is very probal)ly (imleas 
much prolonged) duo to no constitutional taint If it l»ve 
recurred without apiwrently sufficient caiwe, or if after exposure 
to fatigue or cold, it may be cither strumous or rheumatic ;• tb^ 
latter, if the primary attack have been acute rheumatism. But:= 
if the discasL' have arisen li^' a |»iinle!« or nearly painless tuin 
faction around rather tlian in the joint, and have remained oon 
stoutly chronic, it is nearly always strumous. It mnst 




f Oup. V. 



HISTORY OF fiCROFOLOrS niSKASK, 



123 



rwnpmbered thataltlmugh an neuto aynovitia is never scrofulous, 
it mar leave a strumous iunumtuatioD behiud it ; for the stru- 
[ mots cncliexja is especially a tlirtiiait' I'obdition ; when an uoute 
I iaflttQiination is by any uccidput set up in a etnimoua poraon, the 
' waity completely masks, if even it does uot altogether over- 
pOffer, the caehexJu: thus a wound of a scntfulous prrscm, not in 
I llie last stage of the evil, heals as well as it eould do in a sound 
: iDtliridual ; tlic inflummatiou is acute, and liealthy ti&sue is 
I [oulneed : ao in an acute gyiiovitis; but as soun as the inflain- 
[ tnatiun declines and falhi into the chronic or even snlmcuto stage, 
LUteo the c^ichexia can exercise its power, and the malady becomes 

flftcond form of coramencement, that in which a chronic 

J lyinpritis commences after some slij^ht accident as a more ur less 

' piinful disease, is generally the way in whicli the stnimous form 

\ivi^is in tlie a<lult, ISiit the very worst hirttory of any case, 

iliwt which shows the greatest force of coustitutioual evil, is tiie 

Dew^ement as an utterly painless swelling that does not 

"pereiit the patient moving ubuut as usual ; and these instances 

ue g(^ucrally those most sluggish and inveterate ones that form 

tii6 •• Morbid Alteration of Structure " of Sir B. Brodie. 

CwE XXTir.— E. Campbell, i^cd 10, ctme uaderniy core at the Cbaring- 
Ot« Hospital Aogoat Hth, 1858, for diseased knee-joint. 

8be u a verj prottj child, with well-cut features, dark ejclafibca, and 
^ «yt» ; haa no GwolUog of the li{is, nor of the nasal cartilages. 

tliti AwrUiiig of the Icnee was only observed hy the mother three days 
(|B, Imt the child herself says Uiat she haa known of it for much more 
Uua that, but it <litl not over hnrt her, and does not now : she plays 
*^<M is Well and gaily as utiual. 

'^ae1uleo isswoUuu: round in Hbape ; Uie awelting soft, and with a fluid 
^ttiatioD ; there waa a little tenJernetiH to the inner aide of the patella, 
** this was very slight, aud only mentioned when the child was questioned. 
^lered a a[iUnt and |wrfect rest ; tincture uf indine to be appUcd every 
^"^^miDg : quinine and cod-Uvor oil three timea a day. 

On the JGth August lihe fii-&t oompUuned of [win, and the knee became 

^'^^e swollen. Ordered bliater above tlio knee, to be dressed with aimpio 

"'ttaent. 

^ih, — The (iwolling ia increased and .the jwin in greater: whon »he first 

I to me tha knee was ah<nit a quarter of an inch larger, in all diinen- 

*(kcis, than the other, now it ia au inch and an eighth larger. The 

j^'^mpg is round, shapeless, and indiatinotly fluctuating : the mother was 

^t {leniuaded to leare the girl in the hospital, but she was so unhappy 

■* rtio woM fotchod out ogoiu in a day or two. 



124 



STRUMOUS STNOVmS. 



CiiAr. V. 



Sept. Srd. — Having an iutorest in the case 1 oontiniitHl to mc her out ; 
she baa been goiug on much the same : three iiayti ago a blister wtis 
ordered, and the right knee to-day ia decreased ; the left is painrul and 
swelled, but not the least hot. Ordered two grams of grey powder every 
night. 

8th.— The swelling of the left knee increasea ; that of the right has 
diminiahed : it is no longer fiuctiiating, but haa a more solid, a semi- 
Bolid feeL 

13th. — She i» pale and languid; both legs on HpUnta; apitetite very 
low. Two days ago the powder watt discontinued ; the oil ia to be left off. 
Syrup of the iodide of iritn 30 iini\^ thrice a day. 

Having to go out of town, I left efi]>eciaj diroctiona as to the manago- 
ineiit uf the {lationt, ami the name of a gentleman who woulil H^e her, if 
required. On my return, I was shocked to find her vety much worn and 
«xsanguiucou6. The knees are in just the same state ; contain no fluid 
apparently, hut present a soft pulpy swelling. 

The rest of this caaa may be gathered in the ooe word, consumption, 
which was making rapid progress when I last saw her. 

In Case XXVI. (p. 10-i), that of Phcebc Hope, whose leg was 
Hiupufateil for striiiuouu disease of the kuee. the disease bad 
bcgua four years bt^fore, in a swelling, whieh the mother observed 
accidentally, and tliu ehild mn about for six weeks aftern'ards, 
as well, says the mother, as ever. 

Both thet^; CAse^y commeuciug painless, end l^adly. The one 
develops the constitutional hmjI in a vital orj^an ; the other 
pomuins local, but so deeply rot>ted aa to resist aU treatment. 

The local symptoms of this dirfeaee Te<iuire carefid considera- 
tion ; and that «e may the more surely attain a ]>roper descri(>- 
tion wc will divide it into tlirco stages of jwthological progress, 
and give the symptoms proper to ejiclu 

Firstly. — The inflammatorj' and granulating processes. 

Secondly. — The cartilaginous an<l OBseons in Hum mat ion. 

Thirdly. — The consolidating and degenerative processes, one 
or both. 

The first of these is simply ** the head and front of the ofl'end- 
iug;" the others aro conrlitioiis, into one or both of which the 
malady may fall after an indetinite time. The object of such 
division is not only that the diKease may be recogm'zed as it 
appears, but also that those symptoms may bo comprehended, 
which point out its tendency to a spontaneous mre 1^' anchy- 
losis, or to destruction of the part by Hup]>iUBtiou and degene- 
ration. 




'Aoe. — Swelling may come on witli, or withont, pain, 
ad the latter condition is, as w^ bare seen, the lew farourable. 
In witne cajies swelling does not begin till a day or two after pain 
h»> lj«eu felt, and then the patieuU sometimes jn-itly, sometimes 
otherwise, refers the diseaso to a slight ac-cident. In tUiii latter 
cue Um' swelling vnW at first ^lave raiieh the form of the 8yno^^aI 
lUTmhrane; but this eotiditiou u very short, and eorros|>oi)ds 
nnly UiWic few <l)iys, when ihure is some increase of fluid iu the 
joint, and xvry little new tissue in and aroun<l it; in this state 
liesweiUn^ fluctuates sli|;htly. Some time after the disease has 
l«gnn iu this nmnner, the joint may atitually deereasc a lillJi* in 
noe. and the tumefaction left will be no longer fluctuating, nor 
M soft as prL>vious to the diminution. Instead of eoureyicg to 
ibfpnu^sed finj^er tlie sensation of t^mfined fluid, it gives that 
rf 1 soft solid ; the decrease, under these circumstances, is of no 
gnod omen: the fluid may have almuut disappeared, but there 
us been instea^l, fonuation of gelatinniis tissue. From tJiis 
Line the joint ivill continue more or less gradually to swell, tho 
lUpe of the tumour btxwmes very different to that of an acntc 
wnoTitis; its chief characteristic is that of 6lia|>tdt'ssness ; ittt 
(una is not atfected by the position of tendons or of ligaments ; 
'"It it iuclu<le8 tlium in its vague boundaries. 
^ The sensation which the tunit'l'tuUiou conveys to the hand is 
H^ and boggy, such as, to the uneducated flnger, may give the 
HHkirf fluctuation. i^Iany partH of the swelling arc softer, and 
^ *^ <i piirts hanlcr. than tlie general muss. These soft sjhHs are 
^ wore tnily fluctuating tbuu the others ; the increase in eofl- 
T*** is all tliat can be observe*! about them. Tho harder parts 
*wm to lie in the mass^ to have no detiued L>oundarit»s, ami 
cwiiot be sofHirntt^d, I)© lifted up, or be seizetl by i\n: Angers. 
T^lie nuface of tlie joint becomes, by degrees, whiter lliau 
1. This symptom is the more marked, the more stru- 
be tho case, so tliat wo may roughly conclude ou the 
^Bgreti and mode of granidution in the new tissues, by the 
*«itenefci of tlie tumour. This symptom has endowed a large 
'^ of joint diseases with tlie name, White-SweJling, a name 
*mcli. in its tronslalod form, "Tumeur blanche," is now more 
""^ in Kmnce than in England, its native country. Wben tho 
'^' isfur mlvancol, this whiteness is very striking; for as the 



126 



STRUMOUS SYNOVITIS. 



Cuhr. T. 



swelling increases, the skin bfvomt>8 strotehed, polished, and of 
a dead-wM(« hue, timmgh which tortuous HfUteiied veina 
mi>andftr. The whiteness will aid in the ditiguosis, between 
stmmons and malignant disease, in whieh latter the skin ia 
Tisnally of a brown, almost coppery hne. 

ffeat 18, if pre.'wiit at all, eonfinjjd to the first few days of the 
ccTOplaint, In the best forms it may indeed last longer ; there 
may, perhaps, be a suspicion of increased wamith throughont 
the attack, but in the generality of case^, the temiioratnro ia not 
raised, and in tlie wi>rst, tliose in vthivh the sweJIing in moKt 
white, polished, and undefinetl, it has seemed to me that the 
surface was colder than natural. 

J'ain. — At the eommeticemeut of the complaint, there may 
be, as we have 8een, no pain ; if, however, this syniptom be 
pro-sent, it takes the form of aching, to which afterwards a sense 
of distension is added. It is to l>o obsened, with regard lo thi** 
latter feeling, that it is of a passive charticter, tliere is no thrtit*- 
bing or bursting, as is coznplaiued of in acute synovitis, or in 
abscesses ; moreover, this |>ain is iuQucuced much more by the 
position than by the aetiuil use of tbt* limb. If tlie disease be 
in the knee, the mere erect posture whieli keeps that joint low, 
will protluet? as much pain as walking about. In a case of the 
disease in a finger, the patient, a cigar-maker, was ordered to 
rest ; he left ftff his work, at a rather high table which kept the 
hand elevated, and negli-eted to keep it in a sling, bnt let it 
haug down. He then complained that resting hurt him more 
than wurkiug ; the palki came on in the evening, and was absent 
in the moniing. A shnrt Kliug, keeping the hand liigh, clianged 
entirely these conditions. This intluence of po&ition is more 
marked, and more unmistakeable in the worst fonus of cases. 
Sometimes a sensation in the: joint of intense cold is cause 
great complaint The syinptom is very variable ; in sume 
altogether absent, in othera Nlight. in others most acute. I b«Tc 
a case at the present time* in which the patient speaks of this 
paiii with great dread, lie says that the other fmins which he 
suffers are bud, and may keep him awake, but this wNiSiition oC 
C4»ld is so horrible that he has sometimes felt 08 though he cvuld 
tear the limb out of its socket. Burning pain is mentioned ^5 
• NoTembcr, 1858. 




r.V. 



SECOND STAGE. 



127 



antfaors as one of the coDcomitanIs of tliitt discos. I hare fouiid 
stjeatflf when questioned, acknowledge that the joint woa hoi ; 
[>ut 1 have never fuuud any complain uf thi*ir own free will of 
Ekinfiil heat It i^ difheult, or perhnj>s impossiblo, to asMi^n a 
ifticJently proven canso for tliis cold sensation ; it may be, 
that the growth of a hadly (irj.Tirnzed material stairing tlio 
bt^thy partd may produce ttiis feeling in them ; but suidi 
sappofiitton 10 mere theory. The sensation should, however, be 
ej^arded a^ of evil pro^iosttoation ; thr».s<' mai^n 111 whidi it has 
ven most tiituiuse have been invariably, aa far as my experience 
ji««, iIr' mof^t obstinate, and the most prone to defeneration. 

Second Staue. — When the ditiease has continiuid un iiide- 
inite lime, varyinpr from a fi'W weeks to some months, a different 
<:iu^of pain comes on. It is descriU^d by the patient as " flaw- 
ing pains." '* aorencsa uf tho bone," " starting of the limb at night" 
^heev sf>n.wtions have b«3en supposed to be caused by an idcerating 
Ipmcese going on in the cartilage ; and so indeed they are, but 
only in a secondary manner, fur the pain is directly prodnced 
I by tho hyi»onnmia in the snUirticnlar vessels of the bone, caused 
||[iy Uie cartilaginous luilauimatiou. Cartilage, eith«r healtliy or 
1, posseasee no nerves, the only conductors of impression 
fto thi^ bruin; tlierefore, when inflamed, it is as iiiscnsiltle as 
when not inlliimed ; but hyperemia pnxluwd tlifruljy, in such 
la nuyiehling struetuA) as bone, sets up these painful symptoms, 
AnothtT S4*iisatiou, attributed with equal want of precision to 
nleeration of cartilages, is tenderness on pressing; the joint sur- 
d's together. The origin of this symptom, althougli oxtri^mely 
olncore, I believe myself to have delected. By questioning 
«unut4!ly for years past every patient that came in my way, by 
olwinring the species and succciiaiou of different sensations, and 
^Umi&iug, when possible, tho joints of those whose symptoms 
lud been thu.s noted, I have come to the conclusion that this 
*<aidtrmeg8 indieat-es, that the articular lamidla lias given way over 
*Upgur or smaller extent and that tlie cancelli are laid bare to 
^ joint Thp artujd sequence of events can in most iiLstances 
^ tnkcod, tiie ritai*ting-pain coming on first-, two or three weeks, 
'"' even more, before the tenderness supervenes. Having 
^^•nuiiod a very lai^; number of joints, in all sorts and con- 
<lis4»iis<', and luiviug, wherever it was [io«stible, com- 



128 



STRUMOUS SYNOVITIS. 



Chap. V. 



jiarod the syrDptoniH with tlio morbid anatomy. I can ofHnn, thnt 
I have never hoard complaint of this pocal tar joint teudemen) 
without Hading tlio ailiculor lamella broken through. I havo 
found the liimcila given way in cases where there hiul been no joint 
tondoruesa : but tlien the breaches of continuity had been either 
very small, or situated in aomrpart where, in the jKHjitiou of the 
limb, it could not be pressed ui>on by the other bone of the joint, 
Grating or bony crepitation in the articulation h a symptom which, 
whiMi it occurs, proves aw ulcernliuii of rurtilages, throuf^hout 
prolwibly a considerable extent of iKitii bones; hut the nlweneo 
ol thiit grating by no iiieaas proves that the cartilages are sound, 
fi>r granulation from tlie hone may ho so luxuriant aa to prevent 
the two o4weoui> surfaces coming in contact It not unfrrquently 
liappens, tlmt during some part of the progress of the cftse, the 
bones will grate, and that afterwards they will altogi^ther cease 
to do tio. The reason of such cessation is, after what has ju^t 
been said, perfectly evident. 

The constant gnawing palu, and tiie chief shock of the 
Btartlngfl, ai-e in eatdi joint refen*ed to some especial spot, which 
is so invariably the same as to be remarkable. At tlie sliouhUr 
this 8[xit is in front, just below the aeumiou ; in ihe elbow at tlie 
liaok, where the radius is jointed to the humerus. At the wrist 
it is at the Ixick, outside tlie extensor indicia. At the hip, if there 
\ie pain at the commencement of the disease, it is situated on 
the inside rjf the thigh, just beliind tlie origin of the yracUU ; 
aften^ards it shitts and ilxes itself behind tlie great trochanter.* 
At tho knee, it is situated at the edge of the trueldear surface 
of the femur. At tlie anlde, in front of and below the extoruiU 
malleolus. Although to these ndes an exception may here wid 
there occur, it is so unusual as not to interfere with their }irae- 
ticat value. The most patient examinations have led me to no 
discovery of the reason why the pain should be thus referred! t*) 
particular spots ; we must at i)resent be content to accept the 
simple feet While these starting pains, &c., occnr, tho limb 
exhibits a remarkable tendency to deformity from contrac- 
tion of mumbles. In another placi-! we Imve spoken at length, 
conoeming the causes of this action (see Cliapter XI.); in the 
present instance it must suffice to say, that the nervous siiacep- 

* For riirtlif-r oi'rMiiiit uf iii|»')Miiit diwoM' mk< ('lin|)ti.T mi Mint subXt*'- 



Chap. V, 



THIRD STAGE. 



129 



tibility ol" ji)int8, which permit hypcnoraia and inflammation of 
the sithlamellar bono-caiicelli to prodnco starting spAsms of the 
moscles, al^io ullnw the same causes tu bring* about a more 
regular and more cotistaut retraction of those organa. ItisdiflS- 
oiUt, or more correctly perhaps, it is impossible to say why in 
this action the flexora should prodorainato, and why, tlierefore^ 
the limb, if left to itself, should be gradually more and more bent 
up. At die kuce, whore this dideaae is most common, the action of 
the Huxors prevaih; over the cxteuson) to such an extent that the 
joint becomes bent at an acute anj;le. In very little time afler 
such iMXsition has been assumed it becomes pormanuut, and tho 
retracted muscles hold the limb firmly in that posture; any 
attempt to straighten it produces great pain, aud the tendons 
can be felt tight, ami like cords under the akin. 

\\^en inflammation of cartilage and bone comes on the case 
assQuies symptoms referable to this latter diacase, which over- 
ride and mask thosu of mere synovitis. Tlie one may nearly 
always be distinguished from tho other, even in the later stages, 
by the greater size and encroachment of the soft swelling, by 
the less implication of the bone, and less predominance of the 
osteitic symptoms; still they are generally alike, and tho reader 
will find a more detailed account of tliis diagnosis in Chapter XI. 

Third Staxje. — The above are eymptoma, in the first two stages 
of strumous syuovitis, of the growth of false tissue and disappear- 
ancc of cartilage and its bony lamella, provided no degeneration 
or any other disease of the morbid growth occur. If such should 
bapi>en we shall liud the symptoms to l>o now detailed added 
to those already sjx>cified. It ia not absolutely necessary that 
the now tissue should degenerate or suppurate at all, but it waa 
point*Ml out in the imthologwud division of this Chapter, that tho 
gelatinous matter cannot for over abide in that form, but will 
ultimately take a course either towards organization or towards 
disoi^iuxation. It is rare that some at least of thu materiul 
does not take the duvmwurd way, and In those cases, where the 
generaiivt! function of the coll has lieen excessive, and the 
membraue tiierefore very thick and pulpy— in those cases which 
we have placed in the woi-st category — a great part of the falao 
tissue is predestined to degeneration unless preveutod by treat- 
nteut. 



130 



STRLH0U8 SYNOVITIS. 



C«\P. V. 



If tiicn the tnmour of the joint do not dimininh, but coiitinuo 
to increiwe without sign of aolivo inflummation ; if the joint 
become loose from rolaxation or destruction of the li^nionts. 
wo may feel aflsured that defjeneration and suppuration will pro- 
IxiUIy occur; if the akin hu'come whiter and more polished 
and loso ita mobility, wliilo tho tumour continues to eulai'go ; 
if the soil mass feel aa though it were immediately beneatli 
the surface, we may conclude that those rctrogrado actions 
are imminent, or perhaps have actually begun. And if a jjor- 
tiou become quickly softer, even witliout fluctuating, we know 
that at tliat spot degeneration has Ret in. 

The symptoms of these actions differ snlfieiently in their 
amount and place to enable us to diagnose with considerable 
accuracy wlmt is the occurrence then going on. It ranst be 
remembered that suppuration may arise in the substance of the 
tissue, or in tho still remaining cavity, or in both. Small 
abscesses in tho thickness of tho soft tissue occur in almost 
every case ; no sj>ecial symptom marks llieir formation, except 
that when they get near the surface tlieir fluctuation ia pretty 
evident ; sucb abscesses may or may not communicate witli tho 
joint cavity, and after tliey have opened on the skin they soon 
tlegeuerate into sinuses. The formation of a large abscess is 
marked by more than usual depression of constitutional power, 
followed by additional pain in some part of tho tumour with 
increase of size ; soon after the skin at that spot reddens, then 
tho abscess points, and is incised or bursts. Such a coUoctiou of 
pus usually opens into the joint-eavity as well as externally. 
If the punUent matter be gathered into tho cavity and have 
no exit, it will cause a sense of distension and throbhiug, with 
vague pains about the limb ; if the collection of pus bo suffi- 
cioutly considerable to produce pressure, and if it have formed 
quickly, somo feverish symptoms will probably occur. Tlio 
tumour increases in size, but not in the same manner as when 
the absces.t is in ttie substance of tbe tissue, for then the addi- 
tion is confined to one side, to one part, of the tumour ; it is 
general when the abscess is in the joiut-cavity, the skin 
over the whole mass becomes more markedly white and 
pearly, before one siKit, whore the abscesH will point, shows 
a rod blush. The chtiice of this spot is not merely a matter of 
chance, for every joint has a favourite locality tor tho disehargo 



Chip. V. 



DEGEXEIUTIONH OF FALSE TISSUE. 



131 



of ptis, 8o that the first openinp which is made for this purposo 
ncBrly olwayt* occurs at tlie saiuo place This is more remark- 
able in the d»'ep-8eatetJ joints, the fihouldcr and hip; tho choice 
locality for tho former is just inside tfie biceps, below llie pcoto- 
i-alis major muscle ; for th<f latter, behind tlie great trochanter. 
So fixed are thette places that we might couclude. if a first 
abscess open in an imaccuetome<l sjiot, that it was foniie<l in 
t)io substance of the false tissne, and it may or may not have 
oommnnieat*^ with tho joint; bnt is far less likely to do so than 
if it had u])eneil ut the usual place. When a suspicion ariscM of 
abscess in the substance of the tissue from a preat increase of 
sol^nesR, it is better not to open it tmtil tlie skin become red and 
verj* tliiu, jiartly because no good is pnxlufred by st) doing, for thu 
pus does not cause pressure, mid it Ims been already ix)inted 
out tliat pus is not the solvent but the solution of tho tissues ; 
and jHutly aXm Imjcuuso it is sometimea impossible to be quite 
sure that the sensation is due to a collection of pus. In ouo 
case I was tempted to open what 1 believed to be an abscess, 
the lluctuatiou was unmistakable — no pus came, tJie wound bleil 
freely, until a compress was applied. T procured a little pie<'e 
of the soft tissue, and on putting it under tho microst-ope found 
that the cells were very large, filled with oil, and llicre were 
a great number of frev oil^lobules urooug them. 

If the subject be in a strongly marked strumous condition, or 
if he fall into considerable cachexia, suppuration in the cavity 
and in tho new tissue m\\ go on simultaneously, and spn-ad 
further aud furtlior. All tbiise cells in tho focus of suppuratii>n, 
whidi can be converted into, or generate, pus cells, are thus 
affected ; those parts involved within tlie circle of stippumtion 
which cannot be thus employed die ; thus, if ligamentous fibres 
be so included tUey slough aud their deitria will be found in the 
pus. If an al>sce88 be formed in tlie soft tissue which fills out 
tho bone cancelli, all the little plates of bone, wliieh surround 
those cavities, and are included in the area of sU[jpuration, 
nccroee bit by bit (n<x:rosis insensi bills), and come away as a fine 
detritus mixed witli tlie pus. These actions are not, in this ill- 
couditioiicd stiite, rouliued to tho tissues immediately abuut the 
joint, but a slow wasting suppuration cKX'urs among the deep 
muscles : such ulMcesses are ofteu hardly bound in by auy 

K 2 



132 



STRUMOUS SYKOVmS. 



Cdap. V. 



pyogenic membrane, and they diffnae themselves further and 
lurthcr from the origin of the disease ; they nearly aluays com- 
miinicttte with the joint. 

We have 8eeu that the ligaments are, Uke the rest of the peri- 
articahu* structures, involved in the flew tissue formation^ wliieh 
has taken pUiCO between their fibres from tiio celU imbedded in 
tlieir substance, and thiit these fibres an? jiartly changed, partly 
spread out by tliin growtli. It hajipens timt, so long as the 
material remains in its passive stage, the joint will not be very 
much loosened, and we do not fin<l that any such loosening forms 
one of the symptoms of this disease in its early condition. But 
when these retrograde processes come on t)io tissue {^ets soft, 
suppurates, and destroys all the parts, which it encloses, and 
thus the articuliition becomes extremely loose ; at the siime 
time the articular surfaces altor iu shape, so fliat they oppose 
no resistance to any new posture. The joint becomes capable 
of almost any abnormul movement ; the tibia, for iiistauo<?, may 
bo rotated on the femur; the ulna may bo shifted from side to 
side over the trochleur surfaces of the humerus. In this condi- 
tion of joint, and while the muscles are subject, to the spiu^m 
above mentioned, it is not surprising that the boues should be 
dislocated by muscular force. The tibia is sometimes drawn 
buck by the action of the tleiors ; the radius upwards by the 
biceps. The displacements, however, are rarely total ; part of the 
new surfaces, hardly now to be called articular, rest aguinst 
each other. Thus, in a caao I hiid the opportunity of watt>hing, 
ihe outer condyle of the femur rested on the inner articnlar 
surface of the tibia. Such luxation ia followed by a remarkable 
renussion of all the symptoms, particularly of ttmt starting pain 
which produces so much distress. This circumstance strongly 
corroborates the result of my investigations into the causes of 
the starting and of tenderness of the joint siirface. 

The relation of these Bymptoms to the diylocation is as fol- 
lows : — Entire cessation of pressure of one articular surface 
upon the otlier causes utter cassation of the starting pains. This 
(Hjint is of so gre-at impoilance both to tlie senii'iuhtgy and to the 
treatment of tirticnlar diseases that 1 am auxions to lay great 
strt'83 upon it, and to impress it strongly upon my reader's 
• mind. Be it, however, observed that spontaneous dislocation of 
a joint cannot occur till after the sta^ iu which the articular 



CUAP. V. 



ANCHYLOSIS. 



133 



cartilage with ite lamella are either entirely or in great piirt 
removed. 

AnchyUm may commence, wlicn the cartilages and articular 
lamtma have bw?n de8tn)yed, without auy great protluctiou of 
mbsoess in the joint cavity or periarticular tissues, or it may 
occur after these have formed and have been discharging. Also 
aft«r partial di^ilocation anchylosis frequently sets iu. Ita first 
sign is cessntion of increase, indeed aotual decrease, in the size 
of the swelling, which at the same time becomes firmer, wliile 
the skill, losing its white hue, assumes more tind more ite 
natural appearance. Tlie moutlia of sinuses, wlii{!h may have 
formed on the surface of, or at some distance from, the joint, and 
which are crowne<l with large llabby gruuulations, begin to 
contract The grannUtions tirst became smaller and less vind 
in colour, the redness of the akin immediately surroimding tliem 
declines, the discharge dimiulshes. At length the granulations 
sink to a level witli the surtace ; they appear to be sucked in, as 
a suail into its shell, and at last the opening closes altogether, 
the tumour diminitdies, anil hanlens more and more, and the shape 
of the bones again becomes visible. In cases, that have been 
remarkable fur a great amount of pufiy swcdling, and in which 
tlte soft masH lias been immeiliatcly beneath the surface, the 
eontractiun during the progress of anchylosis is so considerable, 
that the circumfeix^uce of the articulation becomes at last 
actually smaller than its fellow of the opposite limb; and the 
skin is girdled in between the liones. The posture becomes more 
fixed, and the health gn-atly improves. Tliis whole process is 
simply analogous to the contraction and healing of an abscess. 

There is no reliable symptom whort^by we may determine the 
commencement of os-tificatiou in the bond of union, i.e., the 
beginniug of tlio change from false to true anchylosis. 



TREATireKT. 
General — Tt perhaps hardly comes within the scope of the 
present work, nor is it otherwise advisable, to enter into any 
long treatise on the treatment of struma. Yet it is evident 
tliat, in dealing with a iliecase, whii^h takes root iu a certain 
fitatc of system, all attempts ftt cure would be fruitless, unlest 
some means were employed to alleviate the constitutional evil. 



134 



STRUMOUS SYNOVITIS. 



Chap. V. 



In Iho tiret placi', all hygienic measorce mast bo taken — close 
dwollinp-roomB iire to be vunliluU?*! ; light iicluuitctl to tlie 
fulleHt possible extent; unhealthy diet ohanj^ed, and cleanliness 
inciilfat*^ Upon theee plain niles of livin*^ we need not linger. 

Two different aspects of stnimoua disease were d(?8oribed at 
page 121, with some ojire, Ixhmuso they oiiglit to indicate two 
different forms of treatment The distinctions, although fre- 
quently as strongly marked an thnre indioat4;d, du not always 
diverge to that extreme degree ; therefore, the treatment to be 
described for each, will not alvjbya Ije so opposed ; but their 
principles may he sotunwhat intennmjjled. 

That form of scrofulous disease, which is marked by thick 
unwieldy connective tiisues, i-s in adults very generally, in 
younger pcrHons invariably, combined with a slu^isli intestinal 
canal, accompanied usually in the latter instance with thread- 
worm. Tin? wh'ile tube is lined by a thick viscid mnciis, which 
dues not stimulate the peristaltic actions, nor [H.>rmit either food 
or remedies to come in contact with its mucous coat. Tliis 
matter must bo piu-ged away, and the best means for the pur- 
pose is a powder of calomel and jalap or calomel and rhubarb. 
In another chapter (see Chapter XI.) tlie action of this remetly 
in articular disease is compared with its effects in stnimous 
ophthalmia. We can, in this latter malaily, actually see the 
inurljid symptoms decline as soon as tlie intestines are clear. In 
istrinuous synovitis the Ixuicfit is not less certain, though it may 
be less plainly perceptible. In one or two cases of commencing 
stnimons joint disease, the exhibition of this remedy, combined 
with suitable loc^ means, has checked the complaint. It not 
nnfrequently happens, that after the medicine has ha^I its duo 
effect the complexion will ri'sunic its muddy hue, and the eyc?- 
lids become ajv'ain red ; the dose should then bo repeated ; but 
projwr dietetic and medicinal measures mil prevent the neces- 
sity of recurring to the purge more tlian once or twice tluvugh- 
uut the whole complaint. >:>maI1 alterativt; dtwes of mercury 
may, however, bo given for a day or two witii advantage. This 
medicine is not in the^e cases to be pushed to any |«jint near 
affecting the gums ; it is simply to rairrect the secretions, and is 
the more beutttieial if it priKlnce ratiier five action of the 
bowels. For this purjiosc, it nniy be advanlagcoualy combine*! 



llliAV. V. 



OENEKAL TKEATMENT. 



135 



with qiiiumc ; ob, for iuBtaueo, two graina of tiio grt-y-powder 
with one of quiniiu% uight and morning for two or ihreo duvi*, 
and then the latter may be administered aloue twice or thrice 
in the twenty-four hours. 

Iodide of potassium is eepeciaUy indicated; it may be givmi 
in some bitter infusion. I liave been in the liabil of uning the 
following forinuht, a little altered from one of Lngol's, the action 
of which is i|uickcr than the iodide alone : — 

Iodide of Potaaaium .. 1 drachm. 
Pure Iodine ..g ,. Sjgrs. 

IcfuBion of Caffimba . . 1 pi. 

It is singular that tlie addition of the pure element detracts 
from tlie metallic taste of the eomiiouud, and renders it Ir^ss 
lasting. 'Ilie formula appears, in stum*, of the reported citscs, as 
the Mistura Potassii iodidi eomposita. 

Quinine, mineral acids, and bitters, are the tonics most bene- 
ticial in tin's form of the disease. Iron is far less vahiable, and 
tjod-liver oil very frequently disagrees, besides aiding the ten- 
dency to clogging of the intestines and sluggistiness of the liver. 

The form of struma, whieh is distinguished Air thi? fine deli- 
cate formation of the connective tissut-'s, is to Imj managed on a 
different plan. I^trges and mercury in any form must he 
avoided ; the inaction of the intestinal canal is to be combated 
by mild vegetid)Ie ajK-rientM ; rhubarb given in pill immt*<h'ately 
before or with the last meal at night is an excellent plan, and 
any thing like a violent or irritating evocuant docs harm. 
Iodide of Potass in the most typical cases of tliis sort of struma 
is not beneficial ; the whole class of alterative* are not needed. 

On thn f>lhHr hand, tonics are extrc^raely valuable. Cod-liver 
(til is especially indicated, its we desire incrcuso of nutriment; 
in these ('.ases it very seldum iiidet-d ilisiigrtres. Quinine, if the 
apjM'tito fail, is useful ; but iron is to h« much more highly 
prized ; in iact, I esttem steel and the oil as the Is^st medicinal 
)ig(ruts : where the latter has been foxmd uusuitable, sarsaparilla 
may be adrantagCKjusly atlininlsterod. Malt liquors, millf, if 
possible cream, Hht>uld be Included in the diet. It may he 
|)oiut4:'d out thiit in these taisos the stomiK'h is usually capable 
nf inimagiug nidy a Uttio food at a time; therefore, the meals 
should Lk- small and fnMjueut. I have often found tliat thes)* 



136 



STRUMOUS PYNOVrriS. 



Chap. V. 



pationta are very languid in the morning, feel faints and arc nut 
able to eat brcnikfast ; on inquiry, it will often b« clicittsl tliot 
tbey tiiko no foiKl, ufua- ii moul nbnut six or st^von in the even- 
ing, till breakfast time ; an interval often of fonrteon or fifteen 
hours, which is more than their powers will bear. They muy 
be tokl to eat a [)i*K«> of breiwl and butter about half an hotir 
before going to bed ; they will then not only sleep better, bwt 
wake less languid. When tliere is much debility I have* found 
nrlvantoge from ordering something before rising in the 
morning. 

The value of all treatment lies in its adaptation to the jjarti- 
cular case. Thi; distinction between the form of scrofulous 
affection has been drawn broadly and strongly ; they are not 
always, however, eo clt-arly outliiuxl ; but »o ctjuvuiced am I by 
experience of the advantages of separating the two sortjt, both 
in diagnosis and troatmont, that it ajtpears to me impossible to 
insist too strongly npiin their varieties. 

Local Treatment, — Tlie first and most important part of the 
local treatment is rest A time arrives, as we shall sec, when 
it becomes a grave question whether entire immobility sltould or 
should not be continued ; but there can be no duubt that at first 
the joint should bo kept perfectly still by baudagiug a well-imddcd 
splint upon the limb. The joint itself must be left uncovered by 
the bandage for the application of any remedy that may be desir- 
able, which in tliis state of tlie disease belong rhieily to the class 
counter-irritants and derivatives. The former arc chiefly lini- 
ments of ammonia, camphor, turi>entinc, &c. ; sinapisms, blisters, 
iodine, nitrate of silver, mineral acids, potassio-tartrate of anti- 
mony, croton oil. As a guidn to a clioico of these remedies, we 
may conveuiently take the following considerations : — Tliat al- 
though tho disease be chronic throughout, its infiammatory 
condition is more marked at the commencement ; and this con- 
dition is at tlie same time as far as possible from the surtace. 
Hence, in the early stage, our remedies should be suHiciently 
active really to attack the disease, and also should be snch 
as are not a]>t to cause deep inflammation. Experience in 
the use of counter-irritants shows that we can produce consider- 
able amount of superficial action with Ultle dL^p-scutcd inflam- 
mation by moans of a brisk application use<l but once or twice. 



Chap. V. 



COUKTEB-limiTATION. 



137 



whOo tho repented employment of a milder remedy induces 
a deep actiou, which nmy penetrate sufficiently to mingle witli, 
and add to tho diseosL'. Hence we should rather uhc, at the 
beginning uf the malady, nitrate of silver witli nitric, acid,* cro- 
ton oiJ, or tlic tji.rt«r eiiietio ointment Tliin last n-niiKly is not 
however advisable in any hut deep joints, since the inflammatory 
action round the pustules spreads to a verj' considerable df^ptli.f 
Blisters are very useful in the eurly stage of the complaint ; 
they should, at the hip or other deep joint, be applied as near 
as possible to the scat of tlie dit^oaso, but at thu knoe or other 
supj?rficiai part they should not bo placed immediately over 
the sjTioTial membrane. The blister should be aUowed to heal 
at once, and another opened at a convenient spot, tlius jjro- 
ducing the greatest amount of irritation with as little injury 
to the skin and as little penetration of the action to deeper fuirts 
as possible. These applications;, freely used and combined of 
course with general treatment, may be sufUcieut in cases which 
are mild and marked by little inflammatory notion or ovidcnco 
of much scrofulous cachexia; but they can rarely cure the 
disease, and (o trifle with the first appearance of such a malady 
is impro{)er; if tho milder remedies do not quickly bent'lit, it 
should 1)0 attaekeii at onoe with means capable of chjiuging tho 
diseased action. These may W onumeruted as issues, moxas, 
and tho actual cauter)*. Issues of caustic, or moxas made with 
fire, may either of them be employed. The issues should not bo 
large ; about the siise of a sixpence, or at most a shilling, is in my 
experience snfllcient. Tho slough separates in fn)m five days to 
a week, and then a glass bead should be placed in the wound : 
one is suflicient to keej) it open, and to crowd it with them la 
ns4*1css and piiinfub An is^uo should never hv allowed to remain 
oixjn long; wlien this is permitted, it loses all con n(er-irri taut 
jHiwer, and simply acta as a i^eton by keeping up a discharge, 
wliiuU weakens the vessels of the part From ten days to threo 
weeks generally changes the wound from an irritible to an indo- 



• Formula— A rgtmti Nitratis gas. 
AcM. Nit. Fort. irnj. 
Aque dUtillat. M. 
t A paper appearf*! in the («Tm(- 
gow M4-1I. Joiirmtl. I>y Dr. Kliiij^icr, 
vuuutiiitf ItiKlily ihn MM} v( vi-miria iii 



t3iiB dttMLSo. [t apiHwrs to inc that tjie 
friotion hn« an mach us tlie rcntria to 
do wilt) 11)0 euro tn ttio caae* bo qaotva. 
Koniinio— Vrriitriin pr. v. 

8p. Vini ivol. 5J. 

AiunKu .y. Ft. wjijj;. 



188 



STllUMOUS SYNOVITIS. 



CaAP.V. 



lent sore, kuomi by ito Uiiuk, pnle, uverted edges, luid Habby 
grnimlntions. As soon as the issue lias |)ut on this appcariinee^ 
it hIhhiIi! lie healed ami another opened in sonie otlior part near 
thi* joint It is well to be cautiuuD iu selecting tht- spot where 
tlio caustic is to be applied, for in 8U|M;rHeial joints it may 
itaj>|>en thtit an ibsne in a l>a<Uy-ohosen seat will actually pene- 
trate the joint and wt up an uneoutmllubk! destrucUve iuflum- 
mation. In the Museum of the CoUegc of Silicons (Fathido^oal 
Serii.'«, No, 898) ia a stjecinien of a kuee-joint, in which this acci- 
dent ha<l occurred. Of uioxhm hut few oxiuu])Io8 have como 
imder my notice, and from what I have seen of them i am not 
inclined to recommend their use, although they certainly pos- 
sess some iwlvanta^s over caustic issues. The first is, that if 
chioroform bo giveu during the actual application of the iirc, 
they are less painful : 1 have frequently seen patients sufTeriu^ 
severe pain for lioura after the cauBtic-applicatioii, while the |«un 
from the btini diminishes very rapidly ami soon nearly ceases 
The second advantage is that the sore produced remains much 
longer irritable, and it is not therefore necessary to renew the 
application so often. But it is to be observed that the action of 
the fire penetrates deeply : it is only miitnhle, if ever, in the lato 
Htiges of this disoas«^ and is more adfiptcd to a raalndy cora- 
nienciug in the bones — to caries, for instance, of the vertebKe. 
All these applications, although if ])ropcrly used in proper casi'S 
they may produce btmefit, are open to verj- serious objections. 
The fre([n(mt lipplipJition of blistHrs or highly stimulating embro- 
cations relax aud otherwise injure the skin, pn_Hlucing therein a 
chronic state of congestion, a passive hyjienemiti, and thickening, 
wliich ia verj* siuitiur to the diseiUH^4l eouditiou they hdj intended 
to combat, but which they frequently aggravate. Issues, and in a 
rather loss d^ee moxas, are liable to inflict similar injury. It 
has frequently occurred to ino to sot; perwjns suffering fr<jm a 
diseased joint with an old large issue in its neighbourhood, 
whose condition, both locally and constitution ally, has been 
gi^atly improved by idlowing the sore to heal. It is essential, 
as we have seen, if issues are to produce benefit^ that they 
should bo frequently renewed. This sulyects tl»e jwilient to 
a great ili'sl of|«uu; and moreover it destroys a large part of 
the skin iuid tilts the MdH'Utaiirous tissue with S|iots of soft, va^ 



CUAP. V. 



EVII^ OF IHSUE8. 



139 



calar, ill-formed scare. The practice also of consUiiitly keepini* a 
poHltioe over Uiosg sorCH is to be greatly tU.'iJreoat^Kl. siuce no- 
thing teiuls lunro to aid luxuriance of fungous gmnulations thim 
tlie application of wurm moisture. 

Another nietluHl of jmiducing *i aore, however, is very difler- 
t>nt in those ri'Sp'cts, namely, the actual cautery. This treat- 
ment wad in gn-at repute in the earliest era of siirgt-rj' aurl 
down to tlio latter jiart of the Middle Ages ; hnt tiflute yv-ttm it 
haff fallen into nndt^-iervod neglert, nlthongh it has had it« 
aojilons snp|iorters. Troljably tlie chief i*eason of its disuse is the 
piiiu wliicii it cuuseit, uuil the ten*or with which the application 
of heuted iron to the slcin might well inspire any patient. 
Without chloroform 1 ^liunld hardly havp courage to recommend 
such a i-emedy ; but with the auiesthesic its iipplication, likn 
that of the moxa, is less painfid than cAUStic potash. In fact ttie 
remiBaioii, in some ciises the utter di-«ipi)eimmce, of the fxiinfnl 
symptoms after a4.'tuid cauterization rentiers it a merciful and not 
a cruel remedy, liust, of Vienna, relates a case of a young gen- 
tleman suflering severely from hip-disease, wh»we parents conid 
oidy induce him to undergo the npcnition by promising to take 
him to the theatre that evening. Tlie applioatiou was fively 
made, and the boy's pains were so much diminislied tliereby, 
and he was so cheerful, that he insisted on the {HTfonnancc of 
the promim; and greatly enjoyed the theatrical cutertainmtmt.* 
Such cases of verj' rapid action will rarely be met with, but expe- 
rience iu the use of the remedy \viU be able to »how its immense 
a<lvautago over all other applications in projjerly chosen ejise6.f 
The stage of etrumons s^oiovitis to which it is mure particu- 
larly adapted is that in which the first symptoms of iuHamma- 
tiou have somewhat subsided, bat in which some such action 



* 'Arthrokakulngie, oJer iiber Vcrrca- 
Ininguii (lun-U iuiivru Uittluiguiigou,' h. 
Idi). 

f Mr. 8ymo, in h'm ' PriiKnptofliff Sur- 
KCty.' when sitiitking of Ulceration of 
C^rtiUgi;a, p. 223, my9, " OniUtic moxa 
aud the actaal cauterj maj all bo em- 
ployed for Uie puriKisc (proJuction of 
AU is^ie) : hnt the loift nionttonci] 
am^ut w infinitely pmtVmWf to tlif 
otli('n». It tfl often thon;;ltt tlint thu 
jiiiiii ulik-li iitt4:-nils tin'' cpt'niii;; nf on 
XinMf HllVirJii I be bv'iii'tlt tlint is derivotl 
fnm it, iind that thcrt-forc thi' moxa. 



whidi tunutlly prodneea a ni|>crfl<;ial 
offvot, ubottld \ms selvcttMl ; but it bnn 
hveti well a«c4>rtiuiu-d that mi)' ronM- 
dt'mhlti aiiieiMimi>nt onn in goueml lie 
hardly peroeivr^l, until the awdnnn of 
the nvw secrdini; >^urfiu,-o hu wen 
fiiirly eatabliflhitl. The ulrtrs of bnint 
nirftkccs art) ulwuvs v^ry slow lirulin^, 
nnd hence tbvro u on ohriniu lulrun* 
tii^ of tlir cautery over cauvtic : but 
itA i'Wu-i ret;iinimcniiatiuu \f cxpcrii-nei.*, 
an<I thnt is ho 6tn>iiK u to Iviivt.* no 
mum for <lo»bt or licsitatioii in prefer* 
ring it to the other mciiiu." 



140 



arnuMdus STNOvms. 



Crap. V, 



continues and enlai^emert is stiU Roing on. In Kiich cases the 
cuntoriwition may be nsed to produce benefit in three ways — 
firaUy. by the twrtiml t'ounter-imtation of the burn on the skin; 
secondly, by the establisfiment of a slowly-healing irritable sore ; 
thirdly, by tlie pressnre on the subjacent {arts of the skin 
Btrougly contracting'' during the healing process, lu the first two 
eflects the slwpe of the caut<*rized siirOK^e is evidently iinmu- 
terial ; but in order to obtain as much benefit as possible from 
the last effect, the skin should bo charred in lines parallel to the 
axis of the limb. This mode of applying the iron ^vas called, by 
Percy, Cauterization Transcurrento,* because he found that 
CgIsus had described such a method in malignant ulcers of the 
lip "nece^ariutn e«t tentti ferramento adurere, ^uod fptati tram- 
currere non imprimi d^het" Tho sliapt! of the iron is a point en 
vrliich much profeffiional dandyism has been wasted ; the moi-o 
80 as its form is absolutely unimportant as long as it has Kidn- 
cient bulk to retjiin its heat for some considerable time, without 
being clumsy, and has an angle or some other port small enough 
to mark lines Hufiicif-Utly narrow. Ilust's iron seoms to ino to 
answer tliis jnirjMtse as well as any : it is a tliree-sided prism 
with the comers blunted and raonnted by one of its oblong sides 
on a bent handle. Au oval cylinder mounteii in a similar way 
IB also a good shape, as its tliinner or its broader side may be 
used ; or again tho end, if it be thought desirable (as in some 
case«) to produce an issue. 

There are different modes of performing even this form of 
operation, which I would venture to name in English, linear 
cauterization. IVrcy, and following him Bonnet, advises that 
the lines shoidd bo at first very lightly drawn, and the iron 
pasRed over them again, imd this is the m<Mle which farriers 
chiefly employ. Rust, on tho other hand, deprtH^te^ any reitc- 
rjited passage of the cautery over the sk-in, recommeuduig a slow 
marking of the liiit'S once with geutle pressure. The iiiet is 
that both are useful in different cases, for in the former mode 
the heat penetrates more deeply than in the latter, and is 
therefore to be employed in well-oovered joints, while the super- 

* He dcacribea three mctliods ot ; tho iiou U only appronohcd to Iko sur- 
uuiigtlio uiiilvry, "CsuU-rizAtiontraiu- I face without timuliiiig it: a lut-lcu 
curruut*;" — " iiilicniiilf " fur tliv ftirnia- inittliud. — I'yrutoctmto ClurufgioalCt 
tionorjMUi!*! — uiul"o))ji'otiv(%"inuliielt ' 1811. p. H4. 



Chaf. V. 



ACTUAL CAUTERY. 



141 



fioial ones BhoiOd be cauterized in once. All surpcal writers 
on the subject^ as well as all experience, show tlic diiinil vantages 
altendiint on dividing the skin with tlie cautery ; that is to eay, 
the iron itself must not penetrate to the subcutaneous tissues, 
but the heat should deiitroy the whole tliiekness of the cutis. 
The iron in to bo white hot ; even I'ercy, llust, and Bonnet, who 
operated without chlorot'orra, found that much leaj piin is pro- 
duetnl by a ver}' hot iron than bv one only red hot ; hence two, 
which nmy i>f changed as they cool, arc to bo used. The lines, 
in the case of the knee, should be an eighth or a sixth of an inch 
broad, and from three to four inches long, or even more if tho 
joint be voluminous ; they should bo at least an inch a{Rirt, 
At tho knee, for instance, one should be placed on each side of 
ilie patella, and one just in front of the inner and outer ilexor 
tendons. These are generally sufficient. Immediattdy after the 
s])plinition tho skin becomes of a dark golden hue, studded with 
little drops of a clcAr watery liquid. A piece of dry hut may be 
placed over the part. The whole operation is easily completed 
in from two to three minutes, and, if th<? iron have been kot 
enough, the patient on recovering sensibility is astonishi-'d to 
find that he does not sufft^r from the bum ; but if tht? iron havo 
not been sufficiently heated actually to destroy the skin, pain 
will remain. Often when the starting of the limb and other 
suHerings liavo been severe, the cautery rtflieves them Uke a 
cliarm, and the patient may pass a better night than for weeks 
presnously. No appltcjition to the part is necessary ; a piece of 
dry lint over the joint prevents the patient examining it with 
too great curiosity ; a rosy Hush, which after the operation jwr- 
vades the untouched skin, soon disappeai-s ; in two or tliree 
days, however, it returns, aud the charred cutis begins about tho 
fifth or seventh day to separate at the edges. Poultices and 
wann fomentations are to be avoided : cold wutx>r or simple 
oiiitmeuts arc the best dressing. If the irritation aud pain have 
disup[>eared on the use of this amplication, wo may feel assured 
that tho active congestion and the 8pre4ul of the disease has 
been arrested : the tenderness even on the localities of its choice 
will vanish, and our next care is to insure tho continuance of 
tliis chimge, and to prtHluco abH<)ri)tiou, or, if not, consolidation, 
aud further developmunt of tho unhealthy tissue. Tho sores 



142 



STRUMOUS SYNOVms. 



Chap. V. 



prodnctMl l>y the mntery shonlil h« allowed to heal as qninkly us 
they will; in doinfj 8o they will contnid and prddiic*:' ft highly 
U'jiefipial itrw*8iire on the soft parts tonoath, and tliis it is our 
duty to aid by tinn bandaging, at first, whjle tho disi^liarpje is 
considerable, with a Bimple roller ; afterwards by means of tightly 
applied 8tra|>]>iii;; plaister, previously pnjtiv-ting the wounds with 
iKimc simple dressing. Pressure of this sort was iirst recom- , 
mended by Dr. 8eott^ of Bromley, but in these stnimouii cases] 
tlie mercurial dressin^^ whieh be also advotwtf'd are, in my 
opinion, injurious. Even and tijfht strapping? over the whole 
joint, so an tuy produce oonHidL^rable pressure, is tho real remwlial 
agent. 

At the same time, it is not advisable to keep the patient in 
b<3d, but 1,0 allow some movement, which is easy, when the dis- 
ease is in an upper extremity ; even when it is in the lower, rar- 
riaj^e ex(>rciae in the open air should, if |x>sBible, be prot^ured. 
Ily tht'W meaiiK we shall cheek the tendemty to pnxluce fn^sh 
graunlation : our next attempt is to get those already fonntMl 
either orpanized or absorbi^d. 

Hitherto we have BjM)ken only of e^utes which, having seen 
them from tho first, we have been able to manage in our own 
way ; but this does not always happen, and we may <mly be callefl 
up<jn after tlio patient has snfferctd for some considendde time; 
has been kept in bed with perlmps an issue that has been open 
for six weeks or two inoutlis, or [loasibly with no treatment at all. 
Tho joint will probably be found «hapr-l(*ss, swollen, pulpy; p<'r- 
hapfl it may U* painful ; probably, particularly if the knee bo in 
question, it will be a good deal flexed. Now, we shall in nearly all 
such cases find on couimiualion, unless tlie (hsonae have gone too 
for, that the whole joint may be manipulated witliont produeing 
pain; that pressure upon the choice scAt of tendoruess will 
cause no expression of suffering, aud that no startings or any 
liciitfi. pains disturb tho patient's sleep. Even in sueli a ease as 
this we may in all likelihoixl cjire the ]>atient by first ap[tlying 
strong pressure, munipulations, rubbing, and passive movement. 
Tho condition into which the now tissue has fallen in simply n 
passive one; the material exists, but there is no action in it; 
p4*rliftps there may have been an abscess which huft left a sinus. 
Iml the supjHinition is very sluggish; tlie rest of tho tissue is 
doing nothing. 



CSAC. V. 



PERIOD OF MOVEMENT. 



I4:< 



Now, if the gTauulutioiia be allowed tti remain in fliis pas- 
sivity, i)wy may, after some years, contract and consolidate even 
*M »pit€ of euch trcatmcDt ; bat their more general course is t4> 
take on a retrogiwle action, griuliuilly to yield to suppuration, 
and to inTolve the textures of the joint which they enclose. 
Our object should be, taking ailvantjigo of the passive state 
to prf)du«e absor|)tion of the jelly-like tiRsue. The painless 
tx)nditiouuiM>n pressure, »i)d ptirticnlarly of that 8[xit which i«tlio 
chfweii »»eat of teuderueaa, is the proof that we may employ not 
merely pn^ssure, 8liamiMKUiig. and rubbing, but passive motion ; 
and we can in a fjreat number of instaucefi. even after abscesww 
have formed, proiluco abaorjttion of a large portion of the false 
tissue and consolidation of the reaL 1 desire to lay powerful 
stress upon this point of onforciug passive motion as soon as 
actiml iiilliimmaliou is checked, and mere vegetative cell- 
growtii irt the only action going on. M. Bonnet, the fimt writer 
who attempted to show the value of such means, has not 
limited itA use mifllciently to the caaes of whieii we are dow 
treating. The counter-iiulicatioua to this treatment are an 
active condition of the swelling evidenced by i>ain and tender- 
ness, any considenible amount of degeneration or suppuration, 
starting paiuis, and tendtfruess of tlu^ joint sm-fw^os. 

It may 1* that when the patient is first seim the limb will be 
in some unnatural ixeition* wliich must be changed ; it is almost 
8U|jerfluoiLs to insist u[K>n the necessity of plm-uig an aiichy- 
lotjing joint in that posture wherein it will be most useful to the 
patient; and it is not now intended to speak of posture in 
anchyloBis, but of ix)6ition as an actual remedy for, or prevcjitivo 
of, further disua»*. \Mien the Urab is in a statt^ wliicli does 
not |iermit the employment of either passive motion or sliam- 
pooing; when» tlierefore, an active condition is still present, 
mill we would by choice not move the limb, unless net^essary, 
even in this condition we are to overcome any malix)st»u'e, and 
put the joint into that attitude most tit for the reduction of 
inflammation. Tliis |x»stnre is in every instance such as will 
prevent any unequal amount of traction or of pre«nire on eithi>r 
woh or hard parta of the limb. For the shoulder joint, the elbow 
should be a Little in fnmt of and sejurated from the side by a 
thick piul. A (Uriciuted elbow should be bent at about a right 



144 



STRtlMOUS STNOVmS. 



CnAP. V. 



angle ; tho wrist fltraight ; the knee most be not far from a 
straight posititHi ; the fotA, for unldc joint disease, at right aiii^lofl 
to tlie leg. If, when we first see tlic [latient, wo find that the 
iliroctitin of his limb deviates much from those above given, we 
lire to place it in a proper position. For partinilarB concerning 
the means of doing this we must refer to Chapters XI. and 
XVIX. It must suflice hero to say that tiie replaocracnt may 
bo either sudden or f^n-adual ; and may citlior be aided by snb- 
oiitaneous divisiitn of opjjosing structures or without such aid. 
In by far the greater number of iiwtances in which inJiammatiou 
still losts, gradual straightening, by the means of my extt'iiding 
apUnt (see Ciiapter XI.), is the boat method ; more particularly if 
there be t^-uderuess on pressing the joint surfaces together ; also, 
in tlus condition uf part^t and mode of proceedings it is less 
frequently desirable to cut the tendons, unless the patient be 
a cliild. On this other hand, if there be no tcnderneKS either 
of the joint surface of tho bones, or that chosen seat already so 
often mentioned, the replacement may be done suddenly, and, if 
much change have to be made, under chloroform. Here, how- 
ever, the tendons are to bo divided, particularly in the case of 
cliildren, eincu their muscles are much more irritable under 
elongation tlian those of adults. 

Another condition of tho malady must now bo coosidered. 
It often happens that patients first present themselves to our 
notice when all the structures of the joint — synovial membrane, 
cartilage, in part tlic ligaments and the spongy ends of the 
bones — have been converted into soft gelatinous granulation 
tissue, tlinmgli which sinuses run, discharging pus, hi such 
cases anchylosis is tlie best that can be hoped for. To produce 
this result, we must bring about solidification and further oi^n- 
izatiou ; therefore, some action of thli soft tissue. It will not 
always continue, though it may do so for a long time, in tlie soft 
gelatinous state ; if it do not solidify, it will soften, ie., degene- 
rate and suppurate. Wo may use tho cautery if necessary, and 
pressure, but not moTcment of the joint. Passivity of the tissue, 
without any means of calling forth action, is fatal to our hopes 
of this sort of cure, if cure it may be called. Keeping the 
patient confined to bed and one room, T^nth a sluggi.sli discharg- 
ing sore, is the best means of weukeuiiig the cuiiiitiluliou and 



Chap. V. 



TO BETATN MOBIUTV. 



Hr* 



|iro;luring that rlfif!:i^iH'mti(m niul tiiqtpitmtion which wc dread. 
Open air, nud as much cxercist^ ax win bf» manned without 
iimvin*; Ihi* joint, are the l>08t ineana of keepuig tlm heidtb 
Huund und tlie tissucif in good ctniditiou. 

That must distieesinf? symptom, starting of the limb, is, us we 
have Bfen, an arcom|)jiuiment of this jiart of the disease ; tlrnt is 
to say, of the Itcmo iiifhimniatioii. For uu account of its mana|re- 
niciit. &('., the reader iniwt refer to tlio chapter ou Arlirulur 
Osteitis (Chapter XI. — Trmtmetit.) These pfiins are very often 
ono great cause of tlio siidJon loss of health, \vhicl» at ihia time 
often siipiin (Jiies, aud of the miexmt roll able suppuration tliat then 
toktiSi pluco in the tisHiie& The case of Hqnm {Case XXXV.) 
showB tlu> )K>iut, and it aUo shows liow. in this furm of disease, 
pressure muy aiinihihite those pains even in a nni1a<ly so fur 
advanced that we can expect from it no other benefit 

If the ti-eatment Ih* Buececdiug the joint will begin to dimi^ 
Mtsh in size, anr], whiit will more quickly attract the ere, it %ull 
lose itfl bagg)' ftha]ieh*sj{ appearance ; at the same time it becomes 
harder, raore elastic, the discharge ceases, aiul tlie months of 
sinuses clos**. At this time we Iiave to reconsider the ]K>sition 
in wliich the limb is placefl, aud to assure ourselves that it is in 
that posture wliich. if it become tixcd, will be moat couveuient 
to tlic patient. Sneh will, of course, bt^ the case if the niles 
already laid duwn have been attended to ; bnt it may hap^K^n 
that, owing to some cause, a little change wUl bo tlesiirable. 
Soon comc« another point for consideration. When the mem- 
branous anchyloids ia pretty firm, the bony may shortly su|jer- 
aede it: it becMjmes a fair question whether or no wo slmll take 
any means to prevent tliis, or whether wv can succeed in doing 
so; and my cunvictioii, drawn from the nuniber of cases, which 
it has been my lot. either to watch or to treat, is that as soon as 
the sinuses Imve soundly healed, it is safe, jtoasible, and odvan- 
tageoufl, to prevent theoocurreneettftrueancliylosis by a judicious 
application of pa^^ive motion. One exception may exist to this 
otherwise genend law — when the disorganizinj; processes about 
a knee joint have I>een extensive, aud have caused luxation to 
such an extent that wo are justified in despairing of obtaining 
sufficient strength in the limb, save by bony union. Such 
cases are, however, extremely rare. 

L 



146 



STHUMOUH SYNOVITIS. 



CUAP. V. 



It occaeioimlly ixronrs tluit no trentmcnt will rhork tlio spreatl 
of the suppiirHtioii, or the case may ouly prosfiit itself to our 
iiotiL-o when the malady is already advunw'd. niid the |)atieiit*8 
health broken; when al>«oe«sos have formed amnnij the deep 
muscles in the neighbourhood. In such mifavourahlo circnra- 
staucos tlie surgeon's thoughts at ouce revert to his knife and 
his saw, and very frc»piently the^^ nro llio only mcaiiHof Having 
life. The operationa to be chosen and the reason of their choice 
are tlio subjt?et uf a special cliapter; at present wo are only 
occupied in <'on.si(ii'ring how the surgeon sliall save a joint, and 
not how the patient shall lose it Tho oxperionco which I hare 
luwl of the fuug'onH fcirm of strumous rbseaiiie, nn<l the efluwy of 
well adapted treatment, convinces mo tlxat extensivo suppu- 
ration and utter loss of health are tho only reasons which 
should caiiso us to remove the ])art. The mere presence of 
(Onggish gmnulntionB, evidenced by in tract Jibh; and long per- 
sistont tumefaction, is no valid cause for such an operation. 
All ijucli tissue may be made to consolidate or to be absorbed 
by tho adoption of fitting means. 

Oases of rnrs PtsEASK. 

Cask XXVIII. — George Cevenier or Eavatit^h, agc»l 5, n thin, jiale cliild, 
with ruddish hair, a tumid uj^pcr tip, and red-bordcrod ojclida, cainu to 
nie at iho Charing-OrosH Hoapitul <ith Ootobor, Ifi-^Jt, with a Hwelling &t 
the atiklo- joint. Tho boy was in no pain and could walk well, but tlic 
mother obaervwi tho swotting nix days ayo ; the boy knaw uothing about 
it. He had aUo a ahght strumous oplithahnJa of the left eye. 

Tho ankle in Awollen ; the tumefaction in chtcHy risible behind and in 
front of each molloolus ; it extends also, in a smaller dogrco, aa an ill- 
defined bond across the front of the joint. It i« alightly tender, chiefly in 
front of intornal malluolus. 

A splint on the iniiido of the ankle; two bandages to be used in 
fftfttoning it, that the limb just above tho joiut be left uncovered ; to this 
))art, i. u., lower end of tibia, a narrow bhatcr to extt^nd from uno malleolus 
to the nthor : five grains of calomel and rbuL-nrb to-night in tnsacle. 

1 Ith. — The blister rose prettv well ; the boy's eye looks better. Orelered 
the following draught three times a day after food : — 

9. Potasaii iodidi . . gr. ij. 

Ferri iodidi K<*. ij. 

Aqueo ,^. H. 

13bb.— TIte boy's eye better, bub tbo ankle mueh the aamo ; tho blister 
IB healed ; splint to bo fastened en with atrapping-plaiater ; blister across 
iuKtijp just l>elow the joint. 



Ctihr. V. 



CASES. 



1*7 



S<tih. — lie (low Dot get on aa quiokI>' oa 1 ahouM like. The oyoia mora 
inlt&iuod iigain. Kcjx'at the caJonid and jatap as l>efon!, aiitl after ita duo 
QctioD lot the following be tiikuii in tho forui of iiill iii^Lt oud luoriiiug: — 

B. Hydrargyri c. Creta gr. i. 

Qiiina* <tiKulph gr. ij. 

Mist. Aoaciro q, a. M. 

7th. — ^TUe eye nearly well ; auklo not tender: the joint to be tightly 

Strapped after Scott's method, with Kmpl. Keainse ; to discontinue the 
pill ; repeat the iodide of potasM autl of iron &a before. 

From Ihis time he progressed continuously to recovery: was discharged 
fnmi attendance at the end of Novemljer. 

Cash XXJX. — Jane Shearman, aged G, a pale strumous child, has been 
sufferin;^ for twenty monthii from pain and swelling of tho lt.-ft knee, and 
wa« admitted into the Cbaring-Croas Hospital, under my care (through 
the kindnees of Mr. Haucock), Dvccinbur 9lh, lUTiO. The knfi) in Hexed at 
about a right angle ; the joint a good deal swollen, round, and sbai^eleas; 
the child criea when it is touched and when any attempt is made to move 
it : tho Hexors, of course, act against any attempt at straightening ; the 
joint is whitu, not hot; tlio thigh aud leg arc ahrivollod. 

I drew foar lines of linear caut4)ri3'AtioD, ouc on each side of the patella, 
niid one on inch behind each of thc-j^e, and got the limb into a slnught 
position without dividing the teudouH ; for under the action of ohlorofomi 
the contraction of the Hoxors was found to bo vn|untar>' or emotional, as 
was aaspectcd. pu recovering from the chlorofoi-m luid the sleep tliat 
osnw on afU-rwards, tho child esprefifltd no t^ense of i>ain, but &at up and 
began to play with otlier cliildreu in the ward and with toys. 

On the 3rd day the skin between the oauterixed lines looked red and 
intlamed ; on the /ith some aej>&ratiDn at the edge of the charred slough 
had occurred. The horny portion gradually separated, and uu the 

Ut January, 1860, the marks left were simply clear lines of ulceration 
with small conical granulatiors ; they were droaaod with zinc ointment 
and gradually ctmtructcd. 

30th. — The knee was much diminished in size ; all the scars of the 
ulceration aro healed, except the one nuxt tlio t>atella ou the inner aidu ; 
for some reason that I cannot fathom, this idci^r opened oi^t wider than 
tho others ; it is, however, oontraoting, and disuhargett very httlu. 1 
strapped the joint pretty tightly, bandaging the limb upwards from tho 
foot. 

Feb. l'>th. — The line of cauterization healed u week sgo; the knee is 
much anialler ; it is kept tightly strapped, Tho child is aliow«d to he \i\*, 
and to move about hy means of a stool and the sides of her bed. 

March Cth.~-The child wan iioarly well, and her mother insisted on 
taking her out, though I should have wished to have kept her anoUier 
week ; [Msaive motion hod been used, and the joint promised V^ he nearly 
an iLscfid as ever. 

Cafk XXX. — Moriotme Taylor, ^eil 12, a dark-haired girl with coarse 
Anitures. come to me at the Choring-C'roiw flo5pitat --'tnl N<»venilwr, t^'o^, 

L 2 



148 



rms. 



CHAf. V. 



with a diseased dbnw whioli, nhe ttays, U»n tronblfwl her moru nr \em tano& 
abe was three years nld. At that time she feU iIdttd and httrt her arm : 
her mother took her to St. (}eorgo*H nospitiU. After about three weeks 
she aeemed vol! ; but, four mouths oftem'ards, tUo elbow be^i^ii aguu to 
•well, and she woa taken back to St. Geoi;ge*8 Hcwtpital ; thoii to nome other 
places : matter came away, and a sore continued dtHcharging iiU she 
tliuika she was almut five ycani oM. aDtl it was umch longer before she 
Oould use the arm. She has had the present relapse for nearly two yean ; 
she is & boot-cloorr, and could do her work till six weeks ago ; now abv 
wears her arm iu a Hlin;;. 

The elbow ia much swollen ; the whole being a shapeless, conical moBs, 
concealing all tlie »hupe of the bones, ami without distinct boundary 
Iwtween the swelling aud the rc«t of the limb ; both upper and foreonu 
are much wasted. The tumour ia white, soft, pscudo-fliictuatiug, perhaps 
a little hot : the acars of old sixinws are to bo seen below thL> sitiiutiou of 
the outer aud inner condyles ; there ia a very soft place near the latter 
which is likely to suppurate. 8)ie has no starling pains, no tendorncsM of 
the joiut-fiurfaoea ; the arm may bo flexed a little way prrKlucing fdight |iAiu 
and uo grating. 



'Mi 



Ur-^':^ 



Stbumoob Sf bovitib or Ki.now. 



<*ii\i-. V. 



CASES. 



no 



Ordei-odspliDtof^ttA-perchato be fitted to the outer aide, and a little in 
fn>ut of the aril), so as to leave the outer ooiid}'lc Imro ■ it was to be out in 
u rectangular form, to extecid from tho axilla to the bund, allowing this to 
l>e in A poHitiou between au2>[natioD and pronation ; to take two table- 
spoonfuls of tho Mistura Potast<ii iodidi composita three times a day. 

27th. — Mr. Short was good enough to administer chlonjform, and 1 
motlo two long lines of cauterization from two or three inchca above the 
beud of the elbow to the same di»taiico bclotv, ouc a Utile hcblnd tlto 
outer, one a little in front of the inner condyle, taking care to draw this 
latter over tin; itofteued portiou of titwuu uliuve referred to. The iron, 
quite white-hut, wus pasaed twice through eacli line. 

3(>tb. — 11k girl bad gone home when she recovered from tho chloroform 
and was lu no |>a\ti ; to-day the c-lbow smarts a good deal : cold lotion. 

5th Dec. — LiiiL-K of ulceration begin to Hri>aratu the e»chrtr from the rc«t 
of the tiiutue ; tho Bkiu baa a bright rosy blush, but aho a&ya the |ia>n is 
not much. 

i 2tU. — The Hluugha have disappeared. On the afternoon of the day sbe 
came to me, about a teaspuunful of pus tlowe4l out of the middle of the 
injier eschar : it wua in order to lay open this suppurating point that 1 
drew the line over it, for by such means 1 hoped to procure tho rapid 
flUing up of the cavity ; this has perfectly succeeded, tho tissues in that 
part arc as sound as elsewhere : the tumefaction has very much decreased. 
Drcas ihe aorca with strips of lint and nitric oxide ointment. 

VJih. — -Itic wounds begin to contract and the awolliug ia atill decreasing ; 
the oomprebsion from akin contraction ia evident ; the oiutment con- 
tinued, and before putting on the spHnt a bandage was ajiplied tightly and 
sirioolhly. 

26tb. — The woundH healing; Uiere ia now Httle enough discharge to 
allow the application of strapping, 

Jan. loth, l&dO.— The strapping lias been kept applied and tho arm is 
iiiuob diminished. Continue. 

2Hb.— The elbow about tho same size, ou measurement, as tho other, 
though it looks bigger on account of wiiating of the Umb ; no jiain on 
prnwiiro luiywhere ; more j»arUcularly no tendcrnoHs botweein outer condyle 
and head of rA<l)iis. Passive motion carefully employed for about ten 
minutes, and the ann replaced on the splint ; the biceps somewhat ouu- 
trocted. 

SKth. — The arm waa subjectctl to passive motion every other day, and 
the splint retained for ten days after tho above date ; since the 20th a 
bandage simply has been applied and the arm kept in a sling. She has 
now vcTj* tolerable uioveineiit of l)»o arm. Bandage to be diswintinuud ; 
the elbow to be held under the stream of a tap every morning ; throat a 
little sore. Since she has been attetidiiig the complexion is much im- 
proved ; to discontinue the compound iodido mixture, and to take instead 
an equal quantity of Quinine Mixture three times a day. 

Tbia patient went on very well ; she came backword and forward occa* 
aiunally, rather to procure u repetition of her medicine than for the sake 
of anything being done to the arm. Hha had, in lUrcb, no other apjiear- 
anoe of dkeaac than tiie ncars of the cautery in thin rad liuua, a little 



150 



STRUMOUS SYNOVITIS. 



Cbap. V. 



ihiolccuiDg, ilciroUble by touob, about the joint, and umbility to got tfae 
wm perfectly Rtnughi. 

Case XXXI. — Catherim; D"gj^ct, aget] 18, strong, stout, came to me ai 
th« Ctiariiig-CruAH Uo8|>iUl Ittb May, 1858, vitli (liseaned knc«. 

The BweUing fin?t came on, with , 
HODio slight {laiii. eigbt mouthit ago ; ' 
she vaa in the country at the tima 
auil was able to rest ; ebe did not 
l^ut the foot to the grouuil for o 
month ; the paiu wont off, but the 
ftwelling (liJ nut altogether dt»a)>- 
jiear. She attributed the disease to 
a Hli^ht Hprajo. 

The knee was. when I saw it, o 
good ileal swollen ; the (twaHing is 
soft and gelattnuu^ with fal^e (tense 
of fluctuation, round, concealing the 
bliAiie of bone, &c. : she has some [ 
pain ill ii, and a bjiot on the inner 
Hide of the ^latella ia painful and 
tunder, A gutta-percha splint to 
the ouUido of knee; a Miatcr to 
the inner aide and above it ; to be 
followed in three daya by another 
below the joint. 

:£3rd.— The knee ia not belter : 
the pain at the inner condyle is, if 
any tiling, increa.<4e<l. Chloroform 
Mlniinistered ; actual cautery ap- 
plied in two liura on each aide of 
the joint. 
i23rd June. — The cautery liiiCH all but healed ; for the last week the , 
iNUiduge hott tu«u very tightly applied and she liuds relief: the joint waa | 
ittnip)>cd. 

30th July. — The joint is still strapped : it is now very nearly the satDQ ' 
sixa HM the oilier, though innst unatoniical i>oiuta, as the Ugamentuin 
jHitellK*, and lite depreKKionn on both tiide^, are not marked as they should 
ni>rtiiidly be. Ordered rubbing night and moinlng with flour or other 
inert |H>wdor. 
August.— This patient perfectly recovered. 

Cabk XXXll. — 1 wan uskcd by Mrs. T. to see her dmighler, aged 17, 
3(>th September, IS.'iU, with a diseased knee of four yeura standing. She 
has dark long hatr ; a white transparent skin ; very white conjancti\tD, 
h>ng dark ladhee. Ker health is a good deal broken by long ounfinement. 

At school, rather more than four years ago, her kne<' became [uuiirul ; 
*lie mwy have liurt it, as nlie was very fond of running and titiier exercise, 
but di'i'H lint remvuil>(;r )U W'lii-ii the knte Uicaniv.- painful it fiWellcd. 



SrKUMOi» SvsoviTU ov Kki:k 
(kaulv trAUU), 



CUAi'. Y. 



OAt4K8. 



Inl 



She remaiuetl at school about three weoka, atid then wiw huuI liouio. A 
(lastebuiinl b^jliut waa applied to the le^ and tUo joiDt woa blistered -, hod 
twu Usiteti, one after another, aud tha koeo got bu much better that tihu 
could ruUini to ncli^Ktl, but had always to wear the splint; could walk with 
a stick, and afltr a time without. Eight niouthd ago she foU down two or 
tUreti HtupH aud hurt her knee very much ; it bwoUckI agoio, slowly, and on 
atiAcesH bunt ai thu inner aide jwtt below the head of the tibia; a littlo 
aftor that nhv htul ttlarting jioiua at iii^lit, and a woek or ho latur these 
occurrwd aljwi in the daytime, aud they do so now. She deairea notliing ao 
much OS that thtise Hhotild be stoppnl. 

I'hcre is a roundt-d awelling, without defiuition oT edgn, at the kneo ; 
the mouth of the sinus f^till often ; marka of iHsiieH, one on inaide, one on 
outciidc of knee ; the joiut in tender and ahti lia» ulartiug |iaiii8 ; thu joint 
con bo flexed a Httlo without causing any aovcre pain i^r producing any 
grating, but it cannot be atraightcned ; it is in very fair |>oKition, but ia 
rather too much bent, licr mother has taken up roBidonce in town, having 
come from shire. 

3rd October. — The long conlinuod starting paiufl, showing that the car* 
iilji^es ore undergoing ulooi-utiou, would nut allow us lo hoi>e a retittjraUon 
beyond false anchylosis: the first object is to stojt thci^o inins; divided 
the flexor tendon with long tenotomy-knife, and fastened a Liston's splint 
at bock of the hmb with well-piidded Htra^ta aud bandage ; to liavo at bed- 
time a gla5a of sherry with fifteen drope of laudanum. Slept better ; bod 
one or two liltio starts towards uiomiug. 

7th. — lias hod loss storting {>ains siice the first bight; has taken no 
opium since then, but has continued the sherry; thinks it prodncra 
acidity; does not like wine. Onlertd to take two la bk-spuon fills nf the 
Mistura Ferri composita three times a day, and tho following drat^fat at 
bedtime : — 

5. Chloroform "l^ijj- 

Tnc. Aurantii 3iij, 

Aqua; Flor. Aurantii .. ^. M. 
Cold water to be ajtpUed. 

I took the litub ufl' tho .^^plint, ftud by inanipulationa got it straighter 
and put it on ihe splint ogaiu. 

12th. — Every other day the screw has been turned halt round ; the 
joint is nearly straight enough ; strapped tho knee, Icnx-ing the mouth of 
the sintui uncovered ; to continue turning the screw in the samo way. 

19th.— A hitter informed mo on the 17th that iho lady thought her 
daughter's knee was aa nearly straight as 1 had deoirod it to be made, and 
there was a little pain in it ; I happened not to be able to go till to-day ; 
the pain woa at the bock of thu joint, and has nearly gone off; the 
Htnipping hail quite driven away the slight recurrence of starting. Ordered 
a leather splint for the outside aud inside of the limb ; strapped the knee 
still more tightly ; to leave off* the night draught. 

2Bth.— The splints have been applied and tho knee feels very com- 
fortable ; she may now get up and move about on crutches. 

7th Nov.— lias been going on mui'h tho H>ime , ttie auelling in now very 



152 



STHUMOUS SYSoViTIS. 



ClMf. V. 



much reduced ami ia lianlor ; there is aUU a slight unouut of tendemeaH^ n 
partionUrly ovtr th« inner cnnilyle of f«mur : to onutiiiuc in the mmo 
wanner. The iitoiitb of tlio uinttH nearly dosed; hardly diacharges; put 
in a Hhred of liut to prt'vont too early healing. 

IJth — Was sent for; the discharge from the sinns hfw incrcflfled. and 
tho starting^ have returned as I>ad a« buftire ; iiwpowd the cautery and 
agreed to go next day and ii«e it. 

ISth.— Clhlorofcimi administered ; two Hnea of cautcrj- four inches long, 
one on each side of jomt ; Listen's splint t^ain ; re[>eiit iii^jht draug>it. 

19th. — Hud hanlly any jiain on recovering fix>ni tho dilvn'fnnn ; the 
startiuga entirely ceoaed when I saw her the day after— The t^xchiim 
sejiaratiug : to drcsH the huett with nine d^ea^iug, tijjbtly l*andHgt.tl. 

Ordered to take of cod>Iiver oil one taaspoonfiU with the following 
draught three liuiea a day : — 



». 


Qiiina} diHitlph. 


.- gr. ij. 




Funi Hvilphati** 


.. gr. iJ. 




Acidi Kulph. ilil. 


mvj. 




Tnu. Aumntii 


5'J- 




Aqiuu dostillatw 


.Ij. M 



SOth. — The »tarUng paius have not recurred ; tho linea of ulcer from 
tho cuiiBlic are beginning to contract ; the granulations aro amull and 
pointuiL 

12th Dec. — The caustic lines very nea]-ly hcolod ; joint strapped and 
leather splints reapplied. As it was probable that want of ciiro, in bearing 
too much weight vn the htuh, cuuaud the last relajec, I have not ullowod 
her yet to get off a sofa-bed which bhe uses. 

liliiid. — This day have penuitted her to get up and go about with 
onitohos, but she is to use a stirrup for the foot, fastene<1 to tho waiat by 
a band cf the proper length to keep the foot from the ground j there is 
now hanlly any, if any, tenderneea over the inner condyle; the sinus has 
healed. 

31st Jan., 1B60. — I have ucen this {laticnt once or twice ; her health im 
much improved and she has gained flesh ; there ia, absolutely, no temler- 
UGna, and ihe joint in as nearly as possible the sanac size as the other; the 
iat4?lla can just be moved, laterally, by L;ra.sping it in the fingers, without 
pain ; a slight crepitation, uot bony ; |>roduced very slight ^lossive motion 
in joint without i>ai[i ; showed her molhur how to movu the joint, and 
directed her to do it, so as not tn cause paiu, every morning ; the strapping, 
also, Is dii>c^>utinued, and the joint in to be shampooed, nibbed with oil, and 
bathed with hot water; the spUut to ho reapplied after these manoeuvres; 
to leave ufl' the sttrrup. 

3rd March. — Have seen this patient three times ; the limb has mom 
mobihty and is not tender ; she puts the toes to the ground in walking, 
and bears a little weight on th^m ; the joint is auchyhised (false aiicliy- 
loeis) ; passivv motion to be uwd with a little iiioru energy. 

This young lady is now able to bend tht; hmb i>nil htruighten it again 
vohmtorily^ to n fair degree; she wolkii Hitli a «;id{ ur tnobrvlla by 



»!•. V. 



CAHF.S. 



153 



of a high-hccLtil nlino ; more migtit be done towanl!* getting n 
flexible joint, but ahe w mtiier iiiiwiUiiig to have any further attt-niiit, at 
all eranta for the pre&ent. 

ntat 7, a lighl-liaired, pale, fttrumoiis 



Cask XXXIll.— Joliii 



boj, was brought tu iiio by Mr. WatkijiK, juri., of (Imniloa-Strtiot. 2ud 
April, 18C<.>, with a struniuuH iiiHiiniiDutiou of the atiklu-joiiit. Thtu cuiii- 
platut was of threo yeoiV duitttiou, ami appvara to have beeu brought on 
by au injury intiictcd by a largo, Uoav}' womao. in thick boots, baviDg 
atupt>ed back upuu tbe child'a foot; at all uvuutti, he ban not been able to 
walk ttincc that accident^ and the ankle has been gradually swelling tnorc 
and uiure. The UitfiuuUv of diagnosis is iuoreasud by i^ouie Amount of 
nialfonnation, ao that the «ouutl joint even looka a Hltlu distorted ; the 
internal uiiUleolua is very lanfv, and tbc tibia, fruui a little atiove the joint, 
»lo|ie8inilwarils and becomes very KumD ; the axis of the log is thus directed 
inwards, and that of the foot outwarda. 






Stbumocs SvNoviitiJ or Amcu. 



The diflcatied ankle, however, is vory much culargctl, an may bo seen bv 
an eiaiuiuatjou of plate ; the tumour is soft and pulpy and extends in a 
smooth oven m&uner around tbo wholu Joint ; is most marked at tlio back, 
but nuvertlick-tM iit very considerable under and uruund the ninlleoli, oJw.. 



154 



HTK0MOUS SYNovrns. 



OlUP. V. 



ia (ronty conoetUing the markings of Uib eitensor teudoiis ; the rcat of the 
foot is thin, uid the limb above the afTooted joint ia wanted, shawing in 
strong relief the putTjr, ill-oonditioned enlftr^gemcnt, at the back of which 
thore is a red, inflnnicd spot where matter has formed. The difficulty of 
diagnodts referred to conai.<tts in the deformity and large tiinj of the intenialj 
malleolus, wbioh much militates ngainut any certain judgment aa tal 
whether or not the buni.^ ia aflTaoted. Finding, however, tliat uitKlorate 
pressure on the boi>c producBs no pain, and that although miMliajMin, it is 
as near as can In: judged of the same sliape as the other, I am pretty 
conhdent that the bf>ne tit free of disease. 

2nd. — A puncture was mode whore the skin over the suppurated port 
eeemed thinnest, i. e., over the Acliillea teudon ; a bandore was then a[>phed, 
strongly compressing the tumour, but leaving the wound uncovered, and 
he was ordered to take a drachut of cod-liver oil, with iodide of iron, thrice 
in the day. 

0th. — 1 saw the child again, and Mr VTatktns agreed with my idea that, 
the disease being a strumous inflamiuation in the sluggish stage, preaiture 
fairly applied offered us the beat cbanoe of aoouring the aheorption or 
(ibrification of the morbirl growth ; therefore the foot and ankle were 
tightly aml«uio(ithly6trap|iod, after Scott's method, with the remu plaisttr, 
leaving the oi>eu wound uncovered, and he was ordered to continue the 
cod- liver oil. 

13th.— The slTappiug having become loose it was removed ; the swelling 
was ooDsidcrably decreuRed. 

Sfith May.— itr. Wutktas baa been attending to this patient since the 
last date, and has been oarefuUy and skilfully carrying out the plan of 
treatment which had been laid down ; the child's ankle was much reduced 
in fiii!e ; thcro was no pain on pressing the tumour, nor the bone, nor on 
prvaxing the joint- surface together ; the limb wos again strapped ; pods 
are now ueceoaary under the mallcolL 

9th June.— Ktill going on well aa far u the ankle ia concerned; tlie 
tumefaction ia reducin;;, and thoro is no pain ; the cod-liver oil no longer 
agrees ; it seems to diminish appetite ; the weather is getting warm ; he 
was ordered to try oold bathing in the mfiming, if he remained chilly after 
it to use it tepid at first ; to t^e throe grains of the ainmonio-citrate of 
iron i the ankle was agiu'n strapped. 

3rd July. —Has been under the care of Mr. Watkina ; the same plan of 
treatment has been carried out, and with such success that the tume- 
faction has greatly decreaaed, indeed, t)io ankle Ir very nearly the same 
niiDe as the other; ho can bear pressure ou the bottom of the foot as 
strongly aa I can produce it with my han<l, and this does not give him any 
iniin ; but 1 cannot [persuade him to put any weight on it in walking. Thu 
eold bath has not been used ; be looks pole and worn, but his api)etite ia 
very much better; the ankle was again strap[red with pads under the 
malleoli ; the cold bath was insisted ou. 

13th Aug. — The lx>y wom brought to mo twioe since the last date ; the 
ankle is not at all |iaiuful ; the wound at the back has healed, but the boy is 
si> uervuut< that it is very iliflieult U> umke him put the heul )>rui(crly to 



caAi'. V. 



CAttl'X 



135 



the ground, altbou;;ti I oau proe» the foot upwarUs very timi]y, forcing tho 
articular iiurfuces tcgeihar more strongly tliaii liiit weight would do. 

Sli&inpooiug and cold douche ; motion }tMsivu and active. 

I saw thiH paLieut uu the S4tb Sepiembur ; his leg was still tbin and 
weak, prex'onted his walking without support, but tho joint is i>erfoctl; 
auuud uud tho limb gaiiui strength ovor^r day. 

O.VSR XXX IV. —William King, aged 33, admitted into Cbaring-CrosB 
Ho«piT4il, under the care of Mr. Hancock. May 3rd, 1S59. Ho bail been 
and van Buflohiig sevvrcly fnuu di-st'oaed knee, luid came into the house 
with the intention of having the bmb amputated. 

Ho ha^l been a porter in tho Uorvugh-Marktit, but had of Iftto taken to 
a sedentary occupation. 

There IK a good deal of BWoUiag in the joint, evidently in iHirt fluid, and in 
part solid ; he coujpiainM of a " bimiting, forcing iiaiii," alwo, nf a " gnawi]ig 
pain : " but hia uio«t bitter oomplaiuta ore against a st-urtiug of the limb, 
which comes on at night just at he is dropping to i^lcup, and wak<.>H him 
uj> in great dread. A iiuus comniuaicatca with tho interior of the joint; 
a probe passed into it comes acivjsa bare bono about tho edge of the inner 
condyle of the femur. Man's health much broken, but no sign of any 
visceral disease. 

14th May, lB50,~Chloroform was administ^i^d; Mr. Hancock excised 
the knee* 

Eraminaliou of Vismae. — ^The joint was greatly distended by thin pua, 
in which floated ouo or two shreds ; this escaped during the oi>eration ; 
the whole inner surface of tho synovial membi-ane was either covered by, 
or cfjnverted into, a pink, soft material, of a pasty consistence ; it was very 
abundant in the snbcrnreal sac, it encroached upon the patellar, femoral 
and tibial artipular surfaces ; the subeyoovial and periarticular tissues 
were quite gelatinouFi. 

The bones sawn 00": the cartilage was found ulcerated all round the 
artieular tniHaces ; in this part the bone was laid bare, and uvuti Horne of 
that tissue had diaapptared, there being a larger angular interval botwoon 
the tibia and femur than oould be accounted for by the more disappearance 
of cartilage and fibro-cartiluge (for this latter was alto abtMnt) ; Uiis 
iulcni'al was filled uii by a sofl gelaliuous mass, growing, ajipanjutly, both 
from the bare femur and tibia, also from the synovial UsttueK ; the crucial 
ligaments were convurtud, hkewise, into a soft, jtiuk tissue, tlirough which 
a few gliatouing fibres ran ; the cartilage was gone from the inner edge of 
the imlella, and false membrane sprouted out of the bono left bare ; the 
post of the»to cartilages wore niilky-wbito in hue, very soft, and occopliug 
tho impress of the nail from tlie wligbteBt pressure ; bone*, on being split, 
showed red blush inside the articular extremity, which got less as it 
receded from that part, 

Mt'crtisroyif J^jtiinitittiUm. — The Bofl new tissues showed the same eon- 
ftuion of oella and Ixire nuclei as havu been alruadv <lcscrihed, but a Urge 



* |-i|illiil' iticounl oflVUir' Hll'lcl (III- llriul III' Kki'lMlnh. 



156 



STIIUMOL'S SYNOVITIS. 



Ciui*. V. 



number of theao couc&ined oil-globules; the number of free oil-globden 
was very sti-Iking; this was clearly proved by the «lditioa of liquor 
l)ota88n< and sulphuric j^ther. 

VartSagfs.Soot'wi\ showed the corpuscle* to be liirge and tho cells 
therein remarkably evideut ; the hyaline substance was, in parts, [ilaiiily 
Btiiated. In order to get a part clear for the use of a Valt»nt)u*& knife, tho 
bi'iim was sawQ through again at one corner, leaving the cartilage ; and on 
breaking this and separating the fragnionts, a thin, tough film was drawn 
from thu free surface like a fine transparent mciiihrane ; placed under the 
microsco|>e tliia showed some Urge cartilage cells more thinly scattered 
than usual, since there was a hyaline part which was finely mottled, 
granular and studded with oil-molecules. I found that 1 could, in all parts 
of ibis case, produce a similar membnuio-likc beard. 

With a sharp Valentin's knife somo very thin sections wore made, one or 
two of which preserved tho outer edge ; there is hero and there a tnark'nf 
separation between this margin (U-013 of a Uue thick) and the rest of the 
cartilage ; sometimes an actual sciNkratioii, sometimes no hue whatever, but 
in all parts continuity of stnictiire and continuity of coU-altcration may 
be traced between one portion aud tho other ; this outer portion would, in 
a short time, have been shed in fragments into tlie jointr«avity. 



Ca8B XXXV.— Daniel Hogan, aged 30, a dark-complexioned man, rather 
above middle height, young-looking, a machinetoan at a printer's, came to 
me 20th March, ISOO, with a bad elbow. 

About fifteen years ago he twisted the left arm in some game ; it was 
painful, and in a few days swelled; ho went to King's-Co liege, they applied 
blieters and iodine, the swelling at tho inner side increased and it was 
lauced ; some pus flowod. Before tho skiu was voM, however, ho went to Mr. 
Vcrral, who put on a sphut ; and then to St.-Bartholomew's under ilr. Skoy, 
who leeched it, and in about a fortnight lancod an abscess which appeared 
at iuner aiilc of upper 3rd of forearm. All this took place in about a year 
or eighteen months ; motion of the arm was painful, hut 1 cannot make 
out whether or not the inflammation was in tho joint; at all events, ho 
got so well that for tho last lifteeu years he has been mochiiicmaii at a 
Iai;gu printing-office, having frequetitly to lift heavy weights, as a form full 
of tyjte, and, owing to a snia^h of the right hand, hu» used tho h^ft one 
most. Five months ago he had a swelling form ut iuner side, just below 
elbow, which got rapidly bigger, and in throe weeks became very |kainful ; 
ho went to a medicmJ man in tho M^aturlucv-Bridge Hood, who louoed it ; 
tho pain was a heavy and Imrating pain. A month ago starting i>ains 
came on. 

2ath March, — The elbow-joint is much swollen ; the swelling conceals 
the shape of the bones, is rounded and shapolesa ; the arm above thin ; 
th#i turneracUon is evidently in and around the joint; it presents n false 
sense of tluotuatinti, which is charoctiiristic of strumoiui synovitis ; the 
skin is rei.1 at inner side and below elbow, where there is on opening dis- 
charging pun : a probo passed into it enterfd the joint, but did not 
come in contact with ba» bone ; \u- .;;uiii.it U-ar tli. Hli-'htf«t moveinent 



158 



STRUMOUS SYNOVITIS. 



Chap. V. 



bmtjuii. It was Bsplairied to him thai hurdlr Uiu raiutest hope existod of 
saving tbo joint, aud ho was odvi.sed to ]>ennit lU removal : be wished to 
IMMstiKJiiy this. With a viaw of trying to [iruveiit the startiug iwiu the 
joint wu tightly utrappod. 

l(jth. — Ho bad. after being strapped, a couple of the Htartiug pain«, but 
has had nooo since ; has slept very well. He tells me t^ilay, for the first 
time, that for about a month i»uit, whenever he has le&ut in a certain way 
upon the elbow, he has hod a peculiar sensation^ as though one bone 
tdip^ved or ghded over the other out of place. 

30th. — lie haR continued to be free fmm the ntarting painfl and hifl looks 
have vr;ry naich improved ; Uto ctbow in reduced in ftixa and harder, but 
the last fuw dayH he cotnpbuns of pain over thti outer condyle ; an altficeaa, 
very superficial but of large extent, was found ; Ibe skin was disooloured 
and evidently »ei>iirati.'d fmm the wibjiioont Umsuun for sun^t) dtHtuiia; ; it 
wa:^ fruuly incised: blod nniartly, to titop which pressure was applied. 

:^ud May. — Tlie tiart of skin which was previously blue and discoloured 
baa ulcerated ; tlm sore is oval, about an inch and a quarter long by three 
quarters brood ; the upper ann is Hwollen ; strapping appUed more lightly. 
I learnt, in the earlier pitrt of the case, that this man was able to live 
pretty well, having, it appeared, ttaved a little money, tut it is now 
exhausted : he is evidently badly fed. 

Qth. — The upper arm is sn-ollen.ii'ith <lcep, hard tuinefiiction ; again cxa- 
mino'l the Umb carefully and paasetl a probe aloug eiuus at intiido urm ; it 
struck bare bone, or rather seemed to iiass iuto a uliafsm, with hare, rou{^ 
not crumbly bone, on every aide. It wiis now pointed out to him that he 
had better make up his mind to the operation and come into the honwe for 
that purpose; to all this he agreed, but he could not bo taken in ; the 
following week the strapping was discontiuued, but the -dtarting j>ainB 
recun'cd with so much violence that tiia health begiui to sufVer, and it waa 
roappUod. 

22nd.— Ue came into the house, under my cure, by the kind oourteay of 
Mr. Canton, and on the 

SGth. — I excised the joint.* 

Kxamimition of Joint. — The synovial membrane was Uned, and the sub- 
aynovial tissues thickened by remarkably soft, yellowish jelly ; on neither 
humerus, ulna, nor radius wms there the slightest trace of cartihige ; (ho 
cancelli upon the firat and lost of these bones lay bare, except that a soft, 
pulpy tissue seemed to prow out of them. The cancelli of the hnnionia 
wei-e not bare, but a holo, about the size of tbo bulb of an ordinary probe, 
in the centre of the surface^ led to a cavity in the bone that wa.s filled with 
pus. 

The man has done extremely well 



* For the rest uf tills cose see Exctsiou. 



Cbap, VI. 



CHHONIO KHBUHATIC SYNOVITIH. 



15!) 



CHAPTER VI. 
Chhokic Rheumatic SvNoviTre, 



rATBOLO(*T. 

mis diseaso is less common than tho frtnimons nialady; it 
Hclduni commeupos in a t-liroiiie form, but is usually tlie residue 
of au Bcwte synovitis, eitlier brought on l>y w^;ideut or by ncuta 
rheumatism, 'lliere is no doubt of the inflammatory nature of 
this disease. Pains were takua to show, at porhajis too great a 
length, that the joint affection in acute ^he^matis^n is an intlam- 
matory disease (see Chapter III.) ; because if the acute malady 
Ihj not inflammation, still less can thechmnio disease be (»f such 
nature. Uut as it is proved that acute rheumatism really pro- 
daf>e8 joint inflammation, so is it unnecessary to go further to 
show the naturo of the chroni*; attack. Wlmtever may have 
been tho origin of the primary acute disease, whether it have 
urisou from accident, exposure, or rheumatic fever, it will, on 
subsidence, liavo left behind it much tho same condition of 
parts. Tho s}-novial niombrano and snbsyiiovial tissues will be 
thickened and the cavity will contain an abnormal quantity of 
fluid. If th(? iroiistitution bo healthy, these relics of the mahuly 
should gmdual[y disappear: but a constitutional evil is likely 
to prolong their existence. Wc have seen that after a slight 
injury a synovitis may arise, which, as it falls into a more and 
more cluxjuic stage, may become endued witli marked stmmous 
characters; the diathesis prolonging the inflammation and 
impressing its own clwracter of non-<levolopment u|>on the pro- 
ducts.* In the same way, if the diathesis be rheumatic instead of 
strumous, an aeuto or subacute inflaiumatiou may be prolonged 
into oliromc rheumatic synovitis, the products of tho inflamma- 
tion receiving the stamp of the constitution. Tlie histories of the 
two forms of iunummution are, however, gouerally different 

* Lot it, howt>ver. hi- romcmlMjn*<l llml strtimouK tiyiutvitu bvgius (titcii lu :> 
elironlc duipoiio. 



160 



CHRONK^ KHKirMATIC SYNOVmS. 



CHAI'. VI. 



bocaose the etnimous freqiienUy begins as a clirouir nmWly, 
niiining a tolerably even nonrse from end to oiifL The rheu- 
matic diseiise very nirt'ly liegins otht-rwise tlian after nn acute 
ittUick; it is subject to frequent remissions und exucLn-batioiis; 
each of the fonucr following, rest and treatment, each relapse 
being generally preceded by some imprudence, over exercise or 
expofluro to cold. 

The first acute and each subsequent attack of inflammation 
cousists. OS all inflammations of connective tissues do consist," 
of ]»iiMitifiil piumlation, i.e. j^niwth of cells. In the rheumatic in- 
flammations the tendency of thin growth is always fibrinogouous 
— organizing; hence the iuflnmmatory product, or thickening, 
instead of remaining in tlie soft gelatinous stage of fnngoiil 
grttnidatiuu, Lec^imes a tough firm membrane. Thus tlie tiKsue 
never reaclieB u rank luxurionsness of gronih, since most of the 
cells, iusteail of generating new celle, bewnne transformed into 
fibres, and those fibres contract. The iimer surface of the syno- 
vial membrane is ther<*fon! hard ; presents lotig rounded undu- 
lations, wliich run in a direction round the joint, and are separated 
often by rather (hjep hut narrow lissun>s; the colour of the 
tissue is uf a light red-brown, about the hue of calf leather. The 
section is evidently fibrous, na ap[>eamnce more easily visible 
when the tissue, which is tough, he torn, not cut This material 
occupies the place of the synovial membrane, that fine fabric 
having disti])]ieared in the much coarser 8ul>stj»nce. which is 
formed around it and im its surface. The growth may be of 
variable thickness in different cases, indeed in ilifferent )»art8 
of the same ease. Thus at the luiee it will be usually pretty 
well developed on catdi side of the ligiimentnm patella', will 
be thinner at the back, but in the subcrureal sac is fonut'd into 
a dense hard cushion, which not uncommonly almost filla up 
that spa(re, and sometimes does so altogether. 

If a thin section of the material be made, and it be jdnccd, 
without much disturbance ami no tearing, under the microscope, 
it will apjH^ar at first sight to consist entirely of cells, fusiform, 
oval, and round, very closely packed together; a more minute 
examiuatiou will show that the oval and round cells are, except 

* S(>f prpvioiw Chapter, nnil mr jn- 1 .lointii,' in Benlff'i Archin*. NoTMnbor.. 
I>cr 'Oil Omnulation m U Aflcet« the | ISaii. 



Chap. VI. 



FIBROUS THICKENmO. 



163 



on tho surfnoe or new parts, siniill in nunibor, and that the tissno 
also contiiiua a great number of fibres, which cross each other in 
ever)' dinwtion, and give a 8tron(*ly striated and croes-harrod 
brok to the section, at tlie edge of which tho fibres, projecting 
beyond the UmitB, arc very visible. On cxiimiiiin^, iiistoad of a 
flection, a shred, which has Ix^en torn in pieces with needles, tho 
fibn'B appear more or less separate, and may bo seen to be long 
cell-tibres, in many of which the nuclei are still pt;rfeutly distinct 
The looee oval and the few round cells hare almost disappeared 
in the tearinff, and uncover certain torn jKtrtions of a bouioge- 
neoiis membrane, which evidently, in its uninjured statu, |>er- 
meatcd tlic whole ti^mie. How this membrane is formed from 
the cells, or whether it be formed from tlh-m, ur only by them, 
it is extremely diflicutt to say ; it scorns to me that the round 
cells of tlie tissue have wtlidified this membrane out uf the snr- 
rtMinding fluid into an intercellular suhstauce, comparablo tn 
the hyaline material of all celhdur Htnictures. The new groivth 
remains a very short time in the form of granolation, but 
becomes very quickly a fibrom* membrane. AVhen therefore 
the part has been for some time free of any inflammatory 
attack, tho thiekouing material consists simply of fibres and 
elongated cells, like any other condensed areolar membnme. 
We seldom get an opportunity of examining the parts in this 
condition of leugtliened quiescence: tho patient will have died or 
the part will have been removed under an iunamnmtory attack ; 
and under such conditions the eel I -producing ouerg)- comes mto 
play, no that we find newly formed round cells even in tlie old 
and perfectly fibrated portions of the condensed nnd now rein- 
fiamed tissue. 

This tough pnxiuct of infiamniatiou grows much more slowly 
than tlie exuberant gmuulatious of a strumous synoWtia; its 
inner siu-faco is smoother, and, as in the last^namcfj disease, the 
cartilages are less covej<'d ; although from addition tc its inner 
Burfaco the synovial membrane will of course overlap them more 
than in a state of health. 

Ill all cases tho joint contains an increased quantity of fluid, 
either thin synovia or synovia rendered opalescent, or perliape 
actually opaque, by aihuixtare with pus. Much of tiic latter 
comes from the imier surface of the tiiickoned membrane, i.e. 



162 CHTtONtC RHEUMATIC SYNOVg-IS. Crap VT. 

from the last layer of oeUe, bnt some of it emanates from tho 
aleore in the cartilage ; tho amount of its ndmixtiin^ has gene- 
rally njipt^an^d U) me |iroi>ortioiuite to the amount of such nlcera- 
tiiJUd. I have novor found aljscesece in tbw thickeued peri- 
articular tissues, nor in tlie Hheathes of tondoua, nor among the 
doep muflelos. When tho tendinous sheathos an? ftffet*tt>d they 
ftre eitlifr distouded with sorous or synovia-like iluid nr, in older 
eaten and a ninru cJironiti tttji|;i', are thickened and jmrtly BUed 
with fihrniifl material. This [wculijirity of the rheiimatie intlain- 
uiution not to suppurat^j ia a mere corollary of the law, that mc-h 
an inJIammatimi tends to fibrinate — for the cell cannot fulftl two 
deetiniee, tho formation of the libres and tliat of jium ; and as in 
those cases they are employed in tlio production of tough com- 
pact tissue thoy cannot at the same time generato tho lowly 
organized and vegetative pua-cell. 

The (cartilages in their turn beoime inflamed, and exhibit in 
some parts a snperabundant cell growth, beginning at tlie froo 
snrfAce and ending in ulceration through the thickn<>ss of the 
frtnicture: the uleen* thus formed are generally clothetl at thri 
bottom and sides witli fibrt«. In other jmrts, and M>n»etimpa 
cloBe to such an ulcer^ a surface of polished bone will be found 
on a level with the rest of tho cartilago, and tlierefore of course, 
projecting Ix'yond the articular osseous surface. There is no 
donbt that this bone is formetl from the cartilage (seo Case 
XXXVl.). I have never ffiund mieh ossificatton of articular 
cartilage exct^pt in rheumatic disease, and it is another instance 
of tho organizing tendency of that form of inllammation. In 
other cases we find these stnictnros lose their pivuliar white 
opalescent or milky app4'arance, and become of a lightish brown 
wlODr, abnormally transparent^ and at the same time very thin. 
This change ia also due to an ortsifying process, more evenly 
distributed ; to one wliieh, instead of being confiuo<i to n Binall 
spot here and there, is distributed over the whole articular sui^ 
face of the bone, and causes a gradual encroachment of the 
Ofiseous uiion the cartilaginous structnrps. This mode of action 
is peculiar to the more chronic forms of the disease. 

In more rapid cases, in which the ulceration of cartilage and 
tlie lftcalizo<l spots of ostiificutiun ajtpear, it is not unfrequent to 
find part* of the eurtilug"' with its articular himella det^ichod 



CHAP. VI. 



OSSaiUS THICKEXINO. 



1(^3 



from tho bone. In a ease reported farther oa (Cobg XXXVI.) 
all tb^*se thrL»e couditious won" present- In Case XXXVII. 
then) were (>tily the grudual tluuniiig of the cartilage and some 
ulcers apparently old. 

The boue is fomid nearly always condensed, i.e., tho walls of the 
cancelli thickened, and each cavity proportionally diminished in 
size, the whole therefore heavier. This is often strongly marked 
in the portion next the articular lamella, whore tho hone becomes 
almost solid. Besidf'S this, thf^ inflammatiou, as it spreads from 
tho synovial, afiecls the iibrons tissues, viz. tho pericjstonm, and 
others lying close to the bone ; the iniiamnrntory produ'/ts wliJch 
these tiirow out do not stop in the condition of graimlations or 
new tibrons-tisHUe, but actually advunce to ossification, thus pro- 
ducing tliickeniug ; and, as much of the new material is in irregular 
masses, the so called ostcophj-tes. Such growths are very rare 
indeed in strumous synovitis, and when they do occnr, are quite 
small and unimptirtant In stnimous osteitis they represent mere 
roughnesses, overlapping carious depressions. In rhcomatio 
synovitis they take a more importiuit place, but still do not 
attain that stalactite form of exuberant growth whiclk is seen in 
tho so called rheumatic artlu-itis. 

When the cartilages have become more or less destroyed or 
osHJfied llio bones of the joint begin to grow together, and in 
this process again tho organizing ehuract^T of the disease is 
manifest. At the knee it is the patella which is first fixed to 
the outer condyle hy a thick broad elevation, which appears to 
emanate from both the bones: the femur an<l tibia tlien become 
united also by broad new growtha When we look at a joint 
anchylosed by this form of synovitis we find that the junction is 
produced by consiilerable addition ; genen*lly tho patella unitt's 
first to the outer condyle of the femur by a broad osseous pro* 
cess that seems to grow from both Itonos ; theu the fenuir and 
tibia become joined, also by processes, that arise from the two 
condyUs of the former and articular surface of the latter ; the 
inter-condyloid groove thus remains oj»n and forms a foramen 
nnmingtlu-ough tho middle of the conjoined bones. I believe tliia 
sort of junction to bo assisted by adliesion to the bones and stib- 
BOtpient i>ssifioatton of the interarticular cartilages, but it is not 
possible te Asaevt positively that such is the case. The mode of 

u 2 



m 



CHRONIC RHEUMATIC BYNOVma 



CnxT. VI. 



bony anchylnsifl is very different to the etnimous, in which the two 
bone« BGt -m to sink iuto one another, and to he bo joined, instead 
of bfiiuji phied to]jri:thi'r hy a cement Iwtweon tlicra. 

There is n pccuhar look about bouea in tliis state ; the natural 
elevations and depre^siuiis become exaggerated, the surface here 
and there ron'^heneti by an ostoopliyte; the oju^nings. whereby 
little artt'irial twigs find tlieir way into the inside of the spongy 
tissue, and which are normally very small, beeome plainly visible 
holpH and grriovcs. In fact, the bones, without being very per- 
ceptibly increased in size, are exaggerated ; as it were, euricatured* 
On splitting a bone of this sort the spongy texture appears 
redder than natural, unless the disease bo far advanced; some 
parts seem [^iler, mi>n' yellow, and on elotwr cxaTniiuition will 
be found harder ; the external shell of the bone is thicker than 
normal ; sometimes very considerably so. The condition of the 
part next the joint ch-pends in grciit measure upon the more or 
less advance*! form of the disease, u|>on the suhacute and remitr 
tent, or upon the chronic, continuous and gi'adual form ofthe 
malady. In some eases the caililago and the articular lamella 
ore hem and thert? ulcerated through ; the cavity of the ulcer is 
cut oflf from the rest of the articular facets by thickened 
oweouB material : in other eases, and in other ]>arts of the Kimte 
case, a great jwiiion of the deep surface of the curtilage is ossi- 
fies! ; here the articular lamella has to a great degree lost its 
peruliHrity of |X)sscssing no lacunae with canaliculi ; many of the 
black undevelopwi bone cells have thrown out such prolonga- 
tions, and the structure assumes more and more the ordinary 
characteristic of Iwuur tissue; uutil, in tht* furthest advanced 
parts, those where the whole thickness of the articular cartilage 
is ossified, the structure becomes ordiiuiry bone. If such an 
altered spot he, as somiftfhies happens, opposite- a piece ofthe 
Otlicr hone still covered by cartilage, nnrinal or ossified, and 
if motion of the joint be still allowed, its surface becomes 
polished and as smooth as glass ; but if the spot be opposed to a 
part on the other Ixtne similarly circurastAnced, and no motion 
of the joint be permitted, the t»o grow together by the forma- 
tion of new bone between them. It thus frequently hapi>ens 
tluit some part of a joint will U- grown together by bone while 
ju other parts cartilage is still remaining, and thiiil, purulent or | 



Chap. VI. POLISHING OF OSSIFIED CARTILAGE. 



1G5 



otherwise, is bulween tho two surfaces. The iirocess is another 
iii8ta!»ce of the orgfainzing quality of this sort of inflainmation. 
I have never found in any otln?r form of syudvilia the black 
celis of the articular hiUiella tlirowing out canaliciili. 

Some of th*!8e eaaes, however, will not nnchylose ; but tho 
cartilage Iiaving been ossified, the bone will polish, and the 
Bufl'nrer will use his limb. Sueh cases are rare, but yet suffi- 
ciently common to deserve notice. The roiiKideralile effusion 
which attended tlie commencement and the first few attacks of 
the disease mil have produced such liixily of the Hj^aments, 
and perhajis other oauseB will aid in loostming the joint to such 
an extent that the altered articnlar eurfaces slip occasiounlly 
from each other, setting the limb fast for a time. Jn two cases 
of this sort, reported at tlie end of the chapter, the imticnts 
were iu the habit of tying a handkerchief tightly round tho 
joiut to keep the bones in their place. 



Symptoms. 

This malady, as it arises from a more or less acute attack of 
synovitis, has always a certain and clearly-defined commence- 
ment, wliich may bo either in some accident or in an attack 
of atmtc rheumatism. Its furtlicr history is one of improvo- 
mcnts, followed by relapses; alter a time the patient himself 
perceives that the oiacerbations become more severe and 
longer. It may be that aftt'r the first acute attack the joint is 
80 little injured lliut it can l»e used without inconvenience, 
except that iji the morning it is "a little stiif at starting;" 
but each successive relapse adds to tlxe swelling; tho stiff 
ness becomes pain even in the intenals, and at liLst there come« 
an attack from which ho does not get well. 

Each of the seiwrate attacks will leave beldnd it additional 
thickening, and as each pr'niuc'cs increased eSusiou of fluid, it 
follows tliat it will be attended with more pain on each occa- 
sion, ccFtiTiJi pariMt*, than the last, since there will be more 
tension and more fulness. 'I'hc symptoms of the first few attacks 
will be those of acute or subacute inflammation ; but tlte subse- 
quent ones will [irescnl tlie clianietiTs of uld disease ; the fluid 
will be less plainly feh, the thickening will be very evident : 



106 



CHRONIC RHEUM ATIO STN0V1TI8. 



Ca**. VI. 



the shape of the distended stic, well marked in an ordinary 
acute synoritiB, will be altered in a way soon to be deecribi'd. 
On questioning: inioh a ptitiont, wo shall leani that since the 
last rekpse or two the joint has never been sound or well ; that 
pain always came on at night in the warmth uf bed ; that from 
the ftfli*ect*id part certain vague pains wandered about the dis- 
eased and the other limbs. 

The Qual attack, that which ia never to leave the joint in a 
condition to be nsed, may not winnncnoe in a nitinner more 
severe than usual ; but as the miH^htef has reached a certain 
point, very little is required to spoil the whole mechanism. 
The ihape of a joint in this condition id uf a square angular 
character which is very reuiurkiible ; the outhnes of the swell- 
ing tend to the straight and the edge of the tumefaction is 
clear find dcfiniKL This shape appetirs to mo duo to the con- 
tracting nature of the fibrous material which, being towards ' 
the centre, binda tlio subcutaneous tissues and the skin itsel 
firmly to the bones. The tumefaction is hard, elastic, in most 
parts leathery, and uulcsii the cavity be very iiili of tluid, there 
is no sense of tluctuation over the joint as a whole ; and even iu 
this contingency the fluid is folt to be se])arate<l itvm the finger 
by a dense tissue. The bursifomi prolongations of llie synovial 
sac are favourite Bo&tH for formation of fibrous tissue, and tluis 
iu the knee the subcrureal sac, iu the elbow the pouch beneath 
the anconeus and triceps feel bnnl and him|vlik(;, very mu<^h 
like additions to the lower part of the mubclcs, or like pads of 
In<lia-nibber. In old cases the tluid will, in one or perlinjH two 
places, approach nearer the surface, tho wall having become 
thinner in this situation, and, in the same way as an abscess, it 
will point 

After a time, starting pains will be added to the otiier dis-j 
tresses, and these are more violent than 1 have ever found them 
m the stmmnns fnnn of the malady. I have swn a |Mior fellow 
start up and seize tlie knee in a sort of fury, grind his teeth in 
agony, and break out in a clammy |>erspii-nt ion; but this cose 
exhibited them in on nnnsiially vi<tlt'nt manner. The limb, 
already much thiimer than the other, begins to waste very 
rapidly and n-markably ; the mitsclei^, [lortJimlarly the flexors, 
got thin, while they remain contracted, feeling tight and sharj). 



CUAJ*. VI. 



SYMITOMS. 



Iti? 



like cords beuentli the skin. Tenderness of the joint snrfAees is 
nut uaual, and wbcn it comes on lasts only a little time ; ou the 
other hand, br»uy grating ii^ common, and often continues to the 
end of thu case. The heat of tho part is greater ttum the slow- 
ness of the inJIammation would warrant ds in expecting; it is 
not of com^K! equal to that of mmto rlieumatism, but is more 
than in any other form of chronic synovitis and considerably 
above that of the fuUow joint. 

The redness is in tlie first few attacks well-marked, after- 
wards less 60, probably on account of the greater thickness of 
ports; but in the continuous iiiHauiination, which always comes 
on unlees the malady be cured, the hue of the joint is deeper 
and of a wanner tint than the rest of the skin. The bn^niish 
line which may have been imparted by the action of blistei's is 
not, however, to be mistaken for a morbid symptom. 

The jouit is not nnfroqucntly movaible in an abnormal 
din>ctii)n ; tho tibia may be pushed back, even from side to side, 
or the ulna may be moved laterally over the humerus. This 
is sijmotinies accompanied by wry severe pain luid violent spas- 
mnlic contraction of the rau8cle«, setting the limb fast until the 
bones be replaced; sometimes, on tho contrary, no pain is pro- 
duced. The abnormal movements are always attended by a 
peculiar hard grating, harder but less rough thtui Uio crepitus 
of fractiire. 

The eheiithes of tendons, as of the ham-strings, if the malady 
bo situated in tlie knee, may generally Int found, m advana^l 
cast'n, thickened and enlarged, as well as hard from contraction 
of the contents. 

It is worthy of notice, that as the constitution fails, in stru- 
mons cj»6t*8, the lungs are extremely apt to suffer from a nithor 
rapid form of tuborculoBis. In rheumatic cases those organs 
incline to be affectetl with a [>eculiar dry form of bronchitis ; 
there ia expectoration, in the morning, of little hard lumps of 
mucus, more or less dark in colour, an<l the broncliial sounds 
are harsh and whistling ; the mucous membrane of the tubers is 
thickened. Tlie heart, m one case that I saw, was slightly 
diseased ; there was a rough sound on the systole ; how long 
this had been present could not bo determined, but it mcreescd 
(>eree])tibly as tin; case went uu. Such an addition to the 



168 



CHBONIC RHEUMATIC SYNOVITIS. 



Chap. TI. 



disease is, Iiowever, a concomitaut, lirought oil by the rheumatic 
coudition, and is not to be regarded as produced by the joint 
malady itself. 

Treatment. 

The Hjftth^Mff^ a|M)n which the continuance of this malady is 
fonnded has bem the subject of much obBenation and H{)oci]Ia- 
tiou ; we have in all probability arrived at a correct kno^vIed<;e 
of iti morbid poison, but its treatment nov<'rtheIess is sciuvely 
satisfactory. Thia is not a matter for astonishment, for wlieu 
it is considered that the source of the poison is the molecular 
change, whicli every particle of the body at some time undergoes 
(sec Chapter III.), it is rather surprising that wc can do so mocli. 

In the whole medicinal treatment of the disease we find 
two separate conditions to be considered : tlie fii-st, an inllamma- 
tor}' htiite, when the local mahuly is active ; tJic second a 
quiescent state wlien the synovitis has yielded, and the system 
is accumulating a fre«h dose of the pfjison. I consider tliia 
separation of tho two divisions as of extreme im|)ortance; for 
while the active stage; lasts, our endeavours will uiid ought to bo 
directed to choc';king the disease then going on ; if, after the 
attack is over, tlie patient take himself away or bo left to his 
o\vn resources, a relapst! is idl Init certain ; but this very time 
of quiescence is that, which should be seized upon as the period 
for troathig the coustitutiomd root of tlie disease, and for pre- 
venting a recurrence of the inflammatory condition. 

Treatment during the attack : General. — This particular form 
of syiuivitis, is that which, of all others (except porliaps the 
Hy|)hilitic), benefits by the use of mercury pushed until it affects 
the gums witli more or less rapidity acxjording to the violence of 
the inflammation. The mo<le in whicli the medicine is to bo 
given may bo either by the mouth or by tlie skin of tlie in- 
flamed joint: this hitter methrxl must bt^ referred to again j it 
is necessary to romepiber that this resource will be cut off if the 
medicine be given intomully Boastoafieettbogiims. Mercury by 
tlie moutli is beat given iji the form of the bicldoride or of either 
iodide : the first of these is that which I prefer ; the last two 
ftrei»erhapH somewliat vorinblo in preimration. and they injure by 
keeping, so tJiut their stioiigth is not w unifonu an that of biicli 



Chap. VT. 



TREATMENT IN' ACTn^: STAGE. 



169 



a powerful remedy ought to be. One or two drachms of the 
Uquor Hydrargyri bieliloridi tlirice a day whilo tho acuto ottat'k 

lis going on. is the mode which »p]>ear%to mebei^t in these cases, 
be reason of my preference for this form of the drug is ita 

I solubility. In administering in.'^olnble preparations of tho medi- 
cine, we present it to the intestinal mucous membranes in a 
condition in which it cannot be ubeorbed, and we can by no 
posHihility estimutc what' proportion of it may be altered and 
taken into the system, nor how much of it hangs ahont tho folds 

■ and villi of tJie intestines. Our dose therefore is in rcalitv un- 

' certain, ami when wo cease giving the medicine, we must purge 
away what may^have remained in tiie canal, or pxpect to see its 
action still going on. Occasionally, even after a free pnrge, 
some of the metal still appears to remain and to continue to bo 
absorbed ; at all events the spongy state of the gums continues 

tto increase. With such a proimration as tlie bichloride, we know 
exactly what amount we give ; when we ceaeo to atlministcr it tho 
action also ceases ; the same amount of effect \a produced on the 

koonstitution by an infinitely smaller quantity of the mineral, and 

'the debilitating eifecta are much less. Moreover, it may be 
added, that even in its immediate results, this salt appears to me 
to have more control over the rheumatic tendency, than any otlier 
prejiaration of mercury. 

Of iodine it will be necessary to speak more at length wlien 
the quiescent stage of tho malady is considered ; but it may be 
here observed, that the addition of from two to five grains of the 
iodide of putass to each dose of the bicliloride is often of marked 
benc'fit, jMirticnhirly after tlio mercury have been given somo 
days by itself.* * 

Opium is a well known remedy for rheumatic disease, and 
ought never to be neglected in the active condition of tliis form 
of sj-novitis. It not merely allays [min, but I believe helps 
materially to check inflammation, particulnrly in tho first com- 
mencement of tliat morbid act. t Given in the form of Dover's 



• Tlu'ro Uhon j>1iu;(' a iK"cnnip4isiliua 
by eluctivo nfHiiity in this fomhiiuition, 
Mvl. in fuct, the biniodtdu uf tuuniory in 
fpvt-ii iliisxolvcil in tlit* excvt3 uf tliu 
iddiilu uf polnmiUD. Ah a luorturial 
Uie I'omhitintiGPit in li»* i)owt>rfiil Uuui 
Uip bicblorUk' alouu: Iml in nc-tivif in 
tlmt iiult-flaublf uuuitu-r w* cnl) nlU-ni- 



tive. To bo perftcUy suro of ib fnuli 
and good cunuitton tlio iodido of ]Kitu8> 
uum Blioald hv adddl m puwdur tu twch 
ilom just iM'fori- it iw tiikeii. luglit 
affticUi tiK- hiiiiodidf of lui-rcury. 

t HcfLT (ti p. AS {»T wjini.- tii'cautit (if 
the iiiitiptiKiKiHtii.' pow r tjf njiiuin. 



170 



CHRONIC RHEUMATIO SYNOVITIS. 



Chap. VI, 



powdor, it also prttinoteB perspimttou, a most dertirablo action in 
all rheumatic disease. 

Colcliicum iH a remedy whoso value is undoubted, but its in- 
HacnccH for ovil are almost as certuiu ; it is more |K)werl'ul iu 
gout than in rlieumatism (Its effects will be mure fully described 
in Chapter XII.). It has a jwwt'r in checking the pain:^, &c., of 
both rheumatic and gouty disease, but it also has on cilect in 
procoriug rela{)s^. Persona who have been treated with tliia 
rcmwly suffi^r fi-ora returns of the tUsoaae moro rapidly than 
tliose treat<?d by somo other niedidne. The relapses are, says 
Dr. Todd, apt to assume an asthenic character. 

Antimony, in the form chiefly of James's powder, is also very 
valuable, and may be combiued with the opium. When mercury 
by the mouth has been pushed as far as seems desirable, ur 
when that medicine is not given by the mouth at all, the anti- 
mouial and opium together may bo advantageously employed 

Active Stage. — Local treatment in the active or subacuto 
phases of the iiiala<ly» must be tlie same in most \muis with that 
alrenily desc^ribi'd in our second chapter. BlotKl-IcttJng Ity 
means of h;eches, or even the cujvping glass, may, if much 
fobrilo disturbance exist, bo carried pretty far ; bnt if the fover 
be inocnsiderabU', and more purtioulurly if thi; j)aticnt be of a 
feeblo habit, and if tlie attack be a second or third, no blood, or 
but a very little, should be taken. Heat by means of hot salt, or 
the old stone -fomentation *, or by india-rubber bags BUed with 
hot water, is more to bo commende<l iu this tban in tho 
gimple form of the disease. When the brunt of tho attJU-k haa 
abated, the joint should bo wrapped in mercurial ointment 
fiprewl Oti lint, the whole to he covered with oil silk. Itlisters 
may also be employed, but while any active inflammation is pre- 
sent these must not be put immediately over the B}'uoTial 
membrane. 

QuiEWKNT Stage. — General Treatment. — The constitutional 
treatment during the quiescent form of the malady is moro diffi- 
cult, find ri'(|uirt's ulcer loaiingcment, Ix;t us again nm over 
tlie patient's condition, that we may have a clear understanding 
of what we wish to effect He has had one or two attacks of a 
subacute inflammation, whosi> Hymptoms have marked them 

* Ciuurtiuili' nowiint lictitotl hj pulUiig tbcm in ^iritu of wiiu< luul iiutUng It 
on flrc>. 



Chap. VI. TKEATBIEKT IN QUIESCENT STAGE. 



171 



rheumatiV, and these havo left the joint tiasues thickpnoH; the 
part i« thorefore rnom or less stiff; it may otherwise be painless 
may bo the seot of nightly vague pains. Now, our aim is to 

^ produce absurption uf this thickening, and so to modify the con- 
slitutionfLl iiiint ; thiit ho Hhall u(jt have returns of the active 
Among the alterative remedies, the four following are 

^chiefly available. 

Mereury, a!id its use in the subacute condition, has been con- 
sidered ; a slower and more alterative mode of giving that medicine 
may be employed, if it have not been pn.she<l or used at all ui 
the more mpid stages ; but hero also the power of employing it 
locally must not be sacritlceti by too zealous desire of administer- 
ing it by the mouth. 

Iodide of potass has already been mentioned ; its control over 
intlamuiatioDB of fibrous tissues renders it of imdoubtcd value in 
rheumatic discu£c. It is more valuuble in very chronic dieturlv 
anees than in the mora acute ; in<leed, when fever is present, it 
should be avoided, its it not uufrequeutly increases this action. 
There arc few medicines of whose motiM operandi we know less 
than we do of this, and perhaps every one who tries to think out 
tlie matter luay Imve a different theory on the subject. My own 
idea is, that it gives a quality to the fluids of the body wliich tends 
to check cell generation ; hence its very decided effect upon all 
oouu«ctive and fibrous tissues — hence its capability of producing 
absorption and ultimate marasmus. This notion, however, is 
ofFerefl as n conjecture simply. A teacher at one of the large 
metropolitan m*1uk)1s once said to a student who asked about the 
action of this remedy, "Well, sir, it is diflieult to define; bat 
it is a very excellent medicine when you don't (piito know what 
is the matter with your patient." To such a doetriuo it is 
hardly n<H;t-'S8ary tluit we should subscribe, but it has tliis amount 
of truth, that the sidt in me<Iicinal dfjses does no hiirm, which 
luis yet been |«jiuti*d out ; ultJiough it may be tliat some one will 
by-and-bye trace all the misibrtunes of the world to this medicine 
— as has already been the fate of vaccination and salt. For 
rheunmtie disease, the rome<ly may bo advantageously given 
in sarsapariJla, or taraxacmu, or the scoixirium. 

AlkalLs,ur rather alkaliuii ourbouates, in small quantities, are of 
very conaideruble value. A dosu about an hour or two after each 



172 



ctntoNic nnEUMATic synovitis. 



CsAr. VI. 



moiil in somo aromatic wntcr^or in a Htnto of eObryraocnoe, will 
have marked effect, not merely upon tlie distension and flatulence, 
which 80 often aecompanies (heclironic rheumatic state, but also 
u]>on the mure distant symptoms. It may be permissible to 
(lill attention to tlio detrimeutat jictiou of tea, and, to a less degree, 
of coffee ; to the fjroat injury often pnjduccd by ale or porter, 
jjarticiUarly of those sorta that contain any considerable auiomii 
of saccharine; and the desirability even tliat the wines vtrhich 
may be fflibstituted for malt liquors should be of that (quality 
which is called drj', but which nevertheless contain as small a 
quantity as possible of acids — ^the tartaric and mallie. 

The other class of nuutKlies, the diaphonitics, comustM rhiofty 
of opium with ipecacuanha, guaijicuui, and James's jwwder; the 
former will be found useful when there is much pain at night, 
an irritative condition, with pood performance of nil sccretit)us, 
except that of the skin ; but eliiofly may the Dover's jwwdcr be 
prescribed wliile the patient is taking some medicine of the 
alterative class. 

Guaiacum is most availing in the atonic form of rhoumatism, 
and therefore, from what has been tiaid aljove, when the more 
acute stage has been treated with colchicum. 

James's powder is most useful wlicu actual fevcrishncss, not 
mere irritation, comes on at night, and when the patient is 
strong and his appetite good. 

A mid place between these two classes of remedies is held by 
certain natural springs, botii for bathing and drinking — Buxton 
and Bath for instance. Some of the continental baths, as those of 
Aix and Wiesbaden, have an advant^ige over ours, not merely in 
the quality of llie water, but in the careful arrnngements and 
adaptation to each case, in the mode of bathing, drinking, itc. 

I do not, however, imagine that the luirticular locality, 
metallic, or earthy solution, is a necessary part of these bathing 
arrangemifnts, althuugli there is no donlrt that chatigc of scene 
and air, regular habits, &c., conduce to the cure. The various 
forms of bath, such as may bo obtained in any good establish- 
ment, are extremely beneficial. The Turkish, hot air, and 
vuiHjur, are valuable, and in eases where either expense or luoring 
is to be avoided, the lamp Uitli, which is very easily urmnged, 
may bo employed witJi the givatest advantage. The object 



Chap. VT. 



AnsonmoN of fame tissuk. 



173 



aiminl at is to procuro a lai^ amount of tmnspiration, and the 
metliod is apparently iuiniat^ml. The Turkish and lamp Imth 
aro the miitit poworftil ; next tUo hot air ;• then the vaj)our bath, 
and lastly uxi'iv hot uutor. 

r.ouAi. TuKATMENT. — Wlicn the subacute inflnramation, of 
whoso treatmeut we have already 8jH)kt'n. lias subifided, thero 
will bo left behind either chri>pio inllammation or simply 
thickening. The former wo must of course try to subdue, 
siuoe, euntiuuing, it destroys the joint. The hitt«r we should 
endeavour to get absorbed, not only because it produces a cer- 
tain amount of dittioulty in walking, but also because it gives 
the next iullamniatiuiu wlienever, and if ever, it may take place, 
a c«!rtain vaiitaire-grimnd, inercjjsing the dilTu-ulty and diminish- 
ing the eflect of treatment. The inflammatory condition will 
compel rest in that posture for each joint, which has been 
dcscrilMKl as its proper position; blisters, not immediately over 
but at some distance from the synovial membrane, are much 
more valuable than in the strumous form, and if it be intended 
Ui ^ve mercur)' by tho skin, blue ointment may be applied to 
the raw surfuoe ; hub care must be taken that this siufoce be not 
too extended. In these coses, setous or issues, near the joint, are 
often beneHeial ; it appears as though the profhiction of a sup- 
purative eond^tion in the nei<:chbourhood of the fibre-producing 
motion eheck(iil the l4Mtdeiii_'y to thickoiung. Ix>cal heat is very 
advuntjigeous, particularly as it can bo so managed as to pro- 
duce local transpiration, a method of securing which is described 
fiirtlior on. 

As the inflammation yields, our efforts are to bo directed to 
procuring absorption. If there be at tlie special p(>ints of [tain 
no tenderness, it is not necessary to keep the limb in absolute 
immobility, although rest must be enforced if the patient's cir- 
cumstani'es in any way admit. A jwwerful absorbent remedy is 
to keep the joint wrappc^d in linen, covered with mercurial 
ointment, due regard being paid to its systemic action and to 
tlie patieut's general condition, for if the health bf* fwible, i>r if 
mercury have already aftected the system, this method cannot 
bo employed. loilide of potass ointment rubbed in gently night 
and morning, and spread on lint wrap[x;d round tlie jt>int, is ah*o 
valuable ; and equal [sirts of this, and of the mercurial ointment, 
* T1m> hut air und the {niii[>-bfUh may bo iirmngcil in bed. 



174 



CHnONIC RHEUMATIC SYNOVITIS. 



OitAr. VT. 



is a Tery powerful absorbent Flying blisters, used only aa 
strong rubefncienttt, not as vceientoriee, increase the powt^r of 
thosf' ointmcnta. Transpiration, pn>duced by (Ittiri^ to the joint 
a loose india-rubber sock, kept dom at each end by bandit of 
the same substimco, and allowing st^^am to pass in from a kettle 
or boiler through a tube, has* b(H»u pnnlurtivo of conxidt^niblG 
benefit. When tliero iB al^eolutely no inflanimation whatever, 
and absorption Ijegina to act, evidenced by decrease in size, 
gentle shampooing is to l>e employed, together with passiTO 
motion and other manipulations. 

It is to bo rcincmborcd that no local treatment will bo of 
much avail aa long as the systemic condition lasts, for unless 
thi- force of the riiemnatic <liathesis bo diminished the iitHam- 
Diatiou caimot bo entirely subdued, and we may net only exjteet 
a return of tlie more acute phttsc in the way that Inis been 
already described, but also a continual eoursn of deterioration 
in the artieular and periarticular tissues. Many jvrsons, who 
may have reoovenxl from an attack of acute rheumatism, witli a 
sound heart, will snbspijucnfly /i^rmhiiilly acquire a disease of 
that organ whose stJurce is undonbtedly rheumatie ; and in a 
similar or rather identical manner a joint will gradual ly be 
destroyed by an inflammation of the same character, unlefti the 
sni^m will tre^it tlte general as well as tlio local disease. 



CXSKS or THIS BiSKASE. 

Caar XLXXVt. — ^Thumaa Uwillim, gartlener, aged 49, came frntn Mon- 
mouth to beadioiited into tho CbariDg-Cross Hospit&l, under Mr. C&nton's 
care, November Sath, ld.58. 

ffistoty. — About two yean ago he mprainod tho right knee while liftjng 
u heavy wheelbarrow ; the joint w&» very patnftil, but ho kt^pt at hitt work 
two days, and then tho koco swelled very much and he iiecaiuo unable to 
walk ; but, after fomentations aud rest, it got ho far better that he was 
able to reaume hia occupation. About a fortnight or thrve weeks after- 
wards he, one evening, was very tired after work, lay down on the ground 
and fell auleep ; when ho awoke it waM late night or early morning, 
and he uot off on hin walk homo (two and a half miles), but before he got 
lhen3 his knee became bo painful that be could hardly get on. The next 
day he could not um the hmb at all ; the joint was niiicli swollen and ho 
sought tltu advice of a surgeon, who applte<l leeches and poultices, without 
procuring much rehef ; he then became a jiatient at the Moummith 
Diapensary ; subsequently sought the advice uf an old woman who gave 
him something that took tho skin oft his knee and inaile him worae. 



Chap. VI. 



CASKS. 



175 



From thai limo iho joint hu continual to incrRane in itino ; till of late 
ho waa able, with great piiin, to work for about two hours moat dflTS in 
the week ; often, '* when walking right well, his kniH.^ seemed to be catcheil 
and hold tight and to be wonderfully full of piun ;" on account of theae 
occurronoua he Iioh aln-ayit, when at work or wBlking, bound a handkerchief 
as tight aa lie could round the knee. During the lust year, particulai'ly, 
the joint has swelled, and ho ia unable to bear any weight upon it, Tlio 
kneo is u good deal enlarged, but cannot be measured against the other, aa, 
oooaooont of an old accident, there ia deformity also of the loft. The dia- 
eaaed joint haa lost the uRiml outline and has a iK^uare look ; the line of tho 
entum (jutelho in concealed, and on each aide of it there la, instead of 
tho uHual foHHa, a hard, Honii-claatic, i ion- fluctuating Hwulling ; a Hiroilor en* 
lorgcmeut is [larticularly well morketl abore the jiatoUa, whore there ik a hard 
lump i there ia ranch thickening under the skin, which is bound down to tho 
parU beneath, and which prevents the diSerent auatomicHl poIuU from 
^being mode out ho clearly as tboy should be ; there is some grating when one 
one ia moved ou the other, this caunca flight pain ; the two surfaces may 
' be pressed together by striking on tho heel or other means without pro- 
dufung the slightest pain. lie complains much of the Umb jumping with 
i>Mvorc pain just as he is going to sleep, and so bod is this that often he is 
r^fraid to sleep. 

The limb was placed ou a sjilint ; issoes, blisters, &a., as local means, 
with dinbront forms of tonics wore employed. lie also underwent some 
treatment by tho aaaiatant physician, Dr. Hydo Salter, for chronic bron- 
chitis, and waa benefited. The knee, however, only got more painful and 
his health more feeble ; the limb, too, started more and more, so that he 
I hardly got any sleep at night. About the middle of January the joint 
I^Bwelled more and aoon became fluctuating inside thu patella, without, how- 
ever, losing tte square form ; and, on the 

2(>th Jan.. Mr. Canton punctured the joint with a trooar and canals 

kvhere the skin seemed thinnest, just inside the patella; so little pus 

escaped that a sooond opening was mode ; yet, altogether, not more than a 

drachm, or a drachm and a half, of a very thin opalescent fluid oame 

away. 

IJth Feb. — He waa in no wise relieved by the evacuation of so small a 

quantity of fluid, and a» his health aoemed giving way under the pain and 

illooplessneas produced by thu disease, it was pru[x>sed to him that tho 

limb should bo removed, and this day the operation was performed. 

Es'iatftitmtioH ty' tie Limb. — On opening the joint a quantity of very thin 

I pus escaped, with curdy floccuh therein; the synovial tissues wore much 

^ihiekoned by false membrane, whose cut edge had a stratified appcaranoe, 

and was in rounded whtos Heparatod by deep wrinkles, which were most 

marked around the patella and its ligament, and thence ran backward 

I becoming shallower as they went ; the intcrarticular meniftci had di>»p- 

[{i^arod, but were, in port, replaced by false tissue, which, however, was 

I both thinner and leas broad than those structures. In no part did tho 

Inembrane adhere to the cartilage. Thickening was produced not only by 

Ithia fibrous formation on tho inside of tho synoviiU membrane but also 

by oousolidation of the tissues around it ; a faint line, which, howovcr, 

waa in paiia obliterated, ran round the joint in this maa.i of now tissue, 



176 



CnRONIC nnEUMATIC SYNOVITIS. 



Chap. VI. 



and seemed to indicate the position of tlie R>*novia] bnaement membmne ; 
the tlitckcning was tougli, hard, o|jaqiie, oiid of a brownJHh-whitu colour. 

The cartilages were, in general, vury much thinned ; thoro waa a nuiall 
ulceration, which might have beco covered hy a silvor penny, ou the 
ion«r side of the patella; a still smaller, almofit a pin-hole ulcer, on the 
inner cundylti of the femur ; and one rather larger, which went quite 
through the atnicturo at a corrcspouding spot of the tibia ; close to thia 
spot and on the aame Irvcl with the health/ cai-tilage. was a surface of 
poU&hcd bone ; elsewhere the cartilage was quite smooth : a part ou the 
e^tcmal condyle of the femur had lost its transluocncy and become of a 
dead opaque white ; this, ou closer examination, was found to be de- 
tached, the deep surfooo was rough, gritty and was covered by the arti- 
cular lamolla, which had separated from the cancellous structure, and loft 
it hare. 

The thigh-bnnc had, on it« iuncr condyle above the articular portion, a 
8iiiftll Hat osteophyte, little more than roughcuod aurfacc ; other such 
growths were scattered here and there over both bouoa. Ltoth femur 
and tibia were sawn throiif^h, and the portions next the joint wore found 
very rod from hyponcmia of the caucellar lujiug-membi-ane. 

Micrwcvpiti Ejiatninutwn. — The thickened ttynuvvd inemhninr was exa- 
mined in two ways:— one, by making thin sections with a Valentin's 
knife through its substance ; it was thua seen to consist of a deiwe 
stnicturo of which roiini) and fuKiform cells appear, at first sight, to make 
up a connideriiililu part; a little mora oxamination, howiwor, shows tliat 
they only lie among and conceal plentiful fine fibrBs, which cross and 
recross each other in every direction : another mode of examination was 
by procuring a fine shred and teasing it out with needles ; in tins latter 
method its Abrous constituents became more visible, and it could be 
aeeu that they formed the chief part of the eulargemeut : some of these 
0brcB wtiro made of fiisiform coUs, others were literally cell-fihrea, others 
were ftno and structureless. 

Thf t«r/(7<jaf».— Those parts which were ulcerated on the surface presented 
the usual inflamed appearance, the hyaline substance gradually changing 
into fibres ; in parts, where the cartilage was detached from t!ie bone, and 
not ulcerated on the surface, the cartilage corpuscles were also enlarged, 
were not filled with dear uucleatod oells, but with a coarsely graniUar 
matter ; the hyaline aubstance around the swollen cells was sprinkled 
plentifully with granules ; the bony spot on a level with the healthy car- 
tilage presented a number of lacunx in linear order, and with few canolicuh ; 
the cartilage at the borders of this new structure showed the hyaline ma- 
terial 0{>a>iue and granular, while the cells still retained the arrangement 
and appearance of ordinary cartilage cells. 

Cask XXXV 11. — J. Leltree, aged 72, came under Mr. Hancock's care 
into the Charing-Crnss Uospital, Xoveuiber Stb, 1859, suffering from 
long-staiiding disease oftlie knee-joint. 

There waw a good deal of fluid in the cavity, and at the same time much 
thickoniugj the joint was loo«e, permitting of some rotation; the man 
waa Bufl'uring a great deal of pain and was extremely weak ; he had a 




Obap. VI. 



CASE8. 



177 



broiicliitio affection and expectorated a large quantity of mucus daiJj. 
UiB iutcotion iu coming to the hospital was to undergo amimtattoii, in 
order, if poseiblo, to aave hiJi life 

Mr. Hanooclc, therefore, unputated tlje Uuib oa the !)th November. 

lixftmirutliou. — The synorial metnbrane was thick and tough, converted 
here and there into a material of cartilaginous h&rdnoss ; it oontainod 
about two ounces of opalescent fluid; the crucial hgaments had dis- 
appeared, which, together with loosealng of the external tigaiQcuts, 
permitted the rotation above mentioned. Both interartictd&r cartilagea 
had diaappoarod; a part of the inner waa reptaeeil bj ehrods of a fibrous 
material, wliich grew from the nynovial meiubnuie. The cartilagea wore, 
throughout uirarl/ their whole extent, pink tn colour ; in porta where this 
was but little marked tbo hue waa scon to be due to little pink spots, more 
or lewi clone together ; these structures wore quito smooth, except near 
the outer border, both of the tibia and femur, where thejr were ulcerated, 
but tliey were throughout aa thin an cartridge paper ; thus the ulcere 
ware of very little depth aud thoir edges were smooth. 'Jlio articular part 
of the fiamur vma surrounded hy rather amall oHteophjtes ; the feuior and 
tibia wore sawn through ; they woro very heavy and solid, the oaocoUi 
being nearly filled u]> by ordinary oaaeoua matter ; this density waa most 
remarkabit* near the joint surfooe. 

Tho microscopic examination ahowed, sa regards the synovial mem- 
brane and t^riarticular tiRsiics, tho nuua appearance as may bo found 
related in tho last case, but those portions of thickened KytioWal mem- 
brane which are said to have apt)cared cartilaginoua had much the 
Uicrosoopic aspect of fibre -cartilage ; tho fibres were thick aud eomn of 
the matorial waa loid of structure ; oval and fuaifurm cells were thickly 
acattcrad among this growth. Tho thin cartilo-^e exhibited very narrow fuu- 
form cells at somewhat rare inter^'als, whose nuclei could not generally be 
found, but a coll here and there presented a lighter, more r&fraoting spot, 
which might have been a nucleus ; the cartilage corpuscloa were mostly 
brokuu up, tbo cells lying singly ; section of the bone showed thick plates 
enclosing small canooll&r cavities ; the osseous corpusclos largo and rnund ; 
the artioulor lamella hod, iu some parts, quite dituppeared, ordinary bone 
abutting on altered cartilage iu other parts j the lameJla waa normal 
in structure, but thin ; and in others, again, there seemed to bo a tranai- 
tioDOl condition, some of the ordinary black cells throwing out oaualiculL 

Cask XXXVIll.— John Middolston, aged 40, a well-grown strong man, 
was admitted into the Charing-Croas Hospital, under tho care of Mr. 
Hancock, 30th Doccmbcr, IB5S, for wound of the kneo-joint. 

Eigktc-cn years ago ho had rheumatic fcvor, which loft tho right knee 
when he went to work, still awollea and oocoaiDDany painful -, the jiains 
came on, chiefly, at riight in bed. Shortly afterwords he severely sprained 
the joint, which became much swollen ozkI Tery painful, and has never 
recovered it« natural size and functions ; the knee has always remained 
ausoeptiblc of pain after h*i bud had either much work or a long walk. 
Ever since that time, ho has ulucrvod also that his kuoe grated " hke twn 
piooos of stone rubbiug together ; " uioroovor, it was no uncommon thi.i£ 

K 



J 



178 



CHRONIC RHEUMATIC SYNOVITIS. 



Chap. VT. 



for the bones to mUp out, when he voald repUoe them and go on with his 
work. He declares (and he is so iDtelligent an<1 nuocinot in his siatcmeute 
that it JR impoesible to doubt him) that ho would lie u baudkerchief 
tightly round bin knee, and could then walk at the rate of five luilee oa 
hour, or run a mile ui five minutes. Lout CbhHtmaa eve he was sphttiog 
trood, when the aio slipped and cut hia knee ou the inner aide : he at once 
went into the house and to bed ; ho bad surgical care and thea came into 
this hospital. 

The wound, in the right knee, was a little in front of the internal lateral 
liganientt and to some distance round it the «kia waa rod, the soft parta 
puffy ; the joint is much swollen ; the sound one meaaores fourteen iodiea 
round itfl middle and over the patella ; the iigurad one Bcveataen ioohea 
and a half; the svelUng implicates the whole sTnovial membrane, bat la 
moflt marked inside and above the patella ; it fluctuates freely. The 
wound dischargea plentifully, I should say considerably more than a pint 
daily of turbid opnleeoent fluid of an oily consistence (synovia and pus) ; 
the akin over the joint, except at the wound, was white, shining, and 
tense ; the tibiu oould be rotated nearly a quarter round with very manifest 
grating. His countenance is pale and anxious ; eyes duii ; be is Tor^- fuebla 
and evideuUy in great suffering ; pulse 99, thready ; tongue white and 
dry ; appetite pretty fair ; great thirst ; sleeps hardly at all ; the limb 
starts violently when ho falls into a dose, and causes aueh agony that he is 
afraid of sleeping. 

It is not Doceosaiy to follow out the details of this case. Under Mr. 
Hancock's treatment the inflammation subsided, the discharge very much 
decreased, and the wound bad nearly closed ; but the bones wore so 
movable, the pain, although much abated, still coutinuc^l, and there 
seemed so little choDoe of a useful joint being ever obtained, that the 
operation of oxcisioa was proposed and the reasons for its adoption ex- 
plained. It was then that the above remarkable details of the abnormal 
mobility of the joint were obtained. Seeing that those were received 
rather doubtfully, he said :— " Oh, I will ahow you t " and immediately, 
before he could be cautioned, be dlslouatud his tibia, bsckwarda, by con- 
tracting the lutmHtring miucles, the joint being then in a sumillexcd posi- 
tion ; be afterwardu ruplacc^I the bone and repeated the performance. 
Tlie dislix^tion was not quit«, but very nearly, entire ; it seemed to cause 
no pain, but he said it was a little more painful than before he received 
tlie iujury. 

Either on account of this exhibition or from some other CAuse ho 
suflfered a slight return of inflammation, from which ho again recovered, 
and this time with a Uttlo more lixity of the joint. 

The end of it was, that in the be;^inning of April he walked out of tlio 
Hospital with a handkerchief twisted round his knee, in uo worse a state 
than ho had boon for years. All the surgeons attached to tlie Charing- 
OroBs Hospital, and I believe several others, witnessed this singular oase, 
and there ie no doubt about the man's )>ower of partially dislocating his 
knee-joint. 



Obap. TI. 



CASES. 



179 



Oask XXXIX. — O. Dempster, aged 32, tailor, cAmetomoat the Charing- 
Cross ]Io»pital Januai7 !^7tb, 1S60, with an affection of the luft olbow. 

He Imil rheumatic feror twenty months since, which does not 
appear to have been very severe, and for M-hioh he waa treated in St.- 
Bairtholomew's Hospital. Ilis elbov has been rather stifi* ever since, and 
in July of laat year be wrenched it while lifting & weight ; it swelled and 
was very painful ; but it waa leeched and blistered at King'H-C'oUege Hoa- 
pital, and he recovered sufEciently to go to work, although he has not 
since been able to bend it or straighten it fully: foar days ago it became 
painful, and now ho suffers froiii it considerably. 

The joint preaeuts a curious appoarauce ; it looks very broad from be- 
hind, but the Mwulling docs not encroach either on the fore or upper arm, 
nor does it grwlually dituitiish, bul is abrupt ; nrur the head of the radius 
the swelling is couHiderablo ; the synovial membrane evidently oontains 
fluid, although it is covered by considerable thickening; the tumcraction 
is irregularly hard and soft ; the hardesr part is above the olecranon, the 
aoftest at the side of the inner condyle : he has a good deal of i^ain in the 
joint, of a dull aching character, which increases in b»d ; ho has, ulao, 
TAgue uncertain pains, sometimes in the shoulder and running down the 
arm to the wrist ; no starting pains. I>r. Myde Salter examined the heart 
antl found no abnormal sounds ; tungue brown, rather dry ; bowels confined. 
His arm was placed on a rectangular splint, wrapped in a piece of tint 
ihiokly smeared with blue ointment, and the whole covered with oil silk ; 
and he was ordered a purge of hluo pill followed by senna and salta, 

Ist Feb. — There is, he thinks, a little leas pain, but the tumefaction is 
aa great. Ho wa*i ordered a blister, the siae of two hngerv, on the outside 
of the forearm above the joint; reapplicution of the bluv ointment: he is 
bo drink no beer, but two ounces of gin, in water, doily. 

To take the following three times a day : ~ 

I^. lodinii gr. \. 

~~ Potaaaii iodidi gr- "j- 

Aqum ij. M. 

6th. — Better ; the pain and the tumefaction both lees ; the gums are 
jurt beginning to be touched with the mercury ; to discontinue the blue 
ointment ; to wash the arm carefully with hot water. 

10th. — The signs of mercuriaUzation having disappeared he was ordered 
to wrap tbo joint in a mixture of equal jmrta of the Blue, and of the iodide 
of Putans, Ointment. 

10th.— The pain has now subsided, and the tumour is leee ; the aligbteet 
signs of mercuriaUxation are present. 

2ud March. — He has been carefully watched that the mercury might not 
go too far ; it was ordered to be dieoontinued on the 29th. The arm is 
now free from patn, and peinlcasly movable to a certain extent; the 
muscles a good deal sot by the long confinement : splint to be discon- 
tinued, but he must ke«p his arm in a sling, aud ia ordered to bathe the 
joint in very hot water night and morning. 

16tfa.— He was permitteil to gu to work, carefully, for a few hours in 

N 2 



180 



CnnONlC RHEUMATIC SYNOVTTia. 



Cnap. Vr. 



eHoh clay lost week : he oonsidera himself well ; but it hoe been expl&ined 
tu liim that trrfttmoat is required to prorent a retapso. against which he 
cannot feci sure until the jolut has retuTDed to it^ uomml mze. Ordered 
* to oeaee the Iodide of Potass, as hix health is a little enfeebled, and to 
iako ODe oudco of Uuaiaoum Mixture thrice a day. I described to bim a 
sock of india-rubber which might be fitted on the elbow and bo conaect«d 
with a tube whereby he tuight giro the part a Tapour bath, for as he' was 
a tailnr, and apparontly a olevor fellow, it atruok mo that he might make 
one, and to-dny bo brought rae a thing wtiich, as it doo8 not require to lie 
absolutely water-tight, be 5nda answerB the purpoae ; it is rather clumsy : 
to UHB this bfttfa every night, after which the joint is to bo wrapped iu 
Hiuinot. 

Uth May. — He has been going on very well ; the arm ia quite normal in 
appearance now ; he can bond and straighton it to the full. 

Since the last data I saw this patient but onoo again, when ho contiaBod 
well 

I might multiply instances of this disease. I have notes of a 
case iu which it occurred in the knee of a gentleman after stnnd- 
ing iu the water a whole day salmon fishing in Scotland. In 
this CAso very small doses of bichloride of mercurj' were given 
with taraxacum, as the liver appcarod verj' sluggish ; no return 
as far as I know has occurred, but tho impatience of treatment 
caused him to leave it oflF before I thought it desirable. Ifo used 
the Turkish baths in Palace-street under my ilirections with 
much improvement iu his general condition. The expense of 
these baths renders them somewhat iuaccessible to all but the 
wealthy. 



Cjup. VII, 



8YPHIUTIC SYNOVITIS. 



181 



CHAPTER VIL 



On HOKE OTHER FoRBCS OF ChRONIO StNOVITTB. 



The Strumous auJ Ithcumaiic diatliesos are those which chiefly 
proJuor or iimiutaiii a chmnif! iuflamnintioii of tlio B)'novial 
mt'iubronc ; but thpn* are besides two other conditions having 
tho same effects : those are Sj'philis and Gout 

Sifphilitic SynoiHtiB, ultliough rather rare, is sufficiently 
cuminon to deserve some notice. A case of this disease, rather 
more acute than usual, was detailed at p. 34. I have seen 
three others whose origin was undoubted, aud several where 
such causo might be susjiected. The previous and immediato 
symptoms of these cases have led rae to the belief, that the 
iuJiaimuutiou always spreads fiom the ueiglibouriiig periosteum, 
with wlu'ch, as we have soon, the eubsynovial tissues are ood- 
tinuons. Li two cases, reported at the end of thia abort section, 
nodes on the ahiu were actually present at the time, and were 
giving severe nightly pain ; in others the oharacteristio sen- 
sations produced by these swellings had only just subsided ; one 
of them, close to the joint, had been opened and the wound had 
just healed. 

Syphilitic emptions ore generally present at the very time 
when thi* joint^attack commences, and by proper enquiry a 
specific history can always be made out. 1 am not aware of any 
case iu which this disease has occurred previous to other cou- 
etitutional eiTeots of the lues. 

The disease is confined to the middle period of life ; its usual 
history is this. — The patient having been subject to the usual 
secondary and ti-irtiary symptoms of sj-pliilia, labors during some 
days or weeks, previous to any complaint liaving been made of 
joint disease, from nightly pains of the bones; probably also 
from swellings along Uie course of the shin bones ; with whose 
aspect and history every surgeon is but too well acquainted ; 
then at some period a joint becomes paiuJul, and swells. At 



Itt 



flinuLmc sT50TTn& 



CmAf.TSL 



ifil llw tundbetkn of the put k iligHuid k not aoi 
dflB to «fliMkMi of fluid into the cmrity a* to aa 
Into tb« peiisrtieiilar tMinrt this is eridemsed hf the vaai 
Unt^maiiaa sad the anftneM of the paita faeaeath the okm ; the^j 
d« rvft pit, bat thef hare ft tecodeDcj to do ao; very 
p nm m u o with Uiu fijix«r wbiiena the part. 6000 after the coid-^ 
menoBmeDt of tho diieaae, an aagnieDted effbsion of flnid ioto ' 
til* ifiKrTia] aae takea Jilaoo; increased heat is peroeptiUai, 
•Dd oecasfonalty the sidn has a pink Hnsb. The pain is, at the 
early vta|^, very aorere, particnlarly white- the jiatient is in be^ j 
and ftl iho finrt amimenwrtntmt of the dist^-asc ; when increased^ 
stf^rt-iion into the cavity lina takon place the pain rery mncb 

■llljMi'IcH. 

II1U ixtMnts of tbo coaofl is rarioiu ; Bomotimea they are 
qtiitu f'hr»ni(% at (^>thc'r8 Huluiftilc; but I have nerer seen one 
ttdvniico U) xthumilum of curtiluges, or pormancnt injury of the 
joint, though it in perfectly concHivable that a cumtfitutiuu, com- 
bining IkjIH tha Mcrofuloiis and syphilitic taint, might set up an 
action in tlio Hynovinl niombranv whoee t^^rmination would be 
dostnictivo. Tbo di«04W() is moat prone to attack the knee aud 
aaklo ; onco I bnvo Hot^u it in tbe elbuw, and once have observed 
a KUHpiciiiiw nu«i tit tho wrist; neither of these however were 
imdcr my »'riri\ lliu former was one of Mr. Canton's patients, tho 
hit lor 1 only saw for a few minutes. and» as the geutlemuu was 
homu)0|>ikUiicnlly trc^ated, declinetl to give any opinion. It 
appears pmbublo, if we may build on tho history of a single 
eiiHc, thiit the joint malady may recur when the other secondary 
OVi'iitH nf Hypliiliw n-tiir?!. 

Tin* |j;ruurul Iri'aliiK'ut of this disease is tlie tn»atment of 
syphiliH: it is well however to remark tliat considerable debility 
litiiy hi^ f'oiiibiiH<d with tho Hynoviul diiiiease ; Kiich st^ite wns 
ovidi'nt tu two out of tho four eases quoted, and I have observed 
it in ttonio wluoh wrn' imt under my own care. Mercury, if not 
nlrwuly piinhfil 8n11iriently far, fdiould be ^ven in small repeated : 
doMS, aud tho value of the ioiUdu of (lotassium need hardly be| 
huiilixl ou. Tho couibination of tonics with tlieso remedies ia) 
moHl tlt'itirable. luoiu'mse quinine and mercury, in pill, twice 
■^ day woM prt^thu'tivo of pi^wt Ivnefit The bichloride of 

wvury with iodide iU* |Mitassium and gentian form a valuable 



Cmak VIL 



CASES. 



183 



mixture. The local treatmeut is lirbit uf all rest, with u tittiug 
spUut tu secure iminobitity of tiie joint, and siiporfieial rountor- 
irritAtiun by nio-ans of blistnrs, or of flying blisters, only ke]»t on 
long enough to produce considerable redne&i of llio mirfooo 
without vesication ; the redness may aftenvards be kept up by 
the tincture of iodine. It would seem, from the fact of pain 
beinji; most wivere when the patiout gets warm in bed, that cold 
would bo a soothing application ; tliis, however, is far from the 
fact ; heat, by means of hot salt or hot-water bags, although pro- 
du(?iug pain for the first few minutes, prociu-es a more rapid 
relief than cohL The caaes are q»it« amenable to antisyphilitic 
treatment combined with the above simple local management. 

Case XL. — William ¥L, aged 33, taJlur, came to my hoitse with pains 
and swelliQg in tbo knoe, '2'2ii<l •i&xiuiLry, 1866. Ho is a pale, sickly -looking 
man : the sweHing uf the knee begaii two days ago, with umch paiu, 
which iucroajaed at night; the tuniefactioD baa not the shape of an acute 
sjruovitiH, but is mure ditfuae, witlioiit dufmed edge, and ooncealH the shapo 
of the boaes. There appeared to me somothiug anomalous in his symp- 
toms which I did uut make out clearly at the time. I ordered him a 
pai|^, and a bhater above the juiul, and tu keep his bed until ho oamo 
again. 

26th. — When he came to-day I observed an eruption, which turned out 
to be syphilitic lichen. On examining the tibia I found two dusky upots 
which had been the seat of abscess from nodes ; uo recent nodcii were 
apparent., but the edge of the tibia was rough with old ones. 1 ordered 
him three graiuB of imitdu of Fotaaaium and infusion of Gentian three 
timea a day ; applied a gutta<]>ercha spUnt to the limb ; told him to keep 
his bed and to come back in a week. 

Slid Feb. — He is in much the same condition ; the man^ appearanee is 
very weakly, but it is doubtful if ho can get well without mercury. 
Ordered to continue the mixture and to take the following pill night and 
momiug : — 

a. Hydrarg. c. Crota .. gr. Jj. 

Quinjs disulphatis .. .. gr. ij. 
Mist. Aoacifo, q. b. M. 

Another bliator to the knee ; complains of very groat pain in tbo joint at 
night ; told him to apply cold wat«r. 

Cth. — C'uld water increases tfao pain, although the same eSeot la pro- 
duced by the warmth of bod: to apply very hot salt bags ; this relieved 
the pain after the first few minutes : add to each pill half a grain of 
opiam. 

I3tb. — The knee ih much bettor ; is etill swollen, but ia almost freo &om 
pain : the eruptiomi continue. 

1f>th.~Tlie gums HUgbtly aore ; tbo eruption fading; to take the pill 
only at night. 



t84 



SYPUILITIC SYNOVITIS. 



Cbap.VU. 



dOth.— Emptton Dearly gone ; to leave off the [lill ; the joint beii^ still 
awollen it was tightly strapped. 

March 3rd.— Joint nearly rodncod to its normal nze; strapped once 
more ; to contiouo the mixture for another fortnight 

April 7th, 1857.— This man catne to me again with sore throat, syphil* 
itic eczema, nodes, and pain of the right knee, cloee to winch one of the 
nodes is sitoated ; the knee ia rery slightly avollen, is also slightly tender ; 
he is in a very weak condition ; has been feeling ill for the last furtniglit, 
and has given up beer, thinking it better to do bo, although be has been 
used to tuko about a quart (?) a day. 

Ordered that he should take a pint and a half of stout a day, and the 
foUoniog draught Uarico a day : — 

S. liqnoris Uydrargyri biohlondi ^. 
Inf. Qcntiana' oomp Sj- M!. 

I pot a paaieboad splint on the outside of the limb and told him to 
point it with Iodine. 

I^h. — Tlie kuoo is more swollen, but is rather less painful and tender; 
it does not fluctuate, is rather red, and has slight tendency to pit ; the 
tumefaction is moro around than ia the joint. Add to the draught 

Spt. £thoriB chlorioi . . nix. 
Potassii iodidi gr. iij. 

Leave off the iodine paint and apply hot dty fomentations by means of 
salt-bags. 

Ifllh.— The knoe is greatly better. 

The splint was only necessary for a fortnight longer ; the same treat- 
ment WHS pursued : the rest of this history is merely that of sjphilis. 

Case XLI,— John Stedman, aged 19, came to mo at the Charing-Cross 
tloRpital with syphilitic lepra, and with nodes on the shins. 

7th April, I8S8. — Uo is a robust, ooarse-featurod lad, and it seems that 
he has had the eruptions a fortnight, and thinks little about them, but he 
wants to be cured of the pains in the shins, which came on abont a week 
«go: the chancre has only juat healed; ho is very uncertain about tho 
time of its appearance, and has had no treatment betudcs taking on occa- 
sional done of salts and using a lotion. 

Ordered five grsins of blue pill every night, and 

Mist. Fotaaaii iodidi comp. |j. three times a day. 

I4th. — lie compkins of pain in the right ankle, which is swollen; there 
is asliglit increase of fluid in the joint, but the chief ewelUng is exterunl ; 
it has not that anklet-Hko form over the jimction of leg and instep whioh 
effUsion into tho joint causes ; tho pain seems veiy severe ; there ia a node, 
which is very tender, close to the ankle ou the outer aide of the tibia, or 
anterior edge of the mallctolus, which is involved in the general swelling. 
Ho was ordered a blister over the front of the tibia ; a gutta-percha 
spUnt ; to rest in bed and to come in & week. 

Slat.— Tho ankle ia rather heiUiSy tho nightly puns atill oontiuuo 



Chap. vn. 



CASES. 



185 



nvere ; the gams not aD touched by the mercury : to disoontioue the 
Uae pill. Add to the mirture : — 

Liq. IlydrargTri bioliloridi ^, 

To paint the tibic and the painful Joint with tincture of Iodine. 

aeth. — The gums ore elightlj affected ; the ankle is better ; the nightly 
paitifl have almoet disappeared, but stiU keep him awake : to take a grain 
of Opium, iu piil, every night. 

3rd ilay.— The nodee are nearly gone, and he has but little ptun either 
about the. ankle or ahin-bone ; the swelliDg about the ankle not diminished 
aa much as oould be wished; the guina are suflicioDtly affected; tbo 
bichloride of Mercury is to bo left out of the mixture ; to oontinue the 
application of Iodine. 

17th, — The eruptions, which have been dirointKhed, are now nearly 
gone ; inflammntion of the ankle and the nodes are well : to oontinue hia 
medicine another week. 

Cabe XLir. — Valentine Mayor, aged 36, au obeae Alsatian^ came to me 
at the Charing-Croas Hospital iu the early part of May, I860, with violent 
paiuB in the ahin-bonea ; nodes plainly tu be felt beneath the skiu of the 
tibia ; the dark marks of old ones still left. She bad I'lummor'a pill night 
and morning, iodiilo of Potass thrice a day, aiid the shins were pointed 
with Iodine at night. For the first fortnight Rhc got bettor, but after that 
iimo was worse again ; I strongly suspeot she drank a good deal ; tho 
medicine had but little cffuct. 

■ith June. — Began to take notos of the case because tho knee-joint became 
affected with violent pain i there was little else than this fact to be made 
oat: the knees were both so fat and fleshy that I could not determine tho 
presence of any swelling ; the joint was apparently tender, but her gestures 
and expreasioos seemed highly exaggerated : abo said the paiu came on 
chiefly at night, and walking only hurt her a little : there was no fever Dor 
any nymptom of acute rheumatism. Being willing rather to see whether 
t these symptoms were real or not, I merely ordered a local application of 
Amioa lotion, and told her to continue tho modiciacs. 

6th. — Ju-st the same : uhu ttays tbo cold gives her moro pun ; there is, 
perhaps, a UtUe swelling, but it is still doubtful : to batlie the knee iu hot 
iraier. 

8th- — The joint-cavity is now eiddently fiUl of fluid, aud the pain has 
very much decreased : a blister to be applied across lower part of femur ; 
a gutta-poroha spUnt at the back of the limb ; the mercury has no effect : 
to take the following pill eveiy night : — 



9. Calomel 
Opii .. 



iL 



And thric« in the day 

Mist. Potossii iodidi comp. .. .^. M. 

To return at the end of a week. 

loth.— 11)0 ewolliug in the joint has dooreoaod ; tho skin where the 



i«e 



QOUTV INFLAMMATION. 



Chat. VII, 



blister wta mpplied is still red ; tfae pains In tbe shina better : continue 
tho pills for aootbor week, tiulcas tho giuna got sore, evoiy ni^t and 
morning; ; if they becomo tender to take them ouly every ui^bt. 

22iid. — Tbe knee is reduced to its Datunil sixo ; is still a UtUe painful at 
night ; gums very slightly ftfiected. Pill erery night only. 

^t>th.— The knee is well : the rest of the case refers only to tbe other 
syphilitic symptoms. 

Oout ia a disease produced by the presence in the blood of 
uric or litliic acid ; the local manif'estatiou is caused by the dnputtit 
of this material, in combinufion with soda, iti tlip various tlKsncs 
of the joints, producing a pcriart icular inilamiuatiou, uct'ijin]miiiLMl 
with great pain aad more or less efluskm. It hardly comes ' 
within tho scope of tliia work to describe ftilly either tlio 
symptoms, tho treatment, or indeed the general pathologj' of 
tliia disease ; but a few retoarks upon the mode in which tho 
local action is produced appear desirable. 

Tho attacks of gout, like those of rlieumiLtiimi, come on at 
irrefrnliir intcnals, although the poisonous matter accumulates 
regularly in the blood. There are some springs which only 
flow at certain pmods, being supplied by a natural cistern, 
tliat only allowe ug4:upe wheu quite full, and tlien does nut 
cease to mu till tho receptacle is empty ; so it seems that tho 
uric acid may go on accumulating to a certain point without 
prudueing any painful symptoms, and that then a severe attack 
will come on, with or witliout some occidental exciting cause 
£}ach of these attaoks ia attended with ii more or less rupid and 
plentiful deiHjait of lithatc of soda into tlio soft textures of the 
joints ; generally at first of the small joints, as of the toes or 
fingers ; but sometimes a largo joint, as the knee, the largest in the 
body, will be the only one affect<M]. (See Chapter 1X1., Case XXI.) 

In the acute attacks of the disease, a quantity of the salt is 
partly dissolved, partly suspended in the synovial secretion, 
giving it a milky or rather a chalk-and-watery appearance, and 
when the fingers are moistened with tliis material, and it is 
rubbed between them, it inipartj* a gritty sensation — at the samo 
time a larger quantity of fluid than the norm is secreted ; during 
tbeee attacks, and also during a more chronic and persistent 
Bufleriug, the urate of smla is deposited in tbe cartilages, tbe 
jKiviarticular tissues, ligameutst, and even in the lonesi Tlie 
depodtiou takes place in the form of u chalk-white gntty powder, 



Cha?. VU. 



LITHATE OP SODA. 



187 



in which, under tho nucro^copt^ acioular crystals aro found to 
be almudant Owing to tho opacity thus produced, there is con- 
BideruUe diflSculty in seeing the histological position in which 
tho siilt is fitortid ; but from many inveHtigations wliich I have 
mode, it seems to mo that tho ntoms group themselvea round 
the cells of the varioua stmctures. 

Tho cartilagOB aro sometimes found covered on the surface 
with the lithato ; this happens during tho most acute phase of 
the diflcaso, whilo the joint swrction is rendered milky ; the salt 
then slowly deposits itwlf on all Hurnmndiug part^. Frequently 
are to be seen Little white spota in the substance of the eaii.ilagc, 
and if scotions bo made tlirough these with a sharp knife, they • 
will be found brn«ider and larger in the depths, than on the sur- 
face of tho structure. The opacity in these place« is so greats 
tbftt it is impossible to procure sections thin enough to be trans- 
parent ; but liy teaming out jwrtious very minutely with needles, 
it may bo seen that the litliate occui>ieB chiefly the hyaline 
structure close to tlie edge or wall of tlie corpuscles, while the 
cells themselTcs remain free up to a certain jmint At some 
period, however, tlie cell-waUs l>ecome invaded, the cells them- 
selves atrophied, when ulceration of the cartilage comjnencos. 

In tho periarticular tissues and ligaments, the same mode of 
deposition is fulluwed; the cells remain tliemsehcs free ixom 
tho salt for some time after the fibrous intercellular structure 
has been invaded. This can only ho seen by careful and minute 
division with needles. In a cam? that was very far advanced. 
(Caee XXJ.), I found the whole internal latonvl ligament of the 
knee converted into a cyst, which contained a lump, about as 
large as the Ubtit joint of tJie thumb, of the Uthate of soda. 

The bones, on account of their solidity and the comiiactness 
of their elements, receive this deposit much more slowly than 
the softer ti^ues. In them also it occupies a position round the 
Iwne cells, tilling up tho intervals between the caualiculi. 

The histological sequence of this deposit, carries out entirely 
the ])athuli»g}' of other joint inflammations, as laid down in this 
treatise. I would oidy n^mark in conolnsion, that the case 
above quoted is a strong argument against the sharp line of 
domareution, which has lately been di*awn between gout and 
rheumatituu, since tluit disease commenced in the iniUimmatiou 



188 



GOUTY INFLAMMATION. 



Chap. vn. 



of an acute rheumatism^ and tin* joint after amput^ition was] 
found completely occupied with the gouty vtatene* morhi, 

Cass XLriT. — Mr. Oalton, of Kiug-Williiun-streot, was good enough to 
aek me to ncoompaoy him to a post-mortem examination, as he thought 
there were points in relation to the joints which might interest me, lIH.h 
January, lg60. 

The mau bad been long subject to gout attacks : he hod died suddenly 
in the night of the Htb, after eating voraciously of boefstcakA. 

The left knee-joint was painful a day or two before death ; it preMnted 
now a slightly Hwolleii appearance. On openiug the synovial sac a little 
more fluid than uMual was found ; it was rather turbid : the inner aurliice 
of UiB synovial membi-ane was periiaps a little re<Ider thaii normal ; there 
were one or Iwo white spots upon it which oould be wiped oft' with the 
I finger, also one or two olhens which could not be thus wiped away, but^ 
Boomed covered by a thin membrane : the cartilagea bad aoroe removable 
powder Bcaiti-rod ht^rc and there upon them, aleo some fixed sjtots ; that 
of the patella was chicBj tlius affected, and it was ulcerated in one spot 
about the size of half a pea, near ita outer edge. I brought away with ] 
mo the patella and a large portion of its ligament; also, some of the i^o* 
Tiol membrane, in which the white 8pot« were fixed, and some of the 
loose powder. 

M\er<acopic Jixaminatton. — The powder was found to contain plentiful 
ftcicular crystals of Utba(o of soila. Cartilages : * section through the , 
whitened spots showed that they were all broader and larger near the 
attached than the frco surface. I could net get any section thin enough to 
enable mo to see the locality of the dopoait ; the whole spot was opaque ; 
I tore it to shreds with needles, and washed away the loosened lithate of j 
soda by a stream of water ; the section was still very opaque, but here and 
there a cartilage corpuscle coulJ be seen ; in these cases it waa evident 
that the powder waa situated in the hyaline structure, and not at all in 
the cells, two of which being eet free were found unoccujjied by the dejiosit. 
Where the cartilage was ulcerated the hyaline stnicture wa» split into 
fibres, between and ii]ioii which the litliate of Hoda was tutuat(Kl ; this was 
seen by treating the »pooimun as an opaque object : as a traa.<iparent apo- 
oimen thi& part of the cartilage could not, in itfl uatuml tttnlo, bo uBod,4 
but I tore off sumo fine shreds and treated it under the microscope with 
veiy dilt:te nitric acid, and then the celts wore found shnvelled and 
oolla{)8cd with ])uckerei) walls ; this appearanoe gradually came to light as 
the ailt dissolved. 

The ligjuaentum patelltD had, n*ar iU centre, one spot of the chalkstone; 
this part was cut out, a fine Bbrod clipped oft* with the scissars and torn 
with needles under water ; after much labour throe of the fusiform cells 
oould be made out without any deposit on their walls ; the material wm 
accumulated round the fibres ; the eame was the case with the subsynovial 
tissue. 

'Hit- Ixme was t<»7 thiolc and dense; a section carefully tbinned and 
washed showed parts perfectly opaque, in all Ukelihood tnio an accumula- 
tion of the lithato of soda, but those opaque spots never cucroaohed on a 



Cbap. vn. 



SIMTLE SYNOVITIS. 



189 



lacuna ; thay were aronnd these itpAooa and ooneeolod many of the coLnnti- 
ouU : the Hrtioular lamella aad subjaocDt cancelli were opaque beneaih bho 
Bpoia of deposit in the caiiilago. 

It may bnve bwu obtR?rved that, wliilo ucuto inflanunation 
of tho Kynoviul membrano bas bron riescribe*! as ariaing from 
several causes, some of tliom acciileiital» othrrs constitutional, 
the chronic attack has been at present only described as having 
its root in Bome cachexia or dJatlicsia: the truth is, that uu 
inflammation of the synovial membrano never commences in a 
clironic form unless from a constitutional c^use. When an acute 
attack subsides, it either sinks into a chronic state, wherein 
the disease, althougli sluggish, is essentially an active condition, 
or it may sink into a merely passive state of venous congestion. 
The chronic inflammation, not complicated by any constitutional 
evil, is easily combated by rest, mild antiphlogistics, or counter- 
Lrritonta, followed by judicious use of iriotions such as are amply 
described in other chapter^ but principally by pressure witli 
strapping plaister. 

The passive congestion is accompanied by certain symptoms, 
the most prominent of which is a superabundauco of fluid in the 
cavity of the joint, and this condition has acquired tho name of 
Hydrarthrosis. It always happenH that when n disease w named 
simply from its most prominent symptom several pathoU)gical 
conditions become confounded together mider one designation ; as 
under tho terra dropsy we may find a renal, cardiac, or hepatic 
disease, or indeed a mere condition of thin, imperfectly assimi- 
lated blood. It ia often, however, very inconvenient to change 
nomenclature, hence the diflferent states wliich produce great 
excess of fluid hi joints without possessing an active inflam- 
matory character must be the subject of tho ensuing chapter. 



190 



HYDRARTHROSIS. 



cnAp. vm. 



CHAPTER VIII. 

Htdrarthrosis. 



Pathology. 

The term HydrarthroBis, and the more ancient one, Hydrops 
Artifuli, denote amiply that the joint contains an nlmormal 
amount of ilmd, without any reference to the cause of its accu- 
midation; hut there arc in reality two sorts of disease wliirli 
produce this elfet't, the ouo unattended, the other attended, 
by Btruetiiral alteration of the synovial membrane ; the former 
of these conditions is tliat which we glanced at in the previous 
chapter as t>cing merely passive congestion of the vessels, 
left after acute inflammation. We know (bat the b<jundary 
between congestion and chronic inflammation is most difHcuIt 
to draw ; the absence or presence of eliangea in tissues, as the 
distingin'shing point, is often variable, for iho former state Is 
itself apt to overstep its own passive limits^ and to set up 
some alow but active alterations ; hence in tliis form of hydrar- 
throsis occasionally a slight inflammation will be present, though 
llio Ktute gtmerally is congestive only, and the weight of the 
fluid itself produces thickening of some of the surronnding 
gtmctures, by a nutrient rather than by an inflammatory act 
It is rare that we have an opportunity of examining patho- 
logically cases of this disease. Tho first report in Sir B. 
Brwlie's 'Observations on Diseases of the Joints* appears to me 
to belong to this cat<^;ory : — 

"A middle-aged man was admitted into St.-George's HospitaJ tn Sop- 
iemhtiT, 1810, on account of a diseaac in one kneo ; the joint was 8woIli:n 
and painful, with sliglit stiffness, and with fiuid in its cavity : the swelling 
cmtcuded sr>ino way up the anterior part of tho thigh, behind tho lowur 
portion of tho oitonsor tnusclefl ; it RubMided under Uie use of hlistera and 
Unimenta. Two months after his admission into tho hospital the [wtient 
was seized with a fever, apparently unconnected with tho diewse in the 
kuue, of which ho died. On examininf; tlio affected joint tho sjrnovial 
membrane was found uiuru capacious than natural, so that it extended up 



Chap. Vni. WITnOTTT fiTRDCTlIRAL CHANGE. 



IDl 



tbo Ulterior Mirface of the femur at least an iDcb and a half higher than 
under ordioar/ oircuiaBtanccfi. Throughout the whole of its tutcniol sur- 
Uco, except whoro it covered tbc oartUagce, iho mombrane vaa of a diirk 
rod colour, the veBBela being aa uuinerouH and as muuh distended vith 
blood as those of the conjunctiva of tbo eye in a violent ophthalmia. At 
the upper and anterior part of the joint a thin tiake of coagxUated lymph, 
of the sixe of a half-crown piec«, was found adhering to the inner aurfacd 
of thoByiiovial inemtrune ; there was do other aptKiaranco of ditwaeo, except 
that at the edge of one of iho cuudyltia of the femur the cartilage adhered 
to the bone lusn Grmly than UBuaL" 

The case is supor^cioUy reported, and the post-mortem 
appearances are not given with that exactitude which generally 
ciiaracterizcs Sir B. lirodie's own olsen-ations, so that I am !e<l 
to conclude that the distinguished author did not himself see 
this suhject oithtT during life or aftor death. The distension, 
however, of the sac, its extreme vascularity, witli only one thin 
ehred of lymph, would point to a congcBtiye condition, more par- 
ticnlarly as thf; quality of the fluid being passf^l over it may he 
concluded that it was clear— at least was uot puriform. 

Casx XLIV.— BoDJamin Savage, a^ed 17, veak, cmaoiatod, was brought 
to zne by his mother 15th July, 18A7, for a burn he had received by faliin;; 
in a fit upon the firo. The iK^y's fits have got worse lately ; he is of wuok 
intellect and getting stiU more so ; he also growH thinner, although his 
appetite is voracious ; he has a very bad cough and cxi>«otoratos a great 
deal 

His mother showed mo his right knee, n-hich was much swollen. It 
appears that two years ago he had an accident to the knes, causing great 
pain and swoUitig, and ho was token to the Middlesex Hospital: the joint 
was weU when he come out, but for tbe last fifteen months it has beea 
enlaigiDg ; it does not appear to produce pain, but oo^ causes him to 
walk with the knee a hltle more straight than the other. The bum was 
treated and the kneo strapped : I was desirous, after a time, of injecting 
the joint, but the mother did not seem inclined to let him undergo any 
truatiiient. The parents Uved close by the hospital and he was oonstantly 
being brought to me for something : ho kept getting weaker, ex|>ectorated 
more, and had longer &ta ; and, at hut, ou tbe 6th or 6th October, IBJiO, 
he died. 

7th Oot., 1859. — X obtuned pennisaion to make a post-mortem exami- 
nation, simply for the sake of seeing the state of the artioulaUon. 

During life the coudition of that joint bad been as fbUows : — it was 
very much increased in size, aimply by the presence of fluid in the cavity ; 
tlie periarticular tisAiioH wore oot at all swollen ; tbo fluid felt vory near 
the finger ; the chief tumefaction was at the front of tbe thigh, oon- 
sidorably above the potut to which tho synovial membrane ordinarily 
extends ; the patella was imshed rather forwarda, away from the condyl» 



192 



HTDRABTanOSIS. 



Chap. VIO. 



of the femor, bnfc not so much bo u is tlic case in acnie Bjnovitis, with 
iufinit*)ly lesa accumnlatioti i>f lluitt ; there was a little bulging of the jaint 
on uaoh side tlie ligameiitiim patcllaa; there had been uo pain, except if he 
attompted to flex the leg considerably, but the joint waa rather eti^. 

The akin waa reflected corefullj back from the front and sidee of the 
lower port of the thigh: the muscles, uamoly, roctits and vasU, wore seen 
pole and thin, partiotilorlT the two last ; they seemed spread out and their 
fibres separated ; when the rectus was turned back the samo was found to 
bo the cose with the crurous : these muscles were diasected as low as 
could be managed from the white glistening outer walls of the pouch 
that extended high up beneath them, and this was punctured in such 
manner as to prevent, as much aa [Kuisjble, tutty Icitw of the fluid ; the aac 
van then opened up by turning bock the patella ; there was extreme red- 
ness and vascularity of the inner surface of the synovial membrane ; thia 
was most marked in the folds between the femur and the intemrticular 
carLitages, also at the sides of the patella, but thero was one part in the 
Buborureal sac which was intensely congested : the folds first mentioned 
wore vor>' vulvetty in texture, owing to turgescenoe in the vcfisela, but the 
Bubstanoe of tbo vilU tbemaelvee did not H&am increased; tlie cartilages 
had become soft and bad lost their opal bluish sheen ; had become dull, 
milky, and soft, ro an to take the impress of the niul : upon the anterior 
crucial ligament was a little cyst containiog serum, the size of a pea, very 
like a bliater ; th&re wait no shred of false membrane anywhere upon the 
Biirfaces of the joint, neither tlooting in the liquor. The fluid was eleven 
ounces in quantity, etraw-ooloured, with acme round spots like oil on the 
surface ; it bad lost all thready quality, but had still a lubricating feel ; it 
waH very like the fluid of hydrocele, and coutatned a good deal of albumen ; 
under the mlcrusoope the bottom of eomo^ left BtamUug in a conical glass, 
showed a few round colls. 

The tcituros around the joint wore next examiucd ; they wore found 
thickened, white, and gUateuing ; the increase was not by addition of crude 
unformed textures, but appareotly by umply greater nutrition of the 
normal porta, that is to say, the growth was uniform : there was no 
distinction of old normal and now abnormal textures. 

Such a state of parts is sufficient to show the absolutely 
passive quality of thia form of Iho <liseaso ; there is, liowever, no 
doubt tliat such u comlitiou may eomo on withont any previous 
acute attack. A hydrocde Is generally withont inihinmmtory 
commencemeut. Hydrarthrosis is more rarely primary, but it 
may be produced by pressure on tlie vessels above the situation 
of the joint 

Another form of diseaae is tliat which brings with it, or is 
caosed by, a certain ftlterulion in the structure of the .synovia! 
membraue, and Uio&c altnTntions, bogiimiiig in tdight luid siniph* 
chaDges, become afterwards very remarkable and striking. 



Obap. vin. 



WITH STHUCTUHAL CUANGK. 



198 



Dnpaj-tren was the first who described tliis very curious condi- 
tion, liaviug observe<l it iu the person of a crimiual whom he 
dissected after execution. Uia account ia as follows: — 

"Both knees had attained a oon&iderable size, knt the skin c>oTering 
tboia had undergooe no change. At hoiU sides of the patella wore situated 
ohloag tumoiira, rising up Tertically above that bone, and w. them, on 
also in the lateral portioua of the joint, fluctuaUun was dintiuct. On 
opening the joints thero Sowed twelve oudcch from one, thirteen ounces 
from the other, of a visoouB, tiiready (/ilitU:-), slightly re"l fluid, having a 
flat odour difiicult to characti;nze, and a rather luUt flavour; its gravity 
vas to that of distilled wntor oa 10a to ino: the articular cavities con- 
taining this [irodigious quantity of lluid bad increased almost entirely by 
their ujiper part. Tlie synovial cajK^ulo rose up under the t«tidon of the 
triofs /emoris four inches above the articular eiirfaco of the femur ; the 
aides of the joiut-cavity were much dilated before and behind the lateral 
ligamenta, the posterior portion had suffered no disteusion ; the internal 
surface of tlie sac, redder and thicker than natural, was studded throughout 
with |ielletrt {julolcnt)^ unequal in size and toIuiho, supported upon 
pedicles of difTereut breadtli, from which could easily be squeezed a fluid 
like that oout&ined in the synovial cavity ; the neighbouring parte tvero 
healthy, and oU the other joints of this person were in their natiund 
stato." ' 

M. Bonnet also reports a case in which he had examined a 
joint affected with tliis disease. 1 will quoto as inucli oh is nuces- 
eary in tliis phico. 

" During Lifr. — The knee was much larger than that of the oppocdta 
aide, painful, without nny change of the skin, and offered manifest fluctua- 
tion, chioHy on each side of the patella. The leg was extended on the 
thigh ; flexion very difficult, and stiflhess in the joint considerable. 

" Juto/my (^ tie Left Knee. — We found still some traces of the liquid, 
which had seemed to be entirely alisorbed. The synovial mcinbrano was 
opoqae, slightly thickened, uid partially fibrous ; its internal surface was 
red and bristled with vascular tufta, chiefly in the parUj which surround 
the patoUa and in those situated above that bone ; the membrane covering 
the crucial ligaments was unaffected. On those spots, where the structure 
was red, there were some false membranes which appeared of recent for- 
mation, but in other parts these membfanea had become adherent. 

"The right siile presented the siune api^tearances, hut in a lain ad^iuioed 
stage. The synovial membnuie was lean rod, but still was slightly injected, 
thickened, and contaiood about 100 granunes of a yellow liquid.** f 

Theee tufts which are pcnendly, idlhongh, aa we have seen, not 
always prest^nt in hydrartlirnsi-s, are luorely exa'Tgorutions oftli*? 
villi wltidi are normal to synovial memhranos, and they become 

• Did. €luB Heii'ncofl M(fil.. t xxii. p. Ho. 
t 'MnUdiL-s dts Artioalatiiiiw,' t i. p, 4!!'.' 



104 



HTDHAitTUUOSIS. 



Chap. Tin. 



thus pnlai^tl whonevor the Bocretion Into the joint is raoreoeed.* 
8ciinetirai>8 earh tuft is swoUnn at tlie end, bearing a resemblance 
to a ourrant on it** Ktalk ; or the secondary sacculi may b« 
enormously distended, so that each tuft becomes a branching 
growth from the inner sorfaco of the membrane. These hyper* 
trophied portions generally contain fluid of the samo consistfuce 
118 that in the joint; vory Croquontly also thoy are Iiardencd 
and cartilapnons, so that there may be found several con- 
siderable pieces of cftrti!ap;o hanpntj: npnn thin stalktt. These 
ovorgn^vn processes may sprout su tluckly fi-om the membrane, 
that they form altogether a large ma^ which, unless tho 
quantity of fluid bo very great, produces a doughy, unevenly 
hard and soft, enlargement at tlio sides of the joint. It may 
liappen that when tho hypersecretion is allowed to flow away, 
these masses first come within the surj^eon's range of touch ; or 
occustoiially the tumefaction, which was at first entirely due to 
fluid eflusion, becomes more and more indebted to the out- 
grov^lhs of tho synovial fringes until (none of the fluid having 
been artificially ovacuatetl) the enlargement is found to bo 
almost entirely produced by the hypertrophy of these bodies. 

This disease is, generally speaking, connected witli tlm rfiou- 
matic taint ; the great growth of the tufts, the occasional hard 
swelling at their ends, edimect this form of hytlmrthrosin, on 
the one hand witli the peculijir false cartilages in joints, on the 
otlior with that malady called chronic rheumatic arthritis. 
Again, the rlmumatic tendency to organise, is scon in the ooca- 
gional transformation of tho etibsynorial tissues into cartilage, 
sometimes into Iwny matter, surrounding the joint in an annular 
form, or more rarely brandling in an arborescent manner over 
the synovial membrane. 

After a time — be it from change in tho nutritive condition, he 
it from the soaked stjite of tlioir tissue — the cartihigos may be- 
come fibrous, and then ulcerated : this is always accompanied by 
a turbifi condition of the fluid ; indeed, there are cases in which 
the fluid becomes more purulent than syuonal. 



• Tho laOTP watery rxmdntion from I iiiFtanrwi finit qn(rt<d, tlit; tufts wen' 
onsOTlaDn is iiot Mcrctfiui : Iteuce, in the [ not enljir|:iicl. 



Ciup. VIII. 



DIAGNOSIS. 



105 



Symptoms. 

The appearances which this disease produces have been pretty 
aocuruf^'ly detailed in the cases already quoted. The accutnula- 
tion of thiid in the sjy'uovial membrane causes a tumefaetitm, 
which is limited by tlie walls of the sac, and which flucluiiU^A 
froely from side to sidt*. After a time, the h\'pprseci'etiou be- 
comes suflident to distend the synovial membrane, and to make 
it yield in that direction in which the least resistance is offered. 
Thus, at the knee joint, the patella will be pressed a little for- 
Wiuxl, away from tbe fuuioral condyles, and at each side of tho 
ligameut will be a certain amount of bulging or tumefaction, 
also at the sides of the joint a good deal of swelling, girt iu Ay 
the lateral ligaments ; but the greatest amoimt of enUrguuient, 
that which chiefly will attract attention, is above the knee joint, 
in the 6ub-crureal sac, grooved lengthwise by tho rectus tendon. 
Such are the early appearances, but later in the disease, the 
areolar ti&^ue thicki:n« so much wheu'ver the weight of the fluid 
produces pressure, that the tumefaction below beeomc^H les6» 
while (Jiat al>ove becomes moi*o marked. Thruughout the 
case, 6uctiiution from one [Mut of (In? joint to the other is ]>er- 
fectly distinct At tho elbow, where the disease is next in fr<v 
quency to the knee, the swelling is cliiefly on tho innrT side, 
over the intt^mal condyle, but also runs up the bock of the ana 
under the triceps muscle, and fluctuation may bo felt from one 
part to the otJier, or from either to tho junHion between the 
outer trochlear surfwx' of the humonis and radius. 

These positive syrapt<ims prove that there is a certain amount 
of fluid in the joint cjivity. Beyond this point we depend for our 
diaguoKis upon negative signs. 'J'he absence of iutlammatory 
symptoms and fever shows that we have not to deal with on 
acute synovitis, while the absence of any fur advanced debility 
and hectic sho^vs that the fluid is not pus. 

Tliis condition nf joint is accompanied by a certain amount of 
stiffness; the limb naturally assumes that position, which giv(!8 
most room to tlie fluid, and any cliange in this posture, causing 
more or less pressure, produces pro|H)rtionate pain. Heuee 
the stifihess is in the (larlier stages directly pro|H>rtionate to the 
amount of fluid distens^ion. 

o 2 




196 



HYDRABTHBOSIR. 



Chat. VtlT. 



In the bepraiinp of the complaint there is no possibility of 
judging, fn>ra the gymptoms tlicn present, wliich form of tlie 
diiunAO wo have imder our notice ; tlie past history most help ns 
to the conclnsion. Hyilrarthnwis from mr^re (•ongri-srtion is a 
floqucla of an acute inflammutory attack ; while, if it result from 
hypertro]>hie<l fringes, the history will probably bo that of a 
disoaso thronirhont chronic. Even that form of malady, which 
commences by more congestion, is apt lifter a time to j>ut on ^)mc 
of the appearances of the other species. Hypersecretion is not 
only pnxluced by, but also produces oularpement of the synm-ial 
papilhe ; jMiasive effusion causes very slight increase of theso 
bodic« in prop(»rtion to the amount of Quid in the Bac. In that 
kind of hydrartUrosia, whose origin seems to 1h» hypertrophy 
of tliese procossea, tlio amount of solid matter is after a time in 
eonsidcrable ratio to tlie amount of fluid ; ao much so, tliat the 
enlarged fringes can be felt as fleshy, doughy masses in the 
sac ; more or less moveable, more or less apt to glide away under 
slight pri'ssurc. Siirli fleshy growths ani situatt^l in the knee, 
chiefly at either side of the patuUti, l»etwoen it and the lateral 
ligaments ; in the elbow behiud, and above the inner condyle. 



TllEATMENT. 

The early symptoms of hydrarthrosis are not always, as wa 
have seen, alike. The disease is sometimes the remnant of an 
acute inflammatiun, and therefore, when such an attack is declin- 
ing, it ia well wortli oonsideriug whether, by a certain local 
treatment too much in vogue, we do not rather than otherwise 
tend to produce this dropsical condition of joint. If we sulxluc an 
ocuto inflammation by abstraction of blood; subsequently, by 
bli.itera (remedies which we know relax the vessels); then apply 
warm poultices, fomentjitious, &c., we conduce to this relax- 
ation still more — are in fact using the very means, which we should 
choose, wore wo endeavouring to establish a venous congestion. 

In several instances I bave seen such treatment followed by a 
troublesome amount of lingering eflusion. The sense of distensii m 
and stiflhess, or the increased size of the joint, may bo got rid of 
iniinit>(>ly quinkerand licttor, if pressuro bo applied a« stKin n* the 
actual acute iullummutiou \m6 diftapfieaittl ; very many casis 



(j'UAP. VUI. 



GENERAL TREATMENT. 



197 



bttvo proved to mc the much greater benefit to be derived from 
8UL'h procc'fjdiiif:!, 

liut if ft dn>ii«y of tho joint have Uist«d some time, or agaui if it 
commence in a chrouio form, wo mfty in either case, and rer- 
taiuly iu tlit; latter, conclude that some constitutiouiJ evil has 
sot up, or is maintaining, the morbid condition. If in mich a 
dieoaso we look to the general Hymptoma and to the history, Uie 
signs of a rheumatic condition will nearly always bo found ; and 
when tliia w tlie case the treatment of chronic rheumatism may 
l»e advantagronsly rtimliined witli the hjcal management; indeed 
it has a|^n>eured to me, that tho reason of many failures to cure 
thin disease is lu the ohtitinate employment of local, to the utter 
exclnuion of r^institutlonal remedies. lotlide of potass, guaiaeum, 
James's powder, ipecacnatdia, diaphoretics, as recommended in 
Chapter VI,, are the chief means at our disposaL I would 
however exclude mercury and eolchicum nearly or altogi'ther 
from this list. In the above-specified chapter, mercury, both 
generally and locally, was recommended. We find, in the form of 
symiritis there des(!ribed, an inllammation of a highly formative, 
membraue-producing tj-pe, and in such diseases we know how 
restraining is tlie action of mercury; but iu the malady now 
under consideration the condition is very different, and the 
rhennifltie action of a depressed form. 'Vhe locid influence of 
mercurials is probably injurious, as I have couAnnced myself (a 
case in point is quoted at the end of this chapter) ; probably by 
wi'aliening still further the contractile force of tlie ve-ssels. The 
systemic action apparently produces similar want of power. 

Antimony in larj^e dosis has been employed with benefit; the 
originator of this plan, JI. Gimelle, reports its efficacy in twenty- 
eight cases. His doses, beginning with half a gi-ain every three 
hours, were increased little by little until thpy lunounted to twelve 
grains in the twenty-four hours, and the cure was generally 
efteiTted in about twelve days.* The same plan has found more 
favour in Germany than it ia likely to do in this country, and 
many reportu of cures have been published. 

Local tiieans, however, during the employment of these 

remo<lie8, must be used for the sake of proiaitting absoi'ptiou, or 

otherwise getting rid of the suiwrabuudant Huid. lieet liaa 

* ' Meiiii>iri8 t\v I'Aoadiiuiiv in HtduvuK,' July, 1840, 



198 



UYDBABTHKOaiS. 



Chap. VID. 



nearly always a very marked eflect in nnluciiig the suce of the 
tumour ; the horizontal posture of course prevents the weight of 
a superimposed hlood-cohimn acting injurionfily in prodneing 
venous distension and tlierehy exsudation. Ulititers and all gortH 
of stimulating linimeut^ tartar emetiu ointment, nitrate uf aUver 
lotion, are all occasionally employed with some temporary jmd 
but little permanent boneiit Such applications are often^ while 
the patient is at rest, apparently beneficial, producing absorption 
of the superubmidaut Huid ; but when he abandons the reclining 
{>ositiou, hy[)erKeeretion again set^ in, aud the diRriaso returiu. 
l're}»sure has haci, in two slight cases, a better effect, and cured the 
disease even while the patieuts were walking about, but it were 
vain to strive against a confirmed hydrarthrosis by such means. 

jSimple ftuncture with tlifl trocar is a merely tenijK)rary rcjiiedy ; 
but £rom the sort of fiuid evacuated, we may bo able to found a 
diagurjfiis as to the species of disease, A viscous tliick liquid, draw- 
ing into long threads rather thtm dro})ping, tdiows a coiisid* arable 
stnieturul change, and it is probable that no means whatever 
will be able to restore perfect health to tha syuoviid membnmo 
of the joint for mouths, if at all. A fluid, whether thick or 
otherwise, which is ojialeecent and turliid, in fact puriforro, sliows 
that the cartilages have more or less yielded to flisease, and 
therefore that entire rt-jiair is barely possible. A Uuid thinner 
than syno^Ta, clear, yellow, like tlie liquor of hydrocele, denotes 
tlat very little or uo morbid change, according to the mom or 
less water)' condition, luis taken ])hiee; hence many of the 
means mentioned may prove curative. Kvcn simple puncture 
followed by strong pressure will in some cases be sufficient to 
produce the desired result Acupuncture has been used, and 
one case is reported in which it was beneficial." 

Suiculofteoua section of the stomal memhrane is a mueh better 
means, and this, combined with pressure, is likely to Ik* followed 
by permanent cure. M. Gtiynuid istheijiventor of this method : 
ho published the following account ofhis proceeding. 

*' On the SiHh Docomber I operated in the rollowiug maDscr ;— placing 
myself ou Iho left of my patient (the disease waa in Ibe right Lnco) I 
pinched up the nkin of the thigh at the upper aud outer part uf the 



* HBiuburgi-rZeitarlirill, OadeehinM, 1851. 



fH*p. vnr. 



SUBCUTANEOUa INCISION. 



199 



tumour into a l&rgo traosTenc fold, which T let an uttiBtaiit hold, and 
prosaiug vriili the left b&nd the patella and luwur part of tbo Hwelling, 
HO aa to distend itn upper [xjrtioii, I pluuged Ihrougk the trauavoree 
fold a uarruw-bladed liistourj-, ivith a cutting cJyo ai\ inch long from 
the poiut, and Uuut beyond this dtstanco to th« hoel. Having paiwed 
the kmfc auSiuieutly far under the akin, I froeljf dividixl the a}H>neurot)i8, 
the out«r and middle portions of the trioops, and the upper and outar 
part of the synovial saa Having thua opcucd the joint, I turned the 
bistoury half round, so ua to direct itH cutting edge furwardK, and divided 
all the deeper parts between the skin and the articular cavity, giving the 
incision into this latter a length of from Bfleeu to eighteen uilliniillrea 
(from half an inch to an inch); the bistoury was then withdrawn and the 
fold of skin let louae : the eitornal puncture drew itaelf up to four ocnti- 
mdtrcs (ou inch and three qu3ui«rx) above the deep incisions, and is 
hardly more than a fifteenth of an inch long ; some little bubbles of air 
had penetrated under the skin, and wore placed in the track of the puco- 
lure. Slight pressure upon tbo tumour forced out some B^uovia, which 
carried the air along with it. I did not endeavour to empty the synovial 
membrane, as I knew that the lii]uid would infiltrate the areolar tiaaue 
and be very sooo absorbed. A little piece of diachylon plaister watt put 
upon the wound: nmt in bed. 

** 3i>tb. — No fluid in the synovial membrane : it has iufiUrated the loose 
oeUuIar tiasuo between the femur and triceps and fonus u tumour, which 
has nearly the 8ha|M of the hydrarthroaia, but ia not tiuotuating. The 
patella is now in contact with the fRinoral condyle, and pressure upon 
dill'eruut parts uf the tumuui- doea not displace tbiti bone ; there ia not the 
aliglitoat {>ain. Compreaaion by meaua of plaiatera and banitagee. 

" This [mtiont went on perfectly well. On the 13ih of January be 
desired to leave the h^iApital, promising to ahow himself if tlie tumour 
returned. On the Ist June he had not reappeared." * 

This case should Imve been kept in sight if tlie euro was to 
be proved, as we know how little reliance can be placed upon 
the promises of patients. M. lionnet relates a curious instance, 
in which a fall bad ruptured tbo membrane and produced a 
cure.f 

Certainly, however, injection of the joint by some irritating 
liuid ia^he moat powerful moiiiLs of cure at our disposal, and is, 
even though it bo not always ctirative, so very slightly dan- 
gerous, and so seldom followed by too violent an intlam- 
matioti, that it may be used without fear. Mr. Gay, of the 
Cape Hospital, Cape of Gootl Hope, the first who, in 1789, 
was BuflfiiMPutly Ixtld to use this means, employed the rUaco- 
tiite of lead for tlie purpose, and suooeetled in curing his 



IMS. 



■Gauttc (lea BApitaux.' Jnly VMu I 



t *MaUtdicatk9ArticnbtJutui,'tuin. i 
p. 131. 



200 



HYDRARTHROSIS. 



Chap, Vlll. 



pfttiP^ut-. 11 tHigresa, tliirty-eeven years old. In 1841, Velpeau 
and Bonnet, in France, took up this plan, and used iodine for 
the injectiou-fluid. This mntrrial is valnablo, in-aA-much as it 
does not tend to produce suppuration ; and although several 
coses have ocomred, iu which au unUeairable amount of intlam- 
mation has followed, I liave not found any reported cases whose 
roHuItti were disastrous, although both in England and on the 
continent its eniployiuent has become pretty geueral. The 
mixture commonly used In tliis country is from a drachm and 
a half to two druchras of the tincture of iodine, with an onuce 
of water. The mode of procedure is extremely simple — a 
trocar and cauuta are plunged into the joint at some fitting 
spot; at the knee, alxjve and to the outside of the patella; 
at the elbow, above the internal condyle, the direction should 
always bo oblique, that tho opening may be valvular. Fluid is 
then allowed to How out: tlie hand may be placed over tho 
joint so as to compress it very slightly ; but no attempt is to 
be made to empty the cavity. A sj-ringe, whose perfect fit to 
tbo cauuhi has previously been secured, is then to be adapted 
to the tube, ac<l tho solution injected When the fringe is 
removed, the finger is to bt? placed over the mouth of the oanula, 
and the limb is to be moved up and down (without bending or 
straightening the joint operated on to more than a very slight 
degree) so tliat tho iluid may come in contact \vith every part 
of tlie synovial membrane. In about a minute the limb is to 
be turned so tliat the cannia is iu the most depending part of 
the joiut, and as much fluid us will escape, under slight pressure 
upon tho synovial membrane;, is allowed to flow out. The canula 
is withdrawn imd the puueture closed with a piece of plaister. 

It is essential to observe tliat no air enter the cavity, and for 
this purpose it is necessitry tlmt the syringe liave a weH-fittiug 
piston, and bo accurately full of the liquid. The amount of 
flni<l injected depends in gnsat measure u[>on the size of the 
tumour, and therefore iu part also upon the amount of liquor 
previously withdrawn ; at tlie knee it need not exreed three, or 
at most tliree and a half, ounces ; at the olbow I have fonnd 
two o^mr'cs HuPlicieut. There is one singular eflect occasionally 
prodiKHMl by iodine, viz.. a sudden and eouaiderable fall of the 
pulse, Uith in Tn »|Ueucy uiid potter. 



Chai-. vin. 



INJECTION WITH lODIKE. 



201 



TIiU is, as we have aaid, tlip moat |iowprfiil nieana nt onr dis- 
\Kma\ for tlie rudaciiuii of liydrarthrosia, but it dws not nlwuys 
cure the complaint It will almost invarioWy greatly climinish 
tlie amount of fluid in the joint : but it« ofloct upon tlie hyper- 
tropbied synovial friugt?n is less marked. It is pn)bftWft that 
their tliiid contents are diminislied, but their solid eulargenient 
can heo^ly be thxis at once decreased* Sometimes, iu those 
caseu wliioh do not depend upon a strongly marked diathe»i», 
and in which cartilaginous thickening of the ports has not oo 
curred, the morbid addition to their siae will dimiuiwh. \\Tieu 
such thjcki^uing has tiiken ]>laoo the ]»i-ognosit( is untavourabh\ 
for the diseaso will probably end in considerable impairment of 
the joint, or even in slow cmppuratlou in the cavity. 



Cases or this Disease. 

Oabr XLV. — Jiuio Higginaou, tgetl :)3, a tthort, voAkly-loolciog woman, 
ueariy e^it months lulvanoed in [irognaucy, csmo to me Ist August, XHGQ, 
with a oooiiiileniblo swelliug iu both kaeea. 

The sweUiiig cuiuiut'ticud, withuut pain or anslgimble cause, fivo days 
I ago ; she found it acuideutally on goiog to bod at ui^ht : tbo only unusual 
seusatiou in slight BtiffneAs. The nght knee, tho luiigecit, preoouts a Buc- 
tuating tumefaction, chiefly obsen'iible above the pate1ll^ but also in every 
other part of tho joint ; it is not hot, tender, nor red. I grdered her to 
rest art much as possiblo, and to put a blister above tho right knee : Qui- 
nine Mixture three times a day, 

6ih. — Just tho same : a blister to the lower part of the joint ; the left 
luiee to be strapped. 

13tli.— Both ja)ut« are larger in size, and she now luus a sense of diBteD' 
aion in them. 

To use tho following lotion every night i — 

^. Acidi Sulphurioi fort, .. ^ij. 
Olei Terebinthimo .. .. ^ss. 
OlciOUvBB .Siss. M. 

18th. — ^Tha feet and legs are udcmatous : this occurrence led mo to 
, abftadun all irriUnt treatment, and to tell her simply to come and lot the 
legs bo bandaged a» fret^iieiitly as necci*saTy. 

3rd Oct. — As this patient hait not lioon to mo for more than a month, 

I I called at her lodgings iu Bedfordbury : she gave birth to a child thnia 

' weeks ago ; tho a>deiiia of the legs has di8appeared, alao the swelling of the 

' led knee ; tbo right one in still u little awoUen : she has been up five daysL 

I told her to send to tho hospital for sume quinine and to oome to me in 

aboat a month. 

12th Nov.— This patient came to mu ; hor kuetn aro now of perfectly 
bonuul »i») and jihu^ie. 



2U2 



HYDHARTHROSrS. 



Chap. VHI. 



Cahr XLVJ. — .Susan Bradlj^j ngod 48, camo among my out-pfttienta at 
tha CUttriug-CVoHs lliwpital I3th April, 1800, with a »woU*?n kuee. 

Thu rijfbt kueo has been painful for iibuut a week; the ^Miiit hta cunte 
on at night ; it in now domcwbnt awoHcn: tlio tumour is tluc-tuutitig ; tho 
[latella uot in contact with tho femoral condyles : alight atitfncpa, uo ten- 
deriR'^, huat, nur rednewi ; &ho is subject to rheumatic iiain», chiefiy in 
the right shoulder, aud has attributoil the pain in the knoc to rbeutoatism ; 
tthu is strong and stout : kuee to bo strapped. 

To take the following draught tlirec times a da; : — 

9. Liq. Antimonii iartarizati (D.) 
Spt. .Tltheris nitrici, a a ., jaa, 
A<xuee destillates ^* U. 

17th. — Knee pnliaps a littlo smaller : i-oapply strapping. 

24tb. — Tbc lojee is certainly bettor i the swelling lias much Jccroaswl: 
knee to bo strapped with tho Kmpltistrum Ammoniaoi. 

May Gth.— Tho uL^dioiue has produced somo feverish symptoms and 
diarrbma. Tho fullowiug to be taken every six hours : — 

1>. Spirilua Ammoniiv aromatici n\x]. 
Potaasaa carbonatis .. gr x. 

Mtst. dmphoriQ Al- ^' 



And al night 



Pulv. DoTeri 



gr. V. 



I'Jth. — Tho diarrhffia and feverish symijtoms Imvo subsided ; the kneo 
has quite regained it!« sha[x> ; there is a littlo thickcuiog above the patella : 
to be ntiiipijed again v. ith the aonio plaister. Ordered to take two grains 
of quinine, in tho form of pill, three times a day. 

19ib. — Discharged ; cured. 

Cash XLVII. — Klizaboth Grant, aged 28, a tall woman with powcrfully- 
formod limbs, uuue among my out-[i&tieni8 tu the Clmriog- Cross Hospital 
Hth January, 1856, fur an eiihirgowcnt of the right knee. 

Six months ago, in doing some hniiKehold work, she knelt upon a 
thimble and hurl bor kut-e. It was paini'u] aud swollen for three weeks i \ 
slie rested as much as she could, but Liiiderweni no treatment : at the and | 
of that period both the swelling and [^aln di»ap])eiired, and she took noJ 
farther notice of the uccurreuoe ; but, ten days ago, the jiriut U^au to 
swell a:aiu and to be painful. She has been suckling up to thn present 
time : the child is fourteen months old. 

The kneu is vury r-onsiclerubly swollen, presenting a bag^ tumefnctiou, 
concealing thu shape or the boncri, and larger in some places than otheni ; 
owe of these is in the lower part of the joint on eitlier side I'f the lignineii- 
tam patalbi' ; but the chief enlargement is on each aide of the rectus muscle. 
The meaaurBments are 





Kouiiil. 


MurtjiiL 


Above patella 


.. 16J . 


171 iiicbcK. 


AcroM „ 


.. 1*4 . 


.. 17 „ 


llekiw 


.. 131 . 


. 15} ., 



Chap. VTIf. 



CASES. 



203 



The tumour is fluctuating ; waves of Huid may be made to poM from ono 
part of the joint to the other ; there in Kome appreciable thiukcniug of the 
poriarttcular tituiiies; tlie joint in neith<!r tender, hot, nor rod: she hna 
veT7 ItUle pain, liut some ntifibess ; ehe can in tbo morning walk without 
any limping, but in the evening, and. when she haa been nhout a good deal, 
abe ha« a scnHaliou of " bursting" in the joint, increaaed »tifliiosa, and ia 
obhgod t(» liuip. 

I ordered tier to wean her child : to have a gutta-percha sptiut bound to 
the back of the joint; a blister across lower part of the femur, and tho 
foUowiug dntugUt three times a <iiiy : — 

9. Potassii lodidi gr. iij. 

Dccocti Sco^mrii comp. .. .^i»i. M. 

13th. — She aaya tliat she is obliged to do her work ; the apUnt preventa 
tliia, and therefore she look it off: there ia no improvement: blister to 
lower part of joint. 

IStfa. — She i£ no bett«r : T persuaded her to como into the house, and 
&fr. Canton kindly allowed her to remcun under my care. ilo|Kiat tho 
blister ubnre the joint and let it ha kept oj>en with Iodide of Potiua oint- 
ment: bed. 

27th. — She IB not at all improved : let the blister bo&l. 

3rd Feb. — Tho blibtcr having healed I poesed a narrow tenotome; into 
the joint, about an inch and a half above the outer edge of the ])atelhi, and 
sweeping the blade upwards, divided the evnovial membrane to an extent 
of about an inch and a half to two inches, and bandaged the knee tightly 
&om bolow upwards. 

Cth. — She id in DO pain : the bandage is quite loose ; when it was 
removed the joint was found rcduoed ; there is sttU a good deal of swelling, 
but it is difiTuacd and does not fluctuate : bandage rcap[ilied. To take the 
following, three times a day :— 

l|. Ferri Bulphatis .. .. 'gr. ij. 
Miaturo; (^uime .. .. jj. M. 

12th.— The knee was strapped three days ago ; she is in no pain : 
allowed to get up. 

23rd. — There is no appeoranoe of return, but the knee has been kept 
strapped : dLiuharged. 

I saw tliift patiuut, caaually, on the 8th April, t8ft9 ; she has bad no 
return of swelling, and has uo inconvenience with the knee. 

Case XLVIIl. — Thomas Qaddin, aged 25, cabinet-maker, came under my 
care at the Cliaring-Croas Uospital with a sweUing of tho elbow, 12th 
May, laiG, 

About Heven years ago he foil and was stunned ; believes he stniok his 
left elbow : within a month a soft swcUuig formed over the head of the 
radius ; he got some ointment and applied it witliout benefit. Ho took no 
farther notice of the tumour, as he had no inconrcnience, exoept that it 
Boemed to weaken tho thumb, particularly when the arm was bent. About 
aix months ago this effect increased to a diaagreeable degree, sometimes the 
hand would he set fast imd he would suffer groat pain ; he applied* by the 



204 



HynnARTnnosis. 



Okaf. vui. 



odvioe of a Burgeoii, the tincture of icrdine, aod about two monlha ago a 
■welling bpf;an rapidly to form on the inner side uf the joint, while that 
formorly uooUoiied tle<:reft.40il. 

The only unnatural appoaronce is a la:^o broad-based swelling upon and 
below tlio iiinnr condyle of the humerus ; this tumour, projecting inwarda, 
Htul a liltle backwards, is larger than Itolf a ken's ^g cut crosswise would l>e ; 
it fluctuates through the joint, i. e., from the swelling '*«elf ^ t^i^f junction 
of radiuH and ImmcruH ; the skin over it is thin ; the juint is slightly hot, 
and, over the moat prominent part of the tumour, slightly red. The state 
of health in not aucIi aa would load mo to diagnose pus in the joint ; still 
in in rather a weakly condition. Ordered the blue oiutmunt to be 
ppliud on lint covered with oil-sllk. 
I'he following to bo taken throe times a day :— 

9. Forri animonio-citratis .. .. gr. x. 
Spirttijs Ammonia] aromatic! saa. 

Aqu.x' destiUato! ij. M. 

2Cth. — This man has been two or throe times since the last report, and 
the arm has been getting worse : the skin over the point of the tumour is 
redder and thinner, in foot it looks as though it would give way ; oLsewhero 
It ifl Bodden aud relaxed. I believe the ointment has becu injurious. As 
the swelling seems likely to burst and lay the joint open, it soonied to me 
advisable to prevent this by a puincture. I plunged in a trocar and canuta, 
not at the thtimiMt, but at the most de|>ending port, in as oblique a direc- 
tion as possible, and drew away two ounces and five drachma of remarkably 
viscid synovia, with some nearly trau!;paront tlokos; there were many 
more such flakes, probiibly, iu the joint, as the canula became often 
stopped, and had to bo cleared with a [rrobe. When the joint was emi*ty 
tho conula was withdrawn and a piece of plaistcr applied to the puncture. 
■A lump could now hi* felt behind the inner condyle, about on inch and a 
half in length, somewhat movable, and of an uneven consistence ; most of 
tho !i\vt'lliiiit givinj- a doughy st-iiiifttion, and hnvin,; little liard liimiw in it, 
which moved away, however, when it was attempted to examine them 
more olosely. The limb was bandaged from the hand upwards and 
placed CD a rectangular outside splint. To take one ounce of the Quinine 
Misturo three times a day. 

Gth June. — ^Tho swelling is rapidly reappearing. 

ICth. — The arm is in much the same condition tin when 1 first saw it: 
punctured tho tumour with a trocar and cauida ; drew off one ounce 
six drachms of the same sort of fluid aa l>efore. I injected two drachms of 
Tincture of Iodine with au ounce and a half of distilled water; in one 
minute let tho liquor flow out, keeping a gentle pressure on the tumonr 
and joint ; withdrew tho cauula and closed the wound with plater : arm 
bandaged and replaced on spUnt. Ordered to take one gi-ain of opium 
to-night in the form of pill. 

17th. — He has hod a little pain in the arm, but slept well last night : 
there is, to-day, a little tenderness over the inner condyle : the splint 
roupphed. 

Ordered to tuko ou ounce of the UisturaCJuiuaci throe times a day, and 
a hot hath to-night. 



Chap. VIll, 



CA8ES. 



aofi 



19t)i. — StitI iin pain in tho ami : tho soft doughy lumps spoken of in 
report for Maj 26th, are to be plainly felt ; they are, perhaps, rather 
harder. 

25th. — llie joint has begun to fill figiun : lot tho arm bo tightly strapped. 
The foUoving to be token throe timca a day : — 

^. Potasaii iodidi gr. v. 

Decocti Taruaci .. ^iaa. K. 

7th July. — In spite of strapping, which ho cannot bear very tightly 
applied, and of all means that I have used, tho arm still continues to 

BWoIl. 

llth. — Injected the joint again with a mixture twice aa strong as that 
uaed before, thus :— 

$. Tnu. lodinii ., .. .. ^. 
Aquse destill&t'e ^iss. iS. 

Very few seconds after injection tho pulse, which was 84 in tho minuto, 
»ank mtbor auddoaly 2<) boata ; ncvortliclcas I kept the fluid m the sac 
for one miuute, aud then let it flow out : bound the arm ou aa uubtiilo 
rectangular splint. 

14th. — I saw th{) patient on the 12th ; there waa no pain, and the splint 
waa not taken off: strapping suSiciently tight to press without causing 
pain : fqiliot. 

28th. — Tho splint and strapping hare been renewed as oocasion de- 
manded, ttiid re«ppUed ; the former may now bo discontinued. 

13th Aug. — 'i'he joint irt not increosiug in size, but it is larger than tho 
other; the doughy lumpn previously spoken of are hanler, and iwrbajM 
rather smaller : leave ofT the »tr:ippiiig ; baoUoge for a week. 

STth. — He has been without Any npplicatiu'U ou the ami fi>r a week, but 
he promised to follow my advice and to havo a sort of bracelet made Idee a 
koed stocking. 

I have lost sight of this man, but consider it probable that tho joint 
has undergone, or is undergoing, a destructive process. 



206 



LOOSE CAnTlLAGES. 



Uhap. IX, 



CHAPTKK IX. 
On Loose Cabtilaoe^s in tog Joints. 



Patholoot. 

This disease is clo8<^1y cnnnectetl with that, which was the 
subject of the previous chuptcr. Wo found that in one, the 
most common form of hydrarthrosia, the synovial fringes grow 
out into tufttni processes, whose swollen ends are frequently cur- 
tilapinous. This coudition is usually combined with so mncli 
effusion of fluid that the solid swelling, pnxluced by the over- 
grown villi, cannot bo felt; but it occasiontUIy, though rarely, 
happens that the synovial membrane is not thus filled, and then 
the villous growths cause a more or less hard tumefaction. Or 
it may happen that the effusion, at flrat very considerable, will 
after a time decrease, and tlieu these proceases come within 
range of the souse of touch. 

But fnIsH bodies, geuernlly so 'called, present themselves 
usually as one or more movable substances in the cavity of the 
joint : they are c^omraonly situated in the knee, are less fre- 
qui'iit in the eUw>w, have been found in the joint of the jaw, and 
in the wrist. Although generally styled loose cartilages, they 
are very frequentfy in part coniposod of bone ; sometimes the 
osseous matter forms merely a nueleus, sometimes one aide of 
the substance will be bony ; occasionally, though ehiefiy in com- 
bination with another dweiLse, (hey are entirely oswhhis. 

It would be hardly warrantable to assort that all false bodies 
in joints are of rheumatic origin ; but it is certain that they 
are chiefly found in connection with that diathesis ; they are 
very fully and lar^ly developtMl in the disease called chronic 
rheumatic arthi-itis, and aro in that mala<ly frequently bony; 
moreover are found external to the articular cavity, that 
is, developed and lying among the poriarticulur tissues. Such 
iustances belong however to the chapter upon that disease; at 



CUAP. IX. 



DEVELOPMENT. 



*2trr 



present wo are only concerned with false bodica as they some- 
timea appear lying movable in tbo sjiioviid cavity. 

No better and nioro suooiuct account of these growths can be 
given than tliat by Mr. Itaincy : — 

** These bodies have a distinct investing membrane which on 
its external surtace is smooth ; but by its internal one is so 
intimately connected to the body itself as to admit of being 
detached only by small shreda 

" Tliia meiubmne is comjxisod of fibro-coUular tissue mixed 
witli gnmular mutter. 

" Their internal stnicture, as exhibited by a section through 
their middle, is seen by the naked eye to consist of two Histinct 
Bubstuuces — tlie one being semi-transparent, like fibro-eartilage, 
the other perfectly opaque and white, like bone. The former, 
under the microscope, presents the appearances usimlty seen in 
fibro-cartilajjo ; the latter resembles remarkubly in its ultimate 
structure tliosc Irenes which consist only of one bony plate 
placed between two folds of membrane, as the thin plate of the 
ethmoid. In the bones, the lacume, as in the opaque parts of 
the bodies before m^ntionwl, are the same as in other bones ; 
hut there are no distinct or well-formed caualiculi branching 
out of tliam. There is in Ixjth a Ht«lhite arraii^'ment of the 
pjirthy matter around the lacuna?, but nothing like canaliculij 
and 'this appearance is more striking in the !K)nes alluded to 
tlian in the earthy parts of these bodies. 

" I believe no satisfaetorj' explanation has yet been given of 
the maimer in which these bodies are formed in joints, although 
I tliiuk their origin, and the eireuiustanco of their becoming 
loose in a joint, will appear obvious, by a reference to tlw 
remarkable character of the epithelium in joints : the tlieew of 
tendons and mucous burste." 

Mr. Kainey then gives the deseription of synovial villi and 
their secondary saoeuli, already quotinl, (p. 10), and goes on 
to eay : 

" Now this being the apparatus by which synovia is eluUirat^d 
in all parts, in which this fluid is foimd, and the bodies thns 
'deecribed being found in these situatiuus, they may bo inferred 
to be the product of disease in thcw structures; the cellules of 
those fringes, in the place of ehiborating synovia from the blood. 



208 



LOOSE CAHTILAQES. 



CoAP. IK, 



prodncing, nnder tho influeuco of morbid action, olhor producta, 
such as cartilage, which bccomcH convortwl into imporfontly 
formed boue. The fact of tlio secondary sacculi being con- 
necttid to the primary by extremely narrow pcdiculi will suflice 
to explain the reason why these bodies may become formed in 
the first iustanco ; the pedicle serving both to keep them 
attached, and to convoy tlic material from tho blood necessary 
for their development until they acquire a certain nize; but 
afterwardit, from its tenuity being no longer capable of holding 
them, it breaks, and the bodies become louse and most likely 
cease to enlarge.* " 

There can be no doubt that Mr. Rainey is perfectly correct 
in hia views regarding the formation of these loose cartilages; 
they vary much in size, from a minute point to that of a 
bantom^s egg. In the cases we are now considering tliey are 
not generally numerous ; although, ns wo have intimated, they 
often are so in certain instances belonging to a difVerently 
named malady. Wlien they attain any considerable size they 
cannot slip between tho bones of tho joint, and thereby i>roduco 
the pftinliil symptoms jjoculinr to this complaint; these are 
owing to abnormal pressure ni>on the joint-surfaces, a condition 
which, on account uf the peculiar innervation of ar^culations, 
always causes nmscular contraetian. 



Symptoms. 

Tho presence of a looee cartilage in a joint cavity first 
manifests itself by the production of sudden severe pain^ of a 
spasmodic character, and so peculiar as to make tho suiVerer feel 
faint and sick; sometimes actual syncope is pi-oduced. Tliis 
symptom is chiefly noticeable when tho disease is situated hi the 
knee ; indeed T am not aware that it over occurs at the elbow, 
the next most usual seat of tho disease; the close fitting 
condition of these joint siu'faces would prevent the intrusion of 
such n subHtance Ixjtwoen tlio bones. Tliis pain is so severe, 
and of so peculiar a sickening cliaracter, tliat the suflerer is 
obliged to sit down wherever he may be; sometiraee indeed, 
ho falU It is generally brought on by certain movements 

• PftUiologii'ul Tnui.-i!»oti.)ii.-«, vol. ii., I tuition of Bomc fulwc txMlicii from Uto 
ItHS. i\ 110, 111. Mr. Ruinfy'ti I'Uitui- | ilWiv-joiut L'xiitliilct hy Mr. SuIIt 



Chap. IX. 



PECULIAIi PAIX. 



209 



nnd positions moTP pflAily than by otiiera, which the pntient soon 
learns, ami trios as far as possible to avoid ; occasioimlly, ou tlie 
poiitrary, it occurs apparently without any provocAtion, during 
the simplest positions, even turning iu bed, or it may be 
produced by some slight movement iu alce|). 

The mere occurrence of this syraptom. although it would 
rightly cause us to presiunc that o false body had been de- 
veloped, does not justify any positive conclusion on ita osistenco ; 
because in a few rare instances an interarlicular cartilage attains 
an abnormal degree of mobility, suffers occasionally a partial 
disloi^tion, falls between the bones, and gives rise to a precisely 
similar pain. The only unmistakable evidence of the existence 
of a loose cartilage is to feel it through the integument* moving 
about in the articular cavity ; but many causes may render this 
extremely difficult, and inability to feel tlie body, even nv 
peated failures to find it, are not to be regarded as proving ita 
absence. 

We have seen thai these growths are generally connected 
with a dropsical tendency of the sj'no^'ial meml»nino ; moreover, 
when an attack of the above described i>ain has come on, in- 
flammation with plentiful effu-sion into the joint is set up, and 
thns much the same effect of an over full condition of the 
articular cavity is produced : this may be condderablo enough 
to render the detection of a foreign body all hut impossible ; on 
the other hand a slight degree of effusion, by giving the body 
some amount of free mobility, renders its detection more easy. 
The most usual position for finding such a growth is at the 
inner side, between the patella and the internal lateral ligament ; 
but sometimes it will be discovered in an analogons situation at 
the outer sidt; of the jtiJut ; less frequently, its favorite locality 
will bo behind either lateral ligament. The body may be 
extremely movable, any pressure upon it in one of its haunts 
causing it to slip away, perhaps to reappear in another place, 
perhajw to lie concealed until w.>me movement of tlie joint 
disturbs and makes it return to some part of the surface. This 
peculiar inconstancy and mobility acquires for it in Germany 
the name of joint-mouse, (Cielenkwaus). Very frequently, 
however, the Ixxly is not so freely mobile, either lieing still 
altfwhed so qs to have choice of locality only witliin a certain 



•210 



U:>0&E CAllTir.AGE. 



Chap. IX. 



rango, or being too lai^o to pass into certiiin siwices in the 
luticulatiou. It foUou's thorefon>, tliat when ilie muss lias ouoe 
attained a size, which prevents its intrusion !)etwpon thu bones, 
the worst conseqiiencos and tho most painful symptoms of the 
disease naturally end. 



Tkkatmknt. 

Two naodee of troatmont may be indicated : one which endea- 
vours to keep tho Jooan curtilage in a harmless place, luul, if 
(Kiesible, to procure its adhesion there ; the other, which removes 
the body altogether. Tho former of these is usually partly, 
soinetiines altogetlier, uusuccessfuL lis aim is, first to raaui- 
putato tho body into a ])lAce where it may lie harmless, and then, 
by some bandage or other means, to fasten it in that locality. 
To do this it ia, of course, firstly necessary that the eartilago be 
sufficiently movable either up or down, that it may be brought to 
lie upon either of the bones; not on the line of junction between 
the two ; for if it be in this latter situation, any pressure exer- 
cised upon it will, of course, force the body into tho very place, 
we wish to canao it to avoid. When tho fiUse Iwdy has been 
manipuUited into a favourable place, a la<^ed sock must be so 
applied as to keep it, if jH>saibIe, fixtid to tliat spot. It is, 
however, rare that the growth can l>e thus fixed ; it will remain 
for a time in tJie right place, and then from some awkward move- 
ment, from tho sock having become displaced, or from some 
other c^tise, it glides into a wrong position, and causes a return 
of the pain. It ia rare that any bandage can bo bomo sufli- 
ciently tight to keep tho body perfectly fixed; but some cases 
are on record in which tliis plan had succeeded ; tlie cartilage 
having contracted adhesions, and remaining fixed in its new 
position, even after the bandage bad been removed. 

Anotlier plan which has been tried, and which has failed, is 
to endeavour to fix the new substance by driving into it needles 
passed tlurough the skin. The pain and inflammation produced 
have necessitated the removal of the needles before the loose 
cartilage has become adherent. 

Excision is tlie radical means of getting rid of these bodies. 
It has been done by cutting directly into the joint ; and when 



ii&r. IX. 



BXCIStON. 



211 



the wound heals by t!ie first intontion no baJ syTuptom may 
follow ; but when tlic incision remains ever so little oi>cn, sup- 
imration of the jrnnt with the wliole string of evil consequencOB 
is very likely to come on. Benjamin Cell first proposed mak- 
ing Uie indsion valvular by drawing up the skin nt the part to be 
incised before cutting into it. If^ when the operation Is complete, 
the integument be allowed to return, the wound will be closed. 

Monsieur Goyrand, of Aix, carried out a subcutaneous mode 
of cutting out these bodies, by two distinct operations. The 
first consista of fixing the body in some superficial part of the 
articulation, passing a tenotomy knife through thn skin, and 
making in the synovial sac an incision through wliich the 
cartilage is pressed into the |>eriartic(dar areolar tissue. The 
second operation is performed'some days afterwards, when it is 
judged that the wound iu the synovial membrane has healed. 
It consists simply in cutting down directly upon the loose 
cartilage now outside the joint and extracting it Some 
skill is necessary for the performance of the first operation, 
because the mobility of the body and its power of gliding 
away are so considerable. Before attempting it, therefore, the 
surgeon must carefully have leamt the habits of the cartihigo ; 
must know in what direction it chiefly tends to slip, and in what 
places it most readily hides. He should endeavour to press it 
as for away as possible irom the lino of junction between the 
bones, to the place where the synovial membrane is rcfiected 
away from tlie periosteum. The clioice of locality is not always 
with the surgeon ; for sometimes even the greatest skill will 
not suffice to make the cartilage take up the position which 
may be most desirable. This is at the knee, over the inside 
of the head of the tibia ; at the elbow, above tJie inner condyle. 
When the body has been coaxed into the best possible place, 
a curved needle or a tenaculum is to be inserted into it on the 
aide towards the joint ; and the tenotome, passed in some dis- 
tance from its opposite extremity, is to incise the synovial 
membrane as far irom the juncture of the bones as possible. 
The opening is not to be too extensive, but sufficiently large to 
allow the body to bo squeezed tlirough it and away from tlie 
insertion of the tenaculum. After completion of the oj)eratiuu, 

p 2 




212 



LOOSE CAIITILAGE. 



Cn&p. IX. 



tJie limb 18 U) be put nlightly bent npon & spUnt* If there be 
more than one body, they arc aU to be bt-ought if possible to the 
8ame [urt of the sacf 

The Becoiid opHration is not always neet^aaary, for the body 
may (limininh rapidly in its new place, and ceow; to give any 
trouble ; when it is necessary, the proceeding is excessively 
simple, cowdsting only in cutting directly down upon the lH>dy 
and taking it out. It is well tu let a nnmber of days elapse, 
BO as to be quite sure that the wound in the synorial sac has 
henlod. 

£ight years ago, Mr. Syme published " A new Method of 
treating False Bodies in Joints," } which ai)parenUy consirtls in all 
the some steps as the first operation above described, except 
that the body is not squeezed out of the sac, but is retmned by 
baiifUgeK to contract adhesions; but it is rather diiHcolt to see 
wherein the advantage may lie. 

* Tbe elbow is to be bent at right an- did nnt appear till loiifr nttar M. Gof - 
giM. : nuitl'B oawd werv ptililulitwl id 1841. 

t Mr. Sjmoufflniu timt ho hit apon t Ediaburgh Mulkfil Joaniul, Kot. 
this plan At tbe Mme time as )!. i'my- lS!t2. 
mivl, but tUo accoaot of hir pruct<iiitro 



Cu^r. \. DISEASES COMMKNCING IN TBE BONE. 



213 



ON DISEASES COMMENCING IN THE 
BONE. 



CHAPTER X. 



AouTE Abticular Osteitis. 

The (liseafies of joints liithorto exiiniined cnmmonce in the 
Hoft pivrts, that is, in the synovial membrane and the siibsynovial 
tissue ; auotlier set of these malatlies begins in tlio bones. Like 
tliose already described, these all originate in iutiammatiou : and 
osteitis^ or inflammation of bone, is a disease that has been 
known fmni lime immemoriaL But in the present instance, as 
I wish to dc^giiate those osseous inflammations, which, being 
situated clofie to a joint, affect the integrity of that mechanism, 
I have taken the liberty of naming t.lie [lartieular mahidy to bo 
considered Articular Osteitis, that is, inflammation of a joint-bone. 
The heading of this clmpter may be remarked as singular in 
annther way, sinoe neither Stanley, our great English authority 
on U>ne diseases, nor Paget, nor systematic winters on surgery, 
have separated osteitis into the acute and chronic divisions, as 
they have done with other inflammations.* There is, however, 
doubtless a wide Hno to be drawn between different degrees of 
rapidity hi bone inflammation, and if the distinction be worth 
anything in other tissues, so is it worth at least as mucli in this. 
The most chronic form of osteitis is probably the slowest of al] 
diseaseiS, wlule a liighly acute species of the malady has lately 
been described by Klose as occurring in joint ends, and occa- 



• Amprii-an authors, e.g. Orona (* Sys- 
tem of Stu-jrery ') miiko no »uch distitic- 
tinn. DciUiLTtlo 1 fLncit such in tliu 'Cum- 

E'uiiuiu ilcf Uliirurgio Prntiqu*-,' by 
euou, Villicra, unH GoMelin. Gitrnmii 
Mithora, Iiowevur. (et-o WKnihnr, and ulno 
Aiigoltrt4}iu'i« ' Utuidbucti (Icr CUirurgio,'} 



liEive pcrfciveil as iniu'li dJifereaoe in 
Hw rapiJiiy uT intlunmiitioiu of tha 
buui' HJt uf any oUii^i' tiwuv, ami have 
uuidu twu utuHLv— ooutf] and chronic. 
Wliilo Stromi'jer, ia liit) • UniKlbook of 
Kurgcry.' iK-jHuntoii tlirta into pencato, 
aouU*, und uiironic. 



214 



ACUTE ARTICCLAK OSTEITIS. 



Chap. X. 



aioimlly qireading to the shtift^ of Iwne, which is really as ocnte 
on action as most mth which we have to do, \\Tiether the cUscaso 
occur in one sitimtiou or the other, it is founded in a verj' cachectio 
eoudition of system ; it is rare, and in the shaft is generally tlie 
result of accident, as of a compound irocture exposing a large 
portion of bone, or deep ttioeration laying that tissue bare. Rut 
any osteitis, even the moatehronie, may put on more rapid, and at 
last higlily acute symptoms, which shall end in death of the bone 
and ]>lentiful suppuration, with some destruction of the |»erio&* 
toum, ulceration and suppuration of the surrounding parts, &c.* 
The whole course of the disease is generally completed in from 
u weelt to a fart night, ending, if the bone luive been small, usually 
in its death, and separation by the surgeon ; if large and deep, in 
pnmlent absorption, and death of the patient The frequent 
necrosis of tlie last phalanx from neglected whitlow, with redness 
and phlegmonous inHammation of the fmger, is a good example 
of the former and slighter occurrence. But when this malady 
attacks a larger and deeper bone, its symptoms arc ver}' severe, 
whether it be the result of accident or of a great chill happening 
in a debilitated constitution. The disease is ushered in by very 
severe rigors, great pain in the bade, and the other prodroma of all 
violent febrile attacks ; soon afterwards there arise great rapidity 
of pulse, heat and dryness of skin, a dry and coated condition of 
tongue, anxious expression and slueplesHncss. The oflected bone, 
whichever it may lL»e, is the seat of intense pain, and of a swell- 
ing which is always hard, and in deep hemes is ahio deep seated ; 
the skin itself in rcil, except when tlie bone be very deep, and at 
all events is very hot ; wlieii the osteitis is extensive the pain 
is so severe that it quite exhausts the patient, and renders 
him comatose or semi-comatose. Low muttering delirium 
appears very early in the disease ; the tongue is dry, hn>wn. 



* It is only duo lu Htn>moyrr t}ist 
the roUowin^ cxtntct ithoiilil ho a[>> 

Sf-TiJod:— "Tlie»o coiiditiona am ovi- 
euUy coDnectcd with ^lurulont fhlegin- 
onoiu (^ryiipcldK, ttIucIi nriitpii fmm 
limilor cMucs. and n-ith whit- li |K>nioiito 
oeteitii bu, even in nntn-nn] npponr- 
anocf. tho greatort rindloritj if it haver 
its vcAt in k niperflciiU bonr, for in- 
ntBitCA, ill tlio front of ihv libiii. lln* 
linu|>ily> >n'U>*-d, i>ii (liw tieiuunt. acuLu 
uidamnuUtoii of Itint buut- b uauully 



mirtakeo for oiywpcliu, until tlif> pructi- 
tioiior finds ty tliu cxpottun? kikI dL-ulh 
of tlio botu' ihut 1)0 lioH to do with an 
osti'itiD. Irt trnumatic er^'sipclnc, after 
anipiitbtion. ttic grvat projection of tlie 
hottv ia evidently duo U> a higlily ncuto 
ostottis, tlip pt-r)ait<:'Um iind tlio inaer- 
tionn iif nituc[i>M hnvo all sepomtcd from 
the bone, und y«t, Htmo^ty enoughs on 
inllamiiintiun of tliu structure lia« m-vtr 
lici-n lliutiKhluf."— ']Ianll^ucllderC%i• 
^^rl{UV 1" Biuid, Stu I^erufUUg, p. 418. 



Cha?. X. 



KATID KECROSIB. 



215 



swollen and cracked. The affected limb ia held immovable ; 
indccdf tlio patient avoids all motion fur fear of disturbing tho 
[tart ; wry soon the swelling becomes softer, shows evidence of 
su[)puration, and, except when very deep seated, as at the femur, 
Hnctuateig. At last intense coma comes on, the patient sinks 
and dies. On examination of tho limb, the bono wiU be found 
lying louse in a quantity of pus, which fills tho periosteum ; it is 
of n dirty-yellow or grey colour, and has a very bad odour; its 
surface is rough and cnimbles. The pen'iwteum is softened, the 
attachments of tlie muscles have aeparatrd, and the inter-muscular 
8|)aces are infdtrated with a blood-stained serum or a tliiu ichor, 
which discolours the luuseular tissue. The internal organs show, 
accoi-ding to Stromeyer, signs of punilent infection, the lungs and 
liver being studded with secondary deposits. 

Id my own practice only ouo coso of such extreme seventy 
has occurred. 



Case XLIX. — John 3(urpby, aged 63, came to me at the dimng-CVoBB 
Hospital, Augiust IKSB, haviog met with au iDJury Ut tho mi(]illu tuid fore 
fingers of the left hand, they having been crushed bctwMii pieoeti of 
zoaohuiery, Tlie fore finger bad sustained a simple fracture of the first 
phalanx; tlie middle linger was cniabed and much lacerated; the me- 
tacarpo-phalangeal joint was torn open ; the proximal end of the phalanx 
was fractured and thmst through the sidn at tho inner aide, and the end 
of tho metacarjHd bone waa broken and partlj protruded thraugb the 
wound. The accident had occurred tiro hours before ; the man had 
fainted, and he had been taken to a drugglet and hod some medicine (re- 
etontive) and brandy adiuiuiatered : ho then wont home, and subsequently 
camo with his Kon to this hospittil: neither of the two men were <iuito 
sober. Uo utterly rofusud to como in. I explained to him and his son tho 
nececjaily of removing the crushed 6nger, to which he oonscnied, and they 
promised to return the next day, or at least that the bod should oume 
to me. 

The operation was extremely simple, since, by nipping off the end of the 
uxpoAod metacarpal bono, sufficient sound integument uoiild ho pnjcurud 
to cover tho rest. 

For ten days I heard nothing of this patient, nor did I know where be 
lived ; on the 10th day his eon came to say that hia father waa very bad. 
1 wont at once : the poor man had been utterly nrglcctod ; the whole hand, 
ono, shoulder, and chent were red and HWuDen ; Iht! bandage on the hand, 
which had never beon removed, waa so light a« to cut deeply into the 
flesh : bullu} had formed in varioua parts. The h|ts of the wound had 
partly ulcerated away, partly retracted, so that a portion of the metacarpal 
bone waa visible, which waa bluck. or rather ash-grey. The man could 
only with ditBculty be aroused ; the tongue woa tiark-brown, in places 



216 



ACUTE AKTICULAR OSTEITIS. 



CUAP. X. 



blook ; it was dry and voty much coaied: tbe pulsu quick aud Uiruody : ho 
had diarrhcea. 

The case seemed hopelesB, but it appcAred right to do all that could be 
done. I maiiu a duop inciaiou along tho back of the ulna imd another iu the 
upper arm : he hariJI}' SBetned aware of what wtts doue : very Utile blood, 
but agrtod deal of reddish saruia and tliiii pus flowed, lie was ordered 
Aramonia, Opium, Brandy*, aud I wan able to procure fur him sonic strong 
bt-ef-tea. However, all waa, aa might be expected, useless ; he waa comtilose 
when 1 n&vr hiin the next mortiiug, and died a Uttle after noon. 

With great djftitiulty I pi-ocured pcrmia»on to examine the limb, but 
not any other jMu-t of the body. AH the tissues of the hand were infiltnitt-'d 
with reddJAb acnini, and beneath the palmar &iscia was a large colltiction 
of pus ; the muaclea were aoftooed. On passing my finger into the wound 
thai 1 had miide duriug Ufe over the uhio, I could foul thu bunu bare, and 
onlarigGd tho incision along the whole length of the arm ; some red 
seruiu and a large quantity of tblu pua and ichor flowed out ; the bone waa 
quite loose and rough, its lower end could easily be taken out of the wouud, 
but the upi>cr remaiQed attached to the humerus ; all that part wliich 
was removed was of an oahvu-grey colour, rough, aud in [larts crumbly aud 
quite bare of periosteum, which wa» left behlud as a suppurating bag. 1 
[MBHcd my finger into the wouud and found that the lower end of tho 
humerufi, and all, or a great deal of the ludius, were rouj^h. I iletachud the 
ulna from the humerus aud found both bones rough, and the former devoid 
of cartilage, the Utter having very littlti still remaining ; all the soft parts 
were infiltratwl with piitn»>cent pua and bUKxi-staineJ sorum. Further 
than this I could not push my examination, uu account of tho impatience 
and jealousy of his boo, who insisted on remaining in tho room. The 
humerus did not seem afTeoted beyond its lower end, but there was the 
aame iutermuacular infiltration with pus and serum both iu the upper and 
fore ana. 

Osteitis of such extreme severity does not limit itself stricitly 
pitlie^r t»t joint end or to shaft, but oversteps tlielKniiKlary whi<'h a 
milder disease observes If then such nu aftoction pass to t!io 
joiut end of the bone, it follows necessarily that the articulution 
will become involved, but tlie intensity of tho whole set of 
symptoms is so great, thut it in s measure masks the eB|>ecial 
si^s of the joiut disease. Upon the nlun, which I exaniiuefl, 
no cartilage was lelty and but very little on the humerus, the 
synovial membrane was suppurating, but during the short time 
that I had an tipportuuity of seeing him diu-ing life the joint 
itself attnicted no attention ; in that case the disease won, when 
I saw it, so far lulvonced, that no especial point of the arm could 
Iki hit uiwn as more affected than another. iJut sometimes 
the epiphysfd end of the bone, and it^ neighbouring joint, may 



Ciup. X. 



AltTHnOPULOGOSIS TOTALIS. 



217 



becorao the scat of a siinilnr inflammation. The cases must how- 
ever be rare : I bavts neither flt.*Cii one, nor have fuund tlie dudcrijw 
tion of Olio, ill any English work ; but Stromcycr gives (in account 
of Osteitis arti^'ularis permruta or Arthrophlogoaia totalin, and Khfse 
lias seen and described thirteen eases, with slightly different 
features, naming them also in different manner. Stromeyersaya: 
** After violent rigora 8Ui>er\'ene puiiis In the jointa, bo severe as 
entirely U* prostrate the patient The pulse is small and extm- 
(irdiuarily quick, the tongue dry and brown, the appetite is en- 
tirely Uteit, and tliirgt extreme. The joint swells, Uuetuates, and the 
fluctiiatiiin extends beyond the limits of the synovial membrane. 
The limb becomes oodematous, and an erysipelatous redncsa of 
the skin uppears ; sometimts gas in develujied by tlie dLsorganised 
imd putrid ilesb and exsudatioits ; generally, befuru it bursts ex- 
ternally, the juitieut dies, cither fixim the a(xx)mj>anying diwiase, 
for instance pericarditis, or from the reaction of the putrid pus 
upon the system. Only in very rare coses con the patient re- 
cover. When the parte burst the pus is discharged, and tho 
sluughs together with the joint ends of the bone come away. 

" Hopjiily these friglitful cases are rare, but not to such a degree 
OS to merit entire neglect in systeraatie works on surgery. 

" Sometimes, as I have frequently seen, tliis process attacks a 
joint Uiut iias suffered fur yeortj from chronic iuHauunation, and 
in which some new unfavourable cause— a blow, a fall, or a severe 
chill— has set up an iiidammatiou tliat soon brings the {>art to a 
destructive termination. 

" On anatumical examitiation, the capsule of tho joint will bo 
found destroyed ; the soft parts in the neighbourhood gangrenmis ; 
the ligaments, muscles and cartilages have uU dftm-hed from 
the bone, and tho large cavity thus left in iUled with brown 
putrid pus."* 

The tliirtetm ca«es which Dr, Kloso saw, and which he de- 
8cribes,t all occurred within eight years, in the ejiiphyses of ytraiig 
porsons; hence he names the Uiseuse, somewhat inaptly: "Sepa- 
ration of tho Epiphyfiis," (EjjiphyscntremmugJ or, Metiimjo- 
0$teo-phUlitie. They were thus distributed — one in the humerus. 



• • Hniidhncli 
ftaud, S, 477. 



<\i.\T Cliiriirgie,' 1" I 



t Pniccr-Viertcl-JalusoUiin,' Jan., 
1860, 6. 07. 



218 



ACUTE AJITICULAU OSTEITIS. 



Chap. X. 



at the elbow ; one in the ulna, at the elbow ; four in the tibia 
(tlirtje in itH upi>cr, one in the lower epiphyaw) ; and soven cases , 
in the femur, ut the knee ; shoeing that the knee joint is by for 
the most exposed to tills disease, since, of the thirteen cases, ten 
occurrefl in that situation. The attack never arises inde- 
pendently", but commences during the course of some other 
malady. "This disease," says Dr. Klosc, "is always preceded 
by an infiammation which is situated in the cancellous cavities, 
and thence 8]>reads over the epiphysis, the periosteum, and a 
considerable part of the shaft, of the bone. If the bone be that 
of a limb possessing but one, in which case it is covcn>d by 
u thick mass of muscles, the disease will owe its origin less to 
traumatic than to rheumatic causes*; if, on the contrary, Iho 
bone be nearer to the surface, traumatic cases will predominate," 
Among the outward signs of tlie commencement of tlus disease, 
when it is of rlieumatic nature, is a severe pain near the jouit of 
the limb affected. The patient cannot use tliat limb, and is 
seized with a severe rigor, which is followed by continued heat 
and great fever. In a few days considerable enlargement comes , 
on, accompanied by acute cedema in the course of tlie diaphysis, 
and the neighbourmg joint, wliich is hot and tense, but not hard; 
there is no trace of redness on tlioskin, but a grey earthy dis- 
coloration on the surface over the extent of the disease. The 
patient endeavours to keep tho limb semiflexed, because in 
that position he suffers least The prognosis is favorable, as 
long as the tenseness of tho Bkiii is uniform ; less so when, below 
tho surface, cord-Uko indurations nm thwugh the swelling, or 
when inflammation of the lymphatics or of the deep veins be 
added. If an acupuncture needle be plunged in a direction 
towards the bone into tho swelling, and it bo attcmptwl to 
move it in circular sweeps, an equable resistance will be found as 
long as it remains in the soft parts, but if it be passed to the 
bone, and then dmwn a little (alxmt a line) back, it may be 
turned in luiy direction. The bone itst'lf will be felt to be rough. 
Thoro can tlieu be no duubt that the swelling of the limbj 
depends upon solid exsudation in the soft pai-ts; but under tliel 
periosteum, which is lifted away from the bone, a fluid is poured 
out which makes the bone surface rough and uneven, because it 
• Aniont' rlii^uiiuiUc caue«a Dr. Klo«c iitcludtM, pivbably, auvcre chilL 



Ohap. X. 



SEPARATION OF EPIPUYSES. 



219 



rlias destroyed its enamelled surface. If the origin have been 
rlieunititic nil these symptoms will liave been very quickly 
developed, nnd will be ancomiwmied by active iiifiammatory 
redness, with rapidty sjircading plLleginonous iuilamiuatioii tuid 
suppuration, oud sometimes even gangrenous destruction of 
tlio skin. The patient is pale, the albuginea of tho eye 
yellowish, the conjunctiva anicmic, the nose dry, ttmguo white 
covered with a thick fur, tliirst considerable, respiration quick, 
pulse rapid, suioll and sharp. The ui)per part of the belly is tense 
and rather tender on pressure, the lower part, slightly protu- 
bumnt on account of u little tympanitis, is however iu no way 
tejider, (he spleen is rather enlarged, the bowels are confined, the 
urine is scajit and red. The cedema being acute does not prcKiuco 
pitting, but pressure with tho finger leaves a light yellow tinge 
behind. By passing a small exploring trocar and oanula 
t!irou/rh the swelling, to the bone, withiirawing the former while 
tho latter is pressed Iiome, one may be sure that the end of the 
tube (by its mobility, as above indicated) is between the 
perioKteum and bone. A suction syringe applied to (he free end 
will furniah evidence of the existence of exsudation, viz. : of pua 
and ichor, under tho periosteum. Now as long as tliis material 
remains iu that situation so long will it increase by its irritation 
the serous exsiidatiim in the soft parts ; but when the fibrous 
membrane breaks, and the ill-conditioned matter is discliarged 
into the surrounding parts, then another stage begins. 

The second stage consists in the suppuration of all the ports 
included beneath the faseia, in phlebitis with obatructiou of the 
veins, in the gradual involvement of the periostenm, and ulti- 
mately of the whole diaphysis, which leads to the last condition. 
Third stage, or separation of epiphyses from the shaft, may be 

I easily diagnosed by the chango in form and position, and by the 
abnormal mobility. At last tho tnmcated end of the femur 
pressing outward more and more, iienetrutes the skin. If loss of 
power, discliarge of ichor, and commencing purulent infection 
have not caused death in the second stage, so will all the above 
©vents hajjpen ; neither the suppurating condition in the second 
period permits amputation, nor can we hope anything from 

I teeection of tlio necrotic eud of the femur in the third. 

Nothing is beneficial, unless a free incision l>e made ilowu to 



ACUt'E ARTICULAR OSTEITIS. 



CUAP, X, 



the bono ; it i& the only hope, and all delay diminiahca the chance 
of life ; if tho bone be found white and of a normal hne tho 
patient will do well ; if on tho other hand it be spotted with 
brown or black spots, or if it be throughout of a dark grey colour, 
the incision has been too long delayed, and the only hope is to 
watch and seize a favourable opportunity for ampntjition al>ovo 
tho seat of disease ; but even after that procedure, purulent 
infection is tho too frequent torminatiou of the case. ^ 

** LoccU atiiopei/* — The anatomical examination of individual^^^H 
who have died of this disease, has always yielded the same^^ 
results. If the patient liave died in the second stage, the lower 
end of tho femur will, on cutting through the soft parts, be found 
in a roomy cavity, bare of periosteum and dark in colour. The 
bono is Burromtdod by pus, wliich liajn an ichor-Hkc quality. At 
the point of junction between diaphysis and epiph)'Bi8, the 
former is sjiougy, soft, and soaked in pus; the line of union 
irt mju'ked by a more or le&s deep groove, and here the 
division between the bones will occur. The longer this stage 
has continued, the more is the end of tlie diaphysis softened 
and the deeper is tho groove round it The miLs<.'h^9 lie in the 
ichor, isolated, and their sheathes arc destroyed. Their colour is 
dark bixjwn, and thuir surface is clothed with dirty bn>wn or 
bhickish little clots of blood and pus, wliich form as it were a 
continuous covering for them. In the latter end of this period, 
when the purulent infiltration has reached half way up llie femur, 
the muscles are found hard mul riband like, and if they be cut^ 
through the middle the surface of the section will be discover! 
dark broim and glistening, the fibres compressed, and the muscle 
itself is hard to the tou«di. Tho larger as well as the smaller veins 
are oblitemted, and throughout their whole course are fi]Ie<l with 
hard coagnla. The walls of the abscess are darkened by the 
ends of small venous branches with open niunths, out of which 
plugs of coagulated bloud project into the space. The cavity 
is filled with pus, and mosses of roagulati^ venous blood, 
sometimes in larger, sometimes in smaller lumps, according to 
the more or less advanced condition of the case. In tlus second 
stage the knee joint is still uuiujuxed. There is some serous 
collection in its cavity, the edge of an incision into it oozes a 

* Tliia Mccuunt refers pprtit:ulart> U> llio Iuwit fi:uionJ upipltybu. 



CUAP. X. 



POST-MORTESl APPEARANCES. 



221 



little ^Wth sorum, and a fo*v fibrous exaudationa are also to he Been ; 
tlie cartilagiudus covering of tlie femur is nf a dull wliitt% Ikmc 
and there spotted dark. In the third stage, the inner and u]iper 
part of the sac is more particularly involved, pus has broken into 
the joint and produced much destruction ; pirtly in the ligaments, 
partly in the cartilaginous covering of the condyles. In places 
this is destroyed, the bared condyle looks grey, is soft and 
ajxingy. Commonly each condyle is separated from its fellow, 
80 that not only does the 8)'noviul membrane form, with the 
aliscess, one common cavity, but the two condyles separated from 
each other and the shaft are found lying free in the bag. If 
the whole length of the femur be taken out, it will bo found to 
be in the second stage, necrotic only as far as the abscess in the 
soft parts had reached. In the third stage, on the contrary, it is 
necrotic almost throughout to the trochanter. Its surface is 
greyish black, its external table (tabula vitrea) cateu away and 
rough ; the part^ still smooth are covered with thready remains 
of the periosteum, and in some places with little osteophytes which 
give the surface au uneven apftearauce. If the btuio bo sawn 
through in a fresh state, it presents inside the medullaTy cavity 
a dark red appciu-ance, its iutei'Stitial tissue is soaked in a 
brown reiJ, grey or grey-brown-red (graubraun riltldicheu), ex- 
sudation according to the stage of the inflammation. If tlie 
cavity bo however still full of medulla, this material will bo 
studded with a quantity of dark red sjxits (apoplectic clots), which 
wil! be found, according to their age, in a more or less complete 
state of putrescent suppuration. Indeed, the whoh; intemtd 
parts of the bone present tlie appearance of a ^videly diffused 
phlebitis, with transitions into exsudation and suppuration."* 

The pa|>er from which tho aljove abridgments ami extracts 
are taken has not excited in England as much attontiou as it 
deserves. In France, an abstract of the thesis was published in 
the ' Archives Generales dc Mcdecine' for August ISoS, and in the 
November number of the same journal, 3L Goaselin points out 
that the disease thus described is identical with Chassaignac's 
Ostet>-rayclitiB, but occurs in younger j»ersons, and is situated in 
the epipliysis; he tlicn divides the bony intiammatious in a way 

• OpLcit.p. iHotwq, 



222 ACUTE ARTICULAR OSTEITIS. Chap. X. 

that appears to be unscientific, and terms the disease which 
Kloee has described, Osteite ^iphysaire aigue mppur^. Three 
cases, two of which only appear to belong strictly to the class of 
cases described by Klose, show that a similar malady is known 
in the West of Europe. « 

It has not been my fortune to see any disease at all similes, 
nor can I find any account in English medical journals which 
would lead me to believe that such has occurred in this country. 
Therefore it is apparently better to give these observations of a 
most destructive and happily rare form of joint disease without 
farther comment. 



Cmaf. XL 



FOnMS OF CHRONIC OSTEITIS. 



223 



CHAPTER XI. 

Stbumous AnricuTiAB Osteittr. 



FATnOLOOT. 

OsTKiTis may be produced by other constitutional taiuts besides 
scrofula — i«y]>liiliHr for iiiBtaiice^ and rhtiumutiam. It is, however, 
rare for syphilis tfj attack the 8|M)ngy end of a long l>one; it 
uffcctfi in preference the harder portions, commencing on tiio 
8«i*£ii('e. Of the rheumatic disease, as it appears in the joint ends 
of boneSf we shall speak in another chapter. 

Stnunoos inflammation of bone lias a great tendency to 
affect the cancellous structure ; it is apt to attack the irregnlar 
bones of the caroms and tarsus, also the euda of long bones ; in 
this latter situation, it is almost exclusively a disease of child- 
hood, or of the age before puberty : affecting a bone throughout 
cancellous, as tliose of the carpus or tarsus, it is, I believe, 
nearly as prev^dent in adult life. The iunanimation generally 
commences in the interior of the spongy structure, but may also 
begin in the cortex and periosteum. These lattt-r modes of 
beginning are more eliaracterlstic of the sj'philitic and rheumatic 
form, and are very raie in primary strumous osteitis. Another 
raodo of coramonc*;mcnt, upproaching a slower form of the 
disease described iu the last chapter, is that the whole epiphysis 
may become involved. Occasionally in those long bones, as the 
metacarpal and metatarsal, which have an epiphysis only at one 
extremity, the shaft. and the uon-epiphysal end are simultaneously 
attacked. In early life, the entire separation, vascular, nervous 
and indeed histological, between the diaphysis and epiphysis* 
suudeni the diseaMis of either from those of the other as much as 
though they occurred in different jjarts. It may also bo 
observed, that the Joint ends of tlie bones are in this stage of life 
undei^ing ossification, and it is the increased nutrient excite- 



224 



STttiniOUS AKTICOLAR OSTEITIS. 



Chap. Xt. 



Tnent attending that act which makes osteitis so prevalent in 
early life. 

The first appearance of the disease (B[>eaking of makrosr^opic 
nnatomy) in hypera-raia: this is muf^h more marked in a sjwngy 
bone tlmu it can ever become in inflammation of dense osseoiis 
tissue ; it may at first affect only one, or perhaps two or three 
siJotfi, in the bone ; or it may be more widely spread, and attack 
the whole spongy textixro. It is, liowevcr, to bo rememhcred, 
that hypenemia is neitJier inflammation, nor an infallible sign 
of that condition, and we must not, in making pathoh^cal ob- 
een-ations on the epiphyses of young children, imagine that 
every congested joint-end is inflamed, or will necessarily become 
inflamed. It has once or twice happened to me, to 6nd in the 
same subject nearly all the larger epiphyses hyperwniic, and I 
believe that we could look into the bones of very few children 
between the ages of two and ten, without finding some snch 
congestive state ; yet how comparatively rare is inflammation of a 
joint-end I The truth is, that the nutritive activity brought 
about by the ossifying action in the epiphysis, is very apt indeed 
to produce a congested condition of tlio part ; and the lui^ 
boue-enda which are found in strumous children arc the accom- 
paniment of such tendency to congestion. As the child gets 
ohler and wtrongfir, thi.s hyperiumia disiipi>ear8, and in the great 
majority of instances is followed by no evil results whatever. It 
is, however, certain, that in a given number of cases, the 
congewtion predisposes to inflammation, and the merely passive 
is followed by an active condition. Thus inflammation may be 
set up in an epiphysal end, which was previously in an abnormal 
state, and sucli, in the greater number of eases. Is the mode in 
which the disease now under consideration commences. All such 
attacks are in the beginning very slow, and hang for months, 
perhaps even years, between a state merely of sluggish functional 
perfonnance and of active disease. It happens however some- 
times, that inflammation of a joint-end commences at a later 
age, when the ossific process has entirely ceased, and when all con- 
gestion owing to that cause shall have terminated ; such cases are 
more rapid in their progress, produce a somewhat different set of 
symptoms, end more frequently than the other form in necrosis of 
some of the cancellous part of the bone, and the joint itself does not 



CnAK XI. 



CANOELLAR UYPERJiMIA. 



225 



iiectwsarily become involvtvl. The seat of the hypertemia, whether 
merely congestive or inflammatory, is not the bony Ktructiire 
itself, but the membranoiia lining of the caucelU, which, in 
healthy is piiik and vtiseular. The bouy luinelh'e which surround 
tlie cancelloiw cavil iea are very slightly aupplietl with Haveraiaa 
canals (see Chapter I., p. (J), hence hyjHsnL-uiia of the osseous 
plates tliemsclves can hardly reach such a point as to produce 
increaseil rednosd. The eougestion is to be seen by sainng 
through thelwne, when it will bo found to imjkirt,to the surface 
of the section, a hue var}ing from a mere flusli to a purj)le 
colour. This Inie extends iu some instances (the most cachectic) 
equably over the whole section ; in others it is chiefly marked iii 
certain spots ; each such spot being surrounded fiartly or en- 
tirely by lighter c<.)loured [Htrtions. Such arrangemt^nt gives to 
the soctiun-fsurface a marbled or mottled look, not easily forgotten 
when onoe seen. The appearances may be merely signs of tliat 
congestion so prevalent in young cliildren ; but actual inflamma- 
tion is marked by some other sigus^^ither by thickening of the 
, osseoiu tiasiic, or by effusion of a pinkii^}i serum. The former 
Rtandfi on the boundary line between increased nutrition and 
inflammation, the latter is the result of a stasis whose occurrence 
plainly miirks the transition from the one process to the other. 
Thus, if on twwing tlirougli a spongy Iwne taken from the dead 
subject we find only redness, we may sot down the abnoi-mal 
vascularity as merely passive congestion; but if there be 
tliickening, that is, if the plates of the cancelli are increased in 
thickness an<l their cavitit^s dimiuishocL still more if the red- 
dened portions be soaked in a pinkish blood-stained serum, we 
may assert that thi> Ixme is inflamed. 

This thicUouing of the bony lauiellse is an a^-tion analogous to, or 
ratlier identical with tlie increase in any structure subject to irrita- 
tion; it is like thu thickenijig of the cellular tisEue under slight 
and remittent pressure ; like the tluckcning of tendinous sheathes, 
or of fnsciie under many circumstances of extmonlinary use, and 
therefore of nutrient irritation. It is idso the mildest, and gene- 
rally the incipient, stage of inllummHtion ; hence iu soft parts, 
when an areolar tissue is attacked by inflammation, it fiist 
hardens ; then, in the centre of the hardened mass, suppurates ; 
this latter action spreads, aud |H:'rha{K soon involves the whole 

Q 



STKUMOUS ABTICULAU OSTEITIS. 



.Chap. XI. 



of the prenously indurated mass; bwt ns it 'doc9 so, the iiiflam- 
motiou also onlarfron its area, and its outer circumfoi'euce 
producing^ hardening, fornis a Iwundary to the absceas, Uig sup- 
puratiag f(XUB being surrounded by eonsolidutcd tissue. If the 
eoastitutiou liowevor be much broken, and caehoxia far devo 
lopfHl, the action is not of a quality good enough to pro- 
duce in<i«ration : hence the abscess is diffuse — uot emJoned by 
hardeucd material.* So also in bones we find, except in th6 
cachectic slate, the same iii(hiratinj; process. suiTOunding a 
OTppurative one; hence that marbled appearance described above 
ofteu increases, the light parts becoming lighter as they thickttu, 
the darker |iarts darkt^r an they get more and more hyperromic, 
uud more full of the reil ofl'usion. 

The (txsudation of a blood-stained pinkish serum, is a sequela 
of inflammatory stasis of a more marke<l aud decided character : it 
is (K>ssible that many gradations exist Itetwiion the dry 8U]KTrac- 
tion, whereby bones are iiicluratnd, and the plentifully moistened 
state whieli is oftf«n found when the cancoUi are full of this fluid.t 
It is, however, certain that a plainly visible exsiidatiou uf serum 
in bono is a forerunner of suppuration. A stasis, which is siifti- 
cieutly niarke<I to produce such an exsndation is at tbe same 
time generally sufficient to cause extravasations. Sometimes in 
tlio stronger cases these are very small, each occupying only one 
cancellus ; sometimes tliey ore larger, and are spread over 
several ; forming in the one instance small speckles, in the other 
lame blotches. The latter mark a disease which will run 
through a rapid and deslructivo cx)ur»e. 

These actions belong to the commencement of the malady 
only, and for the sake of more distinct reference to the whole 
group, viz., iMissdve congestion of the epiphysal ends, which be- 
comes active hypennmia,I)nMlucing thickening and tlm effusion of 
a pink serum, we will call this the tirst stage of artieular osteitis. 

Very soon after the first appearance of this pink senimj the 
redness of the section surface will be found obscured by a tluck 



• Ren my papers * On fttmiig und 
Wiaik IiiU^umntions,' Mv4. Ttinus and 
tiajtcttt.-, Juiio, 1855, will aec], 

t Tli«« Mn(«!-«tainitig U probably 
Am- U> llic' uiij-idding olurauturof Ui« 
litMiu^H : At all uvonta A Bimilar amount 
n{ (ixMidatioii in mtt parta is not co- 
loured. 

t Ttic pruocascB of infl*iiimntion can- 



tH>l, of (-■oiinw', b« followed otit npoii 
OIK' aii'i the game lont*: but lUvy may 
Ikj Imu-tl Tint nifTtily u|Km sf>vcni) dif- 
fi^rent Bulijwts. but bvtior still on the 
auaiv i}iibji.'cl. on dilTeivnt )»jne« wliicli 
Hie foDud io Toriotifl stage* of tho 
dbeasc : aach occgr fre^iwnUy in tlu.> 
oarpus Kid tareua. 



Oqap. XI. 



SUPPUHATION ANU GRANULATION. 



227 



yellow pns, wtioli oozes from the cavities, aud covora tJio sutfftw 
of the bone, which, oven wben that surface is wiped clean, still 
romaina in tho rancelli, and f^ives the section a dirty-yellow line. 
If, however, by directing a stpcam of water uiwn the aurfiwe, this 
pus be washed away, the hyperncmic redness bocoinea a^in 
visible, but is never so piire as in the first stage, before suppuration 
has commenced. In those sjtots. wliero the suppurative action 
is going on, tho eanccUi will be found occupied by a red or pink 
gelatinous material ; that is, by granulation from the lining 
membrane. These actious. namely, suppuration and gruuulatiou 
iu the cancelli, are accompanied by caries, or wasting away of 
the osseous material. The walls tif the caviti(;s become thinner 
as well as softer, luny ultimately disappear, and their place is 
taken by the gntiiulKtii>ii tissue, until ut last this portion will be 
" a fleshy mass j>ermeated by a thin imd brittle bony net-work."* 
Even from thow* portions of suppurating bone, which are not in 
their totality absorbed, the earthy matter is extn\cted,t so that 
the tissue becomes flexible, sojt, and may easily be cut witli a 
knife, or imjiress<.'d by the finger ; and in some rare ami very 
cachectic instances even the external shell is involved, so that 
the whole joint-end is reduced to a soft mass. 

8ueli a result is, however, very unusual : when it occurs it 
is calhil carien diifwa totalut. Tho more usual event is, that indu- 
ration aceomjmnics and surrounds tho ulceration, caries circujtir 
geripta ; and sometimes both processes go so far that all the bone 
in the centre is replaced by pus, which forms an abscess, sur- 
rounded bj* indurated tissue — sueh cases are almost confined to 
adults. \Mien caries of an epiphysal cud is taking place, it 
begins genemlly by one or more spots of 8Uppurati<m nlxiut tho 
centri', mon* or less surrounded and scjHinitcd from one anotJier 
by thickening; the action gradtmlly sprca^ls, the hardening 
process also enlarges its area, until all the iliflerent points of 
suppuration come together, while the indumtiug process reuehes 
the outer shell of the bone and Uie periosteum, which latter 
intlames, swells, and constantly deposits new anil new layers of 
osseous matter, while the uldcr ones are wasting from within. By 
those pnxiesses the cancelli increase in size, partly by tliiuning, 

* It^iktUinitk)', ' Hn(u]t)iu^h(K-r I'titliK- auinuU jMirtjn arc uUaurWt), anil tlw 
logisviii-u AiiiiU'Uii*.',' :U(-iiiil]uKr,s. iu:i. (iirlliy ninUrrs Ivtt a*, littli' Crinljlc prt- 
f ILerc aud Ihorc. in small ftfwU, tJic biocoiu ]iuap« Msld.**! in ime. 



228 



STRUMOUS ARTICUIiAR OSTEITIS. 



Cdap. XI. 



partly by alwtirjifinn, of their ^alb, two or more cavities boinp 
thiw laid into one, who ruby Uie bon*^, growing in cin!iHnfen^n(!e, 
acquires tlie appearance of being sou^Sy or tliKtcndwL Stanley, in 
hift work on the diseases of bones, bas descrilwd tins rendition as 
" Eiilurj^emont of the Bone by Expansion of it« Tissue ;" but if 
we consider the mechanism of cancellous structure and the relative 
position of the lamcUio, wo shall peixieive that for a bone thns to 
enlarge by true expansion, each cancellous wall would have to 
grow longer — an action wliieh reflection will show to Ix: incom- 
patible with the conditions of caries. Pnibably, however. Wr. 
Stanley iuteuds to designate the appearance produced by, rather 
than the means employed for, this cliauge in bone. 

Necrosis is the result of a more rajiid inflammatory act — it 
may follow induration, or it may stiporveno in n bone already in 
part carious. It may be total, partial or centnU. The first 
me^us, of course, that the whole tliickncas of the boue h imjdi- 
cated ; the second, tliat a i>ortion only is involve*!, and timt some 
part of tlie dead piece is on the surface; the last, that the ne- 
crotic fragment is entirely surrounded by living osseous matter. 
Sometimes small but sensibh' pieces scattcR'd among a suppurat- 
ing bone necrose and come away — this is called caries necrotica ; 
bnt when only one or two large masses die, and are snrrounde*! 
and separated from tlie rest by an ulceration, this hitter action is 
rightly regarded only as a result of the necrosis, and is not con- 
sidered in the name of the disease. The indurated, the carious, 
and the necrotic processes may be mingled together in the same 
spongy end, in all proportions, there being an indetinito 
number of grafhktions between total necrosis and necrotic caries ; 
and, again, between diffuse or entirely tJrcumacribed caries and 
an induration, ulcerating merely from the surface. 

Tuberculous deposit in bone is, I believe, very rare ; when it 
docfl occur it is a result, and not a cause, of Osteitis. Dr. Cor- 
nelius Black* has published some observations on what he terms 
" tuberculous bone ;" but he has described under that name what 
I believe to be the filling of the c«ncelli by granulations from 
their lining membmne, the gradual thinning of their walls, 
and en lHrgi:>ni("!nt of their cavities, with just that sort uf generation 
of bone, which we find in a not very far advanced degree of 

* 'On Uic Futholo^y uf Tul>crcuti>n« Jkntv.' Ctliti. Modival Jonnwl, vol, iv. 



CUAP. Xt. 



nAKlTY OP TUBEIICLB. 



22(» 



caries. Tliere ts no proof that tlie material which he fomid 
stufBng the caucelluiia cavities was tii>»ercle. Mr. P. C. Price, 
III his Htllf |)ainphlct oil '* ExciHiou of the Knee," refuses to His- 
oiiss tlif tiiht^rculous or non-tuberc ulcus nature of the dejH^ifit in 
spougy boue ; but he ossiimce a peculiar nature for the dejxMiit 
"under the character n('» morbid matorial which jmrtjiki-a more 
or less of tl»c nature of stnima as developed iu oUier localities 
of the body." (Loc. eit. p. 3.) In Clinpter V. of the present work 
was discussed the mode in which tubercle was formed from 
granulation — it is unnecessary to go over exactly the same 
ground in the present instance. We must, however, mentiun 
the undoubted fact, that many an old and desiccated purulent 
deposit IU bone has been mistaken for tubercle ; the position in 
spongy bone wliich favours pressure, the assumption therefore of 
ft peculiar form by the dried eoneretion. and the fact that such pus 
consists of broken down and disintegrated cells, with granules, 
&c, reuder the ilistinotion extremely difficult. I most confess 
that I could accept no case as undoubted tuberculosis of bone un- 
less some of the dejwsit were in a state of crudity. It must be 
remembered that when wo find tubercles in other organs, even 
though morit of tlie material may be in the fartliest advanced 
stage of siiftening, some will very nearly always be crude; but I 
am nut aware of any oliflervations uf crude tubercle in bone. 

Tlie osteitis, whether it be tuberculous, indurating, suppura- 
tive, or neen.>ti(-% will ut some time reach the external shell of 
the lione aud the periosteum, producing a deposit of new osseous 
matter, ulceration, or death of tho tissue, or all three sucoessirely. 
The periostf nm under the Hrst action becomes itself thicker aud 
tuugh(;r than normal, soon a jelly-like material is fonned between 
it and the bone, which gradually ogsifif^ ; but if the inflamma- 
tion be in the next stage tlie effusion becomes converted into pus ; 
the ptfriosteum is thickened, sodden, softer than nomml, and can 
with great ease be strijtped from the osseous surface, when it does 
not merely drag away with it thin fibres (capillaries) that run 
between it aud the bone, but tliick sodden plugs and ridges, 
whicli, as they come out uf the tissue, leave it marked by 
deep holes and grooves, giving it the appearance of being 
wunn-eaten. Oiteu a few thin, porous, softened, aud |)rrlmps 
disculuun^d plates uf friable boue adhere tu the periusti^um and. 



230 



STRUMOrs AKlICUIiAR OSTEITIS. 



Ciur. XI. 



come away with it The tmrface being tlius »-tri|>j>ed bare its holes j 
and grooves are covered and portly Blled with pus ; its oneootj 
teitnreUsofteinK],iDuy bfcnt with a kuifc, or {K-ThAiis may yield 
to pressure with ihi* tiiiger. If tlic caries b« circuiuscTiUHl, induru- 
tioii and ihickeuing of tlie bctfie-surfoce take place iu a more (V 
leMs circular form arouud the focos of snppmatiou. The indura- 
tion IB of course pro*luced by deposit of new osseous matter, but 
snch deposition is by no means always regular ; frequently erratic 
growths, called Osteophyte*, surround and overlumg the carious 
portion. They ore by no means so largo in this form of i_»sti?iti8 
as in the rheumatic; nevertheless they are aUvaj's present, 
though often very small, and they frequently attank a neigh- 
bouring bone ; thus, I have won an astrafralus, whose texture 
was quite sound, cxtwpt tliat, in tlie neighbi>urhood of m\ 
carious part of the os calcis, little ost^'ophytes sprouted thickly 
on its surface. These growtlis show tin? first attack of iieri<ist«'al 
irritation, and when a caries is spretiding tliey develop at the 
edge of the ulceration, then are overtaken and destroyed by that 
process wliile new oncH ariw^ further away. 

The actions thus bricHy described arc remarkable, not only 
in themselves ; but also on account of the similarity in their 
results to tliose of inflammation in soft |mrt.s. in which we find 
induratiuii, suppuration (circiimiteribeil or difl*use),and gangrene. 
In both it appears that the first effect of a tolerably hoaltiiy 
inllanimation is to harden and condense the tissue, in which it 
occurs, subsequently to soften and convert it into pua Tbo 
process in bc^iio is, however, much slower, and months may be 
consumed in the establishment of a small aljsoess, which woidd 
have formed in al)out as niuiiy liours in the subcutaneous areolar 
tiasue ; but this diiVercnce is by no means generic, and ahbough 
there may be voriation in tlie mere rapidity or slowness of tbe 
process the actions are alike. 

It cortfiiiily is to be oxp»H:teil that processes wluch lead to the 
same eud should in themselves be similar, and we might, hprtori^ 
imagine tlint the actions which pnKluce indunition or softening 
of bone nhould bear some resemblance to tlitise which hnve the 
same effect on the soft [tartfi. This subject has been with roe 
the object of consiilerable care and research. In another plain** 

• Hriti)i|i antl F<*r( igii &[t<lii;o-Cliirurgk^l Ki.view. Aiiril. iHl'iil. 'On lUi- MurMil 
Actioiw curutitntiii;; (J«li.'«titt.' 



Chap. XI. 



LACUNAL CHANGES. 



I publkhod tt piipir njK)!! this subject, whence somo of tlie fol- 
lowiug acmujit is taken. The firat objejijt was to obtain bone in 
oertAin dif1en'»t and early stages of inflammution, and for this 
purpose the logs of soveral rabbits were broken, tlui animals 
killed at certain dates frtim tljo receipt of the injury, ond the 
condition of the osseous tissue examined. 1 found that the first 
eflfect of an inflammation. 






.^, 






VN' V> 



or ]»urha{iti one should rather 
say the first organic change 
producing iin inHummafion, 
was enlargement of the la- 
cimsB and their oaualieuli. 
Tho annexed plates reprtt- 
sent sections of the iMini's 
of rabbits, in different 
slates. The first is a section 
simply in the normal con- 
dition, the relative luzes and 
appearances of tho ^mrts be- 
ing strictly prcsen'ed ; the 

lost is a section six days after fracture, equal caro being taken in 
the representation. 



W 






SmUod of Uio teeat of a nbbO— MmtAl— nuvnlOed 

ftOOdlUBB. 



V 






13^*' 



^^i 



K 



Tbe bcuiK* iiuiy V k-. i . j.i 1 :-jUiuL 



232 



STRUMOUS ABTICULAH OSTEITIS. 



Chap. XI. 



h 






Xnflammatioii producing simple iD<lurutioa (*oi]unoiKX!S by 
Bome enUrgemtmt of the lacunic ; those of the Havprsian sys- 
tems, which, on trftusYftree sections, Apppar normally long and 
narrow, assume under the disease an oval shape ; they remain 
dark, except in rare instances. In the ispuugy texture, in which 
the lacunce are ordinarily htrgcr and more broa<tly oval than in 
the solid suhstunce, the increase is not so marked, but in not less 
real The appearance of the sections shows, therefore, an un- 
mnial crowding together of the hone cells ; but the observer will 
bo priiiripally struck by the increased development of the 

oanaliculi; theee channels ore not 
only more pUinly marked, but 
rire more numerous than natural, 
80 much 60, that the boue, t-xce pt 
for the lacuuoe, assumes almost 
the appearance of dentine. The 
portion of tissue tlius affected 
may be detected by tlu; naked 
eye : if a section, simply filed 
tolerably smooth or rubbed on a 
stone without being ground thin, 
present any white opuque portion, 
the canalieuli will, in those parts, 
be certainly thus allooted. The 
section looks so vei-y nearly like 
human bone in the same state 
under less magnifying power 
tbut the same cut \nl\ sulHc& 
Passing onwards to the focus of the iullammatiuu, wliero sup- 
puration is taking place, a further series of changes becomes 
ap[>arent. The lacanie have increased still more in size and 
breadth ; even those of the Haversian systems are very biywjd 
ovals, or an^ rudely circular ; their interior, instead tif rcmatuing 
dark, has, as it were, opened out into a light space marked by 
Ught-ooloured round spots, suiTOundcd by dark lines, or vicv verm, 
according to the focus itud ilire<;tiun uf tlie light ; some of them 
are very granular, othtrs, more rare, are crowded with round cell- 
like bodies, forming a mulln'rr)' njass, which appt-ara to stand 
out above tlu' Ume sin-faoe. The ranaliculi remaining, large in 



Hft^i 



r^ 



iLi'pn'ff iiic 



an Of th* 



q¥<n)[y rvrtlim «t thp upi-T mk) of • 
idn of* cuioeUBB. 'Dm lnD)ci->l tacnr* b 



Chap. XI. THE CELL EXTRUDES FHOM LACUNA, 



233 



r^.^ 



iiumbor, have increasod iu ulze, chiefly at their conuucnceznent 
iu the hicima, so that they appear to open iiito that spAce by ft 
broad month, hke an estuary, 'lliey are tliroiighout more 
Diarke<] than the uoruiul tube ; thoy branch aLio in many instanoua 
into three or four ehunuels, and sometuues at the sjKit whence 
these branches diverge a consiihtrable enlargement in the main 
tmtik is perceptible, as though at that point a new lacuna were 
being f4)nned. 

Daring these changes in the appearance of the cells and their 
braucht'-s the iutereelhilar substance begina to HufiVr a peenliar 
truntiforiuution, wluch eummences first in the part8 next the 
Uavcrsian canal, or cancellus, aa the cose may be ; the bony 
Bubstaaee becomes perfectly granular, that is to siy, it looks as 
though it were compoded ol'daik uud light coloun^ dots placed 
oloee togctlier. As this change 
spreads from the Haversian canal 
or eaucellus outward, the margins 
of the cavity lose their distinct- 
sees of outline and lM3c<^)me very 
insular; iu ports the edge h 
gpoib, tlie cavity is therefore on 
tiiat side increased ; iu other 
parts the spotted bono tissue ap- 
pears to mingle, or to be con- 
tinuous with some grannlar con- 
tents of the cavity. It is quite 
evident that in these places the 
bone tissue is stiftened ; one can 
trace the gratlnal completion of 
the process from some jh>iut which 
is only slightly spotted to the 
part next the cavity, which is a 
mere pultaceous granular mass, 
in wliich many of the dots have 
the appotirunce of nuclei. 

Another change in the cell forms part of this softening pro- 
eeae, viz., that aa the dotted or granular eoudttiou reaches a 
certain wtage, so do the eu»alii;uli dlHiippetir ; therefore of 
eonrse front that sidu tirvt, which is turned towards the cavity 






;sfe 



^^^^ 



^m 



Fli-]>r'w-ni* a Uinina Ukcn uoi of Ibe 

i^pi.44(y pwniiiu uf lilt uiipiT fiid uf ft 

hunuin llbU In a cAritnu ciwdltiDD. Tho 

porihiu of ihn cut sbnm « iptfv 

EiHiiM auum Inlw wMcb Uio botM Iu* 
r ainftrUtl, and In wblcli dark ertU 
from Hut twii"' on- xaltm-iL In th" Ucunas 
moiif nuclralnl cella ^tr trtuwiitiy ■<> t>* 
M«D ; cnr, in (lir luni-j' rif bl cunirr, I* t.va- 
Aptctioa* fiir liK nIm and af|)wt«ncc{ U 
UKanmm ^ Km iii diaiuvUr. 



234 



SmUMOUS ARTICULAR OSTEITIS. 



Chap. XI. 



(XaTorsian or rt»u«>llar), tlioy vanish by simplo shortening, by 
receH:>ioii from the i*ntirc'ly softeuci! b*ine, until they are r©- 
dnccd to mere little rmlimnntiiry j)r<ij(K'ti(ins on the surftip* of 
tilt) coll At this time the cell itsolf is visible as a ^^nmulated 
dark Img, more or less trane|Kirent, auil vtiry highly refracting, 
wlii(?h ]>rojont8 trcim the wall of the Hcare«ly resistent bone, and 
18 of large size ; it bnlgea ont, and seems swoUen ; projects more 
and mifr<*t and at lai^t breaks away from it8 attachmeut, and 
lies among the softened di'bru in the eavity, still retaining itn 
ilnrk oolonr. In hntnking away, however, it nf^en loaves liehiml 
those of ilsi'anaiienli whieb were turned away fnmi the cavity, and 
which may often be aeeu on tlie edge, but which soon disappear 
OS 8ofti^^ing goes on spreading outwards. Frt*fpicntly seveml 
smaller cells come out of the lafMuia, inst^twl of one large one. 
In this way a lamina between two cancellous cavities very soon 
disappears from afifteniug on Wh sides: in this way also cirelet 
after cirelet of eoIU around an Haversian canal cavo intx) tlio 
cavity, and thus the system melts away and leaves aroimd the 
vessel only a soft granular and eeUidar mass. 

That |>oilioti of osseous tissue, wliieb lines witliin and without 
the shaft of a luig Iwue, may be regarded as having the same 
rolutions in the Wo case to the periosteum, in the other to the 
medullary membrane, as the Haversian systfiu has to the canal, 
or as the lamina^ bear to the cancelli. The ordinary cells of 
this tissue have cerfairdy this relation, but those very long cells 
already described as peculiar to t his situation (p. 4) are not so ona- 
logous. Tliese ceils appear destineil toaiil ij^uickly and uniformly 
in the circumferential growth, and therefore also in the internal 
absorption of the bone, their action under inHannnation is so 
rapid that, nidess by ex|)eriiiieut, one has hun.lly any chance of 
detecting their agency, for as soon as disease commences at the 
outer layci-s of the bone, they lifigin to swell in thickness, looftoning 
thin tlakes of the structure, even before it is sofleneil, so that in 
8tri])ping off the iwriosteum, however gently, such pieces will (if 
the attack be sufticiontly recent) renniin adherent to the mem- 
brane. If, however, the loosened Hakes be not disturbed, they 
soften with great rapidity, and add their quota to the thickened 
stale of the ]M?riusteum. It was tiaid (p. "A'll^). that if the jieriosteum 
be 8trip[K>d i»IV a bone inliamed on the surface, '* it does not merely 



Chap. XI. 



CELl^HANOES IN NECUOSIH. 



235 



dntg aw»y thin librcs (capillaries), biit thick, Hcxjden, pings and 
ridges, which, as thty como out of the tissues leave it marked by 
deep holes and grooves, priviiif^ it tin* appoamnce ol' Itein^ worm- 
eaten." If one or more of these plugs be cxivmincd, it will be 
fouml to ct'nsist of a vesttcl Burnmndrd by o pultoooous mass of 
grounie*, among which are some scattered cells. If the worm- 
bitten kicking holes be studied they will each bf found to ropre- 
sent thi.' absence of an Haversian wytrteni, and the parts left 
between them the Havei-siau interspaces. Some of thede holes 
run obliV|noIy into the substance of the bone, and from these the 
]>Iug IB drawn oat witli tlie i>eriout4 nm ; otlifrs nin tilmi^ tiip new 
surfatt% luul trom tho«e the ridges come ; thus, it is evident, 
that the pultaceons ^rraimlnr ma88 wliirh sunxfiutdH the vessel is 
a molten and altered llaversiaii system. It di>es not always 
hap[>eu, huwevcr, tliat the whole cirule is thus dis8(dved. and 
conie« out with flic ve.ssel; frcqupntly, only its imicr layers are 
Huflieiently softened to do so, and it is by no means ueci'ssary 
that every Haversian canal ou the iiiHauied surfuoij should bo 
ill tlie samu state of adviincied softening. 

Necrosis presents to our consideration three conditions of 
oeeeons tissue — necrosis, caries, and induration — the two lost 
have been describ<*d ; but the relative positions in which the 
threo tuviw must claim atlenliou. When a portion of bone dies 
ulceration must separate the dead mass. This action does not 
take place immediately ou the surface of tho necrosis, but a 
littJe beyond it. In soft parts the slough becomes separated by 
uiceration, which occurs on both aides of the demarcating line^ 
at the t-'dge of the sloughed portiou as well as at the e<lgo of the 
part to 1m^ pre.ser%-c<i : that is to say, that a certain jMvrtioii of the 
tissue sepimted is not dead, since on it.-^ surfact; uUvratiuu and 
granuJatiou occur. Thus nUj. in osmcous stnieliire, tlie ulcerating 
>tction eontinnt.'S in still living bone on tlif* surface of the de^d 
material; the iutei^relation of diseasi'd part* pi-oceeding from the 
healthy to the nwritscd jtortion may be thus stated : — healthy — 
indurated — ulcerated — indurated— necrosed; the two last together 
constitute tlie mass sejiarateil ; hence in all sequestra are two por- 
tions, the actually necrosed, and the indm-atetl but liviug tissue ; 
if the slough liave (Mitirrtd in the centre of a Ikjiio it is siir- 
roimded by the hurdeuod material; if oidy on the surlocc, with 



STRUMOUS AJtncn^R OSTKlTia 



CHAT. Xi, 



death of the perioetemn* the dead purtion will only be lined hy 
indiirated bone on that ni^le whirh was attached. On sawing 
tbroi^i a •eqaestmm, and rubbing tho. t>ut surface smftoth on n 
file OT<ni a stone, tho distinction l>etween these two portions will 
be Tery evide-nt ; the centre, or tlie edge, as the case may U% will 
K^etr (rf a dall leaden grey, surroandtHL. or only line<l on one 
side, by white and hard bone ; the slongb bearing;, iu coloiir, the 
aame rclatiou tu the inditratcKl fKirtion as a piofe of note ]>a|>er 
on wliirli ii (Imp »»f oil lift** fallen dotra to tho olcan whit*? siirfa*re 
Hurronnding the pjirrt, A sectiun ^mmi thin anil plnocd under 
the microecopc presents a similar difr»Tcncc of colour ; tlie lij,dit 
coming tliruu^rb the iu:tujilly necrosed bone ret*eives n duaky- 
yellow tinge, wliich is not Imparted to it by the hard ti&sue. The 
fnuiHTersQ Bection presents lacunce not at all enlargijd and void 
of cannlicqli, whose traces only appear as £ilight serrations of the 
cell's edge ; the lominuted lines of the Uavenian Kystt'ms ans 
abnormally distinct, each canal being snimiiinded by circles com- 
{Ninitivti to those which in smooth water summnd the s{iut where 
. stone has been thrown in. These aj>]tei)i-auce8 are so j>ecidiar 
I at ouee to dit>tin^ish the necro!«ed portion from the rest of 
the sequestrum, and it is well worthy of remark, that at the edge 
of Iho slou^ Haversian systems lue frequently to be seen, half 
of which are necrosed, the other half indurated. Ilie longi- 
tudinal section also shuwu absence of canidiouli; a certain dimi- 
nution in the sizo of tlie lacuuEe, many of which, Iming their 
distinctness of outline and hollow api>earauco, are tilled with 
granules, that look like drops of oil ; tlie laminated lines are now 
seen longthwisi.' running along the vefwels. 

The three changes in the bone cells, which liave just been 
dcscribeil, corre8|wnd then with tlio tliree states known as inda* 
ration, caries, and uecrosis ; we hare followod out the minute 
anatomy isuliioitMitly cloesely, let us now consider the rtitionale of 
the process. It cannot fiiil to strike the attentive reader that in 
the first of these conditions tho lacuna* and caualicnli being in- 
creased iu si/e tlie actmU osseous sulwtauce mu^t be diminislied, 
and yet the bone is condensed ; a combination which, at fii»t 
sight, seem» impossible, Itnt if the fimetion of the bone-rells 
and their brancbeji be consideretl, this up[>arent disi^repiiney 
becomes not only reconciled ; but the intcukivudence of tlie two 



Chap. XI. 



INDURATION AND ULCEHATION. 



237 



procosaes will bo found necessary. The locnneo and canaliculi 
being the nutrient portions of Uie bone, it follows that their 
Afisninptinn of more active performance would be followed by 
increased nutrition of the part« they supply ; hence to increased 
condensation of those parts; — to greater haniness of the bone. 
This condition has its physiological analogies, for not only is 
dentine more tubular than lione, but where a hartl condition is 
ntrcessary there do we find a more complete tubular nrrange- 
ment of elements. The hanlest ivory is most closely permeated 
by tubes. The cxtenml shell of certain crustaeeaj, as the crab 
aud lobster, becomes (uhiilar instead of cellular in those hard 
tooth-like projections on the inside of the claw. In fact, this 
Ciimmeneement of tlie inflammatory pronesa is in Iwme, as in 
otlier parts, increasefl nutrition, and in its least marked form is 
hardly, if at all, distinguishable from the condition of growth in 
the hones of very yoiuig animals ; it is simply a vt^ry active 
condition of the cells of the structure. If the inflammation sub- 
side, the laeunic gradually resume their narrow chink-liko 
shape, but the great plenty of long, almost straight, and strongly 
marked, canaliculi remain — at least for a lengthened period : 
whether as the texture ijecomes more and more normal these 
tubes resume their usual appearance, I am not able to say. lu 
A section through a huinenis (which I t<>t>k from the dissecting 
room and thus examined, on account of the nppnreut weight and 
density of the bone), no signs of active inflammation still present 
could be discovered ; but the canaliculi have this intensity of 
development If the nutritive activity of the oelh*, wliich con- 
stitutes an iuduratiug innammatton, bo increased to a formative 
action, so that they not only grow still further in size, but 
actmdiy multiply witliin the lacuna;, then follows absorption or 
softening of the intercellular osseoiL*! substance to support this 
iucniiSG<l cell-growth ; ultimately dis<!harge of the cells from 
the lacunae into tlie softened mass.* 



faring an kccftuut of Profiautor Virolmw'B 
views of O^tcitiii mill hL>f modu uf iuviut- 
tlgatiun. Uii offlmin tliut nil the nv 
Bearclit.''M mtut Uu made ujhju fn-sli 
plecva of bum- : tliat tlrifd junlUnm luid 
pieces gruuiid tliiii 1<rh' iii<«t dikuji of 
change; and he ^itca ou to eaj, " I huvo 



eitlii^r Lrukuri litUo huuollic out of the 
iulluui>tMl |>ortiuii, pla<.;€d Ili4<m as a 
whoh' uiidt-r Ibtt mtcruacdp.', imd tlicm 
qiiii^kly ili-iirivml ilmui of thfir eortby 
t^atttm Iry uiciuiA of uonoentTnlocl Iiy- 
(lju>cblurio ocitl : or, what in oltcn 
vasj. bavo out off thin sliccH witli n 
sliaqt knife : nr, Iiuitly, \tajc put piivM 



238 



STnUftlOUR ARTICULAR OSTKITIS. 



C«AP. XI. 



The dead portiou of bone, acting like a foreign I»ody, becomes 
cDveloped in condensed bone tissue, just as a bullet or other 
foreign matter, in soft part«. bocomwt enclosed in a fibriuoUB bog. 
Soon afterwards tliiw ti-ssm; u](H?mtes in a lint? of diMuaivution in 
the midKt of the indurution, so that the slough, ovrn when 
sepai-atod, reonams covered in by some indurated bone tissue, 
'file caries is acoomfninicd by tin* fonnation of griuudatioiis and 
of ])us from the osscons tissue itself from excessive gennrution 
of the bone cells, in the same way as these constituents arise in 
initaioiuation of all connective ti&^uea. When i>ui< from l>one is 
put under llie microwopi', it is seen to contain minute liine 
particles ; moreover, my friend Mr,Ta9on, Professor of Chemistry 
at the Charing-Crofis Medical School, and of the Veterinary 
College* was kind enough to U'sl fur mt? some such matter, by 
mixing the jiuk thuroughly with dirrtilled water mid filtering tli(3 
li<jmjr, when hcfrtnnd in it distinct evidence of phosphoric acid and 
of lime, fibowiiigthat the pus contains bone material in solntion. 

Thus, then, in osseous tissues, we find that inflammation con- 
sists of precisely similar actions as those which constitute that 
ahnrtrtnid stiito in ojirtilagcs, or in areolar racmbnine, namely, a 
superabundant growth of the cells of the tissue, which, destroying 
the intercellular suljslance, become converted into granulation or 
pus cells, or may by becoming fatty and hwing (luickly their nutri- 
tive powers, wmse the integral death of the dependent tissues. 

fuiil ohrtcurcH even tlio linrvloiit ports. 
It is, JiowcviT, wrtrtin tlmt tliP upwi- 
mi?ii dhuiilil he frcjih. T)il> pruceatt of 
ulL'eratioii in procitielv similar, wliL-tber 
li i^urtiuQ uf iyiiuv hv ui-cruiti-d oi not: 
tlie iifL-nisin c-oiuiiata in fHtty de^cuvrif 
lioii of tin- licjui'-vflls, wliich (Juta not, I 
lii.Oii-Yi', take pliiCf t.-xi-(.-pt in, nud b« ii 
i*uusf of. iJicit mnludy. J Luvo riwcr 
found it in caritti pru^wr cxtx'ptiu n cell 
herb uud tlitTV \\ii\ji aniuug titc oioiit ttoft- 
en»xi parts of lln' titf-iKTi. Tliii* di-j^'ue- 
rutiun of tht- ct-II i'iitimch )uu of it^ nu- 
trii-nt iwwtT (Hmitin)^' thi.i tirra to I he 
puwiT of iiMiiriitliiriK u Murroumlinj; diR- 
trictj. at^f^Dnling l^i llir Idw llmL u cfll 
whii'Ii iibM>rl)K u spL-ciit! AutMtjtuc^' in 
unty capiiliU' of i«.-lf niilriliuii utid Uhmii 
till' fiinnutivi' piivvir liUufrfLlirr, 1«,mic-«* 
till' Ufiiinlii'iili, liuviiig Ihh-miih- UFtoliwx, 
dlu-ivcl. I Imvc nut nuwi-C'dt'd in BC- 



inlo cniiffntrottKl hyilrt>-plili»rip neid. 

and I lien, from tht> ontu-ncil innrw, cut 

off littlo abrvtla with tho ticbBont, or 

torn tLcm ofl' with needlrB." — 'Uclxir 

FiLrvnubymuliue Ealziiudunf;,' Vlr- 

cliow's Aioliiv. vol. i?., li. 3, a. a04. 

After tliiit pro<ec<dinf* ho fluJ^ tliat tlir 

fir»t I'liiiiim.' ie u ffttly dcgi'iumlioii; tlie 

s(M.-und la Uiat «omt.' of tlic Ucmiw aru 

slightly culiir^f-^I, a I'uw bi-iiuvU>nlo(l : 

tlic thinl iS(U)ftoiiins of thf bont tissue. 

I Uavv nut oiily trifd llicw motlifxiw of 

Viri'huw!*. hilt havn pomiMm-d hinn-Un'' 

tukt'ii fnim intUrni-d jiarta iiiid .simply 

mounti'd with uIIrtb (lU^cti from ilio 

sami' purU imd pn'Viuu-tly ^nmiK^ uiid 

hnvf fiiilol to M.-U ill vhid uiumiir 

griiidinf: luid ]x)li»liini;, if nropiTly dun<-, 

iDJiut-H Ihc s-pi-ciuiciut. whik I luu «iuittj 

sort! thai thv upjiliLutiun of uii noid, 

jifirticuJarlT of n tfinjiii: iR'id, nut only 

t4it«ny dc-fitniv!) idl uutiafiu-toiy viiw of , i-ountitis for tlii' iiiurt-itM>d uiarldn^ of 

llbat int<'rc»tuig portion wIk'R- IIh' I>uiiil> tlu< liinuiuiLi'd tttrurlnm. 

in MiftcriinKt hut :iIh) gT<iil1y iiUt-n 



Chap. Xr. 



arUEADS TO INVESTING TI881IE. 



23I» 



lullummation of a bone will, evo^n whon it bep^ins in the rentre 
of the tissno. at flome time invnlve the jieriostenm, and theu also 
the soft piulsin tlic neiphbourhood ; tliure ai-ises a hard swelling 
over nn iiiflaineil bom; which in very cluiructiiristic, and pus may 
quickly form. II' these aetions are taking place in the immediato 
vicinity of a jtjint, it mnst certainly happen that the infiamrna- 
tioii, first coming to the (leiiarticular, suhsequently aftbct** the 
articular tissues ; nr if the primary bono iuflamniatiou be situated 
close to the articular facet, the disease may possibly affect first 
the cariilafr*\ and thtni the rest of the joint tissues. 

The latter nuKle, more fully explained, is this: the earics of 
the bone checks thesupply of nutrient fluid to the cartilage, and 
tlie cells of thnt structure fall therefore into fiitty degeneration ; 
while the hyftline Ktnietnro becomes first striated^ subHequeiitlv 
studded with oil globules, and then distinctly fibrouB. The 
whole appearance under the microscope is different to that con- 
dition described, ill Chapter V., asreauUiug from inflammation ; 
in which we found, first considerable growth and multiplication 
of cells inside tlic coi-puscles, subsequent nipture of these latter, 
diBtributitin of the cells into the hyuliue structure, where they 
still continue to enlarge, multiply, and chnngo their form in mani- 
fold ways. In fatty degenenUioii, the corpuscles, and the cells 
therein, also eidarge, but they do not multiply. The enlarge^ 
meut arises from accumulation of oil globules around the nuclei 
in the cells, and Hubsequeully in the corpuscle itself artmnd the 
cells, and ullimately in the hyaline substance. Tlio eorpustles 
occaaionally burst, iJiongh 1oj*3 frequently, and after having 
attained a larger size (chiefly in tlie loiigitiidiual direction) tlmn 
in the inflammatory form ; but the cells tlius discharged are 
incapable of any further growth or function, they simply 
delique«w% diftn.siug the oil uromul. The fibrification of the 
intercellular material is due in jiart to loss of nutrition ; it 
always commences at the su[)erflcial a-^pcct of tlu; cnkrged 
corpuscles ; thence spreails iu uU directions, meeting on every 
side with similar morbid actions set up round the nciglilx>uring 
corpuscli?s. 1 am unable to say whether a linear arrnugemeut of 
oil globules, frequently to bo seen around the fatty cells, is a cause 
or a conse<inenco (»f the t^plittiiig of the intercellular material ; 
but am inctiuixl to believe that this arrangement iaatiirsta coiist^ 



240 



RTRDMOUS ARTICULAK aSTKITlS. 



Chap. XI. 



qiienoe of, and subsequently ^eatly promotes further Bbrinoatiou. 
Those portions of tlie sertioiis whk'h arc farthest advanced in this 
degenerative process impart to transmitted h'ght a pecniiar dull 
brown eolor. While the inflammatory uloeration nearly always 
commences on, or but very little beuealli the free surface, fatty 
defjencration fmm osteitis iK'ginsiiear tlie attaeJiedsurfm^e oftlit- 
cartilage. The peculiar dull white hue of an inflamed cartila- 
ginous sjwt, its velvety consistence, and its irregidar surface 
8tiidd(.>d with cruter-liko doprcssious, ore not marked in the 
ulceration (rom fatty degeneration with ('(pm! cloamess. On the 
contrary, a mass of the cartilage appears soflden and swoljen, 
and of a yellowish wliite ; and this portion is either marked by 
one large id<:pniiion with soft sfKlden fibres, or it will be studded 
by a iinmbLT of smaller unequal erosions. 

lu other places, the cartil&ge over a larger or smaller bone 
Burfaee will be detached from the bone itt*elf, and only keep its 
plaee by lateral fontiuiiity with the rest of tlie^ structure. Tf thiH 
loosened piece bo removed, and its deep surface examined, the 
articular lamella will be found adhering to the cartilage ; in fact, 
it has become dtUuihed by ulceration through the eanccllar 
walls whereby that bony plate was supported. The piece of car- 
tilage begins to undergo the fatty degeneration, and may even 
ulcerate, and by degreoi*, unleas considerable in size, disap|)ear ; 
but it very frequently breaks away and may l>o found loose in 
the joint upon subsequent examimitiun. 

At some indeterminate perirHl of the osl<^itis, the synovial 
membrane of the joint Ijcconies involved : this happens before 
the cartilage has greatly suft'ored, but its eiact time and manner 
of implication depends upon various causes. If the bone inflam- 
mation have ended in a ntierosLs which lies verj' ni^ar the joint 
surface, or actually involves a jwrtion of the articular lamella, 
'portions of di^ml hone, accompanied by pus, may break into the 
joint cavity with more or less suddenness and produce suppurative 
inflammation. Such ceases are fortunately not very itommon, 
and wo know that osteitis affe<!ting the spongy end of a bone is 
much more likely to end in caries than in necrosis; certainly in 
children, and even in the adult, except at the head of the tibia ; 
in tho latter event the synovial membrane rceeives the inflam- 
raatory impetus, but vor)- slowly, so much so that there rarely 



Chaf. XI. 



TENDENCY TO CURE. 



241 



seoms uny incroa-wd effusion of fluid into tlie joiut cuvity. It 
has been explained in Clmpter I. that the fi*co portion of tho 
synoWiil momhraue curling round upon the bone to reach the 
rartitAg^o, lies for some little distance upon tho periosteum, and 
that in this situation tho areolar structure of the suljsynorial 
membrane m actually in continuity with tho periosteum ; hence, 
when tliis latter texture inllttraes, tlie nction naturally spreads 
to the serous tissue. The synovial membrane may therefore 
become affected tlirough one of two ways — either from within or 
without: tho first throngh the rartilages, becoming diseased 
and 80 far vitiating tiTo secretions, that the inner surface of 
the membrane is imtated; or from gradual dissemination of the 
action from tlie poriosteal to the periarticular tissues. In either 
CASO, the joint is in the following condition. One of the bones is 
ulcerating, and the cartilage upon it has become eroded ; it is 
sodden, and in parts detached from the osseous tissue. The other 
bone and its cartilage are beolthv, or at least in a state not far 
removed from health. Now, all natunil processes tend, even iu 
disease, to cure, although tlm means are often inadequate, blind, 
and frustrated by irritability, debility, &c. Tho tendency of tho 
processes, which nature sets up as soon as the inilammation has 
reached a certain point, is to obiiternte tlio joint cavity, by 
causing all its constituents to grow together. This could not 
happen as long as one bone surface was laid bore, and the other 
was covered with cartilage. The synovial membrane, becoming in- 
flamed, carries the action across to the parts hitherto sound, the 
cartilage inflames and ulcerates on the bone as yet healthy, 
laying it also bare. It is singular, that pathologists have not 
fixed upon this peculiarity of osteitic joint disease, which, com- 
mencing iu one bone, attaclcs tho cartilage in its oivn manner, 
from tlie deep surface, while, since the disease spreads by the 
synovial membrane to the other cartilage, that structure will be 
affected after the manner of a synovitis from its free surface. 
Thus the bone not affected is put into a position to produce new 
organizable tissue and if the actions be siitlQeieiitly healthy, 
to form anchylosis with its opposite fellow, which Imd been 
primarily diseased ; but many tilings prevent this, and instead 
of formation of new tissue, more and more destruclion of the old 
will often take place. 

R 



242 



STRUMOUS ARTICULAR OSTEITIS. 



CflAP. XI. 



Ono of the ctrcQTnstancra in this disease, which is most re- 
markable, and which has the g^rcatcst effect ujwn its Rubsequont 
eoiirse, is its constant aceompaniment — the spasmodic contraction 
of mnscles. Wo have seen that wbeu a synovitis advances so 
far that tbo cartilage becomes ulccmted, and the hone eancolli 
laid open to tbe joint, there come on certain sharp pains, called 
"starting pains" by most sufferers, which occur at night, just as 
sleep commences, and drprivti tbe patient of rest Now a very 
similar but a more violent set of Hpasmodic pains come on much 
earlier in articular osteitis. It roust be remembered that tlie 
innervation of largo joints is derived ffom sensory filaiuenU of 
muscular branches, and that a close connection exists in health 
between muscular action and articular pressure (See Chap. I. 
p. 25). The anatomist's Itnife can, with tbe greatest ease, dis- 
cover which nervous branch sends a twig to the articulation, but 
wlien the twig has passed into the joint it is hardly possible to 
trace the actual spot of its distribution. Pathology, however, 
shows us that in a synovitic disease no especial action is produced 
among the muscles of tho limb, until the bone luiderlying the 
cartilage becomes affected ; and again, we see when tliat {xirtioQ 
of bono is primarily diseased tliat these spasms of tlic muscles 
producing the start and the shock arc among tbe earliest symp- 
toms ; we find that a carious state of this portion of bone is 
extremely irritatiiig, and Fcts up not merely temporary spasms, 
which pass Uko electric shocks over tho limb ; but that a slower 
and a lasting contraction takes place. This phenomenon more 
or less affects all the muscles moving the lower bono of the 
diseased joiul^ but it predominates in tho flexors, and therefore 
that bone becomes rigidly bent upon the other, tho muscles 
feeling tight and cordlike luider the skin. Such contraction is 
produced by a morbid form of reflex action carried from tlie 
nerves supplying the joint to tliose of the muscles. 

There is a close correspondence between the amount of pain and 
these ^>eculiar spasms ; so much so that there e\'idcntly is between 
tho two Bome coimection of cause and effect* It is generally con- 



• It in hardly wiao to muko n very 
mlDnti: division of dtflTimmt Koria of 
pun ocoarriiig ui tlio mam part of tlio 
ume porion, l>at tliore U no donlit tlutt 
titan Mv tlirco dbtiitct paiuB in the 



jcnnt itaclf: dull ucbiofr. and giutwinK 
with Itcat ; Uto vlectxic-likv puitu of 
•posou}; And Ihc pain oii any ulUtiipt at 
motioa. aod porUcuIurlj- ut t:xU)U£aoii. 



Chap. XI. 



MUSCULAR SPASM. 



243 



Bidered that the spasms, both momentary and constant, are pro- 
diic4.id by a 8eini-vt>hiiita.ry flinchiug from the pafu, and that (he 
attitude is nssnmed for tho sake of ease. This, however, is proved 
not to bo the cai=e : Firstly , Bifjiiiw! the spasmodic starts are by 
far more violent when the will is withdrawn and sensation dulled 
daring sleop^ Secondly, Because cases occur in which the starting 
precedes any other painful symptom. Thirdly, Itecuuse the 
constant contraction is of greater power and of longer duration 
than any voluntary action could be, and it continues during 
sleep. Fourthly, Because tho muscles affected with this peculiar 
contraction waste more rapidly than in any other disease except 
in certain cases of irritation of the spinal cord producing spasmo- 
die muscular oontnu-tiou. The pains of the joint are therefore 
otherwise connected with tliis spasm, and we find on examina- 
tion that^ although the muscular phenomena are originally pro- 
duced by tho irritation of tho joint disease, they eventually much 
increase, or altogether support its morbid actions by forcing one 
tender bone-.siu*lhce against the other.* 

Now the actions thus fully described, viz. suppuration in the 
bono with degeneration, ulceration, or detachment of the articular 
cartilage, granulation of the synovial membrane and iiarUal or 
total conversion of its secretion into pus, spasmodic starlings and 
contractions of the muscles form the second stage of the disease. 
During, and at an indefinite period of its progress, abscesses 
form in tho soft parts around the diseased joint, and burst out* 
wardly. This condition is that which I would take as the 
boundary mark between the second and third stage ; it is not 
very sharp nor defined ; such abscesses are extremely slow, and 
remain in a stato near pointing for a long time ; hence not the 
absolute bursting forms the line of division, but the first un- 
doubUftl establishmeut of external abscess. Few cases run into 
the second stage witliout passing also into the third, and suffering 
some supjmration of soft parta ; but botli stages may be mild, 
and the tJiird hardly develo[>e<l, amounting oiJy to the breaking 
of one or two small abscesses before the patient recovers. On 



* Bometuui.-«. but at a later since, 
when toulc cimtntvtiuu of tbo musGiM 
pro(luco« (lUlocotiou, tlio t^Kistiis and 
ltl^t« abelo Very mucb bultx!d. or dii»- 
appear ullugotkir; Ibo diiplMcment 



of oae boDO surfnco from tliu otiier. 
^ving iiutant relief; a proof, in aid of 
the fact, Uiat it » thin luutiml prcasuro 
which produccfl thut whole tiuin of 
qrmptoni. 

b2 




244 



STRUMOUS ARTICULAR OSTEITIS. 



CnAP. XI, 



the other hand the snppmration may be Tcry extensive, ehecemj 
forming and bursting, first near the joint, le-aring siuuses crowned^ 
by red {loiiting granulatioua ; subsequently they are produced 
'furthrr and further frt)in the articulation, among the deep 
f mmcles of the limb, these also bnmtiug nnd leaving einnses. The 
di^faai^e from the sinuses near the joint, and communioatiiig 
with the carieS} is thin and irritating. Evenwhf re it is plentiful 
and exhausting; tlio patient suiters from hectic, has night 
sweatft, gets thinner and thinner, and, unless artificial or uaturol 
canso bring some helj). must soon boeomo a victim to tho disease* j 

^me cnrions deposits of sorum between tho bone and pcrioe- 
teum take place ooeaslonally before external suppuration has 
commenced. I know of no means of distinguishing these from 
abece«s, except a grooved needle or exploratory trocar bo used : 
they usually disappear and aro not necessarily followed by sup- 
puration. It is at this stage of the disease wlien the soft parts 
are a good deal destroyed, tho ligaments softened, and the joints 
surfaces altered, that dislocation most readily occurs ; it happens 
as a rule more frequently in those joints, in which the bones do 
nut closely embnice each otlier, but lie merely in apposition : tins 
tho ulna is ver)' rarely, if ever, spontaneously dislocated from 
the humerus, the radius more frequently ; and the tibia is not 
uncommonly drawn backward from the femur.* Dislocation 
occurring thus, when the patient is almost in the very grip of 
(jf'ath, produces a wonderful change ; the pain, tho starting, &c^ 
all relax, from that moment the disease mends, and tiic patient 
pmbally recovers, if recovery it can be called, with a distorted 
nnd guneraily a useless limb. 

Occasionally, though rarely without the production of a dis- 
location, an amendment s^^ts in, and tho action, instead of con- 
tinuing to be destructive, becomes reparative. The bone cancelli 
become filled with healthy fibrating granulations, the syuovial 
membrane also converts its gelatinous growth into good solid 
fibrous tissue, the parts grow into, and contract upon, thu cavity, 
until it be obliterated ; then discharge ceases, the abscesses fill 
up, and from this point anchylosis is merely a matter of time. 



• The liifvjoirit appears to fonu an I 
itliTQplion lo Uiii rale, but iu Tuct Kpon- | 



taiicaQB dUlorntion of that jnint U far 
lew oommoQ tJum ia gen«.-niUy euppoird. 



Cuxr, XJ. 



ACUING A^D Ll.Ml'JKO. 



^6 



Symptoms. 

We have seun that strumoos inflammation of tbo joint-end of 
a lung hvuii is rare in thu adiUt and eonimou in the ynimg sub- 
ject, lltniw, when a grovm |)orson i« fonnd aficc^ted with osteitis 
in such a part it is generally traceable to some other oanst; — 
rhcnmatifim, syphilis, or injur}'. Yet it ocrosiunally happens 
that such disease docs occur ingrown persons, but tltcn it is more 
rapid, and ends rather iu necrosis than in caries, and i» almost 
confmed to the head of the tibia, though it does occasionally 
attack the femoral condyles : a somfuluns innanimation of bono 
is among adults more common in the sLoii, incgular. spongy 
bones of the carpus or tarsus, but in childieu xiolhJug is more 
common tlian inflammation of the epiphysal ends of the bones. 

The first sign of an osteitis corameni'ing a^ a ehr(*nic disease 
is a dull aching pain in the iwrt, generally im reasing at night. 
When it occurs at so early an age that the patient is not able 
to give an account of its sufferings, the nurse or mother will first 
observe that the child cries when, during washing or dressing, 
the aflected limb is moved ; and when once attention has been 
thus tiircctcd to tlie part, it will ver}- soon ht* fuund that the child 
avoids using that limb as much as possible. Such symptoms, 
when they have for a day or two been sufficiently constant to 
be undoubted, slionid never b*! m^leuted, but the sufferer should 
be subjected to skilled examination.* Tiie cliild's nurse or 
mother will point out to the surgeon which limb or which joint 
appears to her the one affected, and tlic movenientfl which caune 
crying or flinching. HoshoiJd theti examine those movements, 
joint by joint, so moving different parts of the limb that only one 
joint is stirred at a time, and thus, by watching the expressiou 
of face, he will soon know in which the pain is sittinted. At 
this early stage the eyo will not be able to dt-tecl auy difference 
Ijetween the affected hmb and its fellow. He shoutd then siib- 
jeet the juirt to a careful manipulation, and hhonld accurately 
compare the slmix; and size of every jwiiit of the bones forming 

* Tbo reailor will rfinctnbcr that in ccptible, or ttiat, at l»i»t, wlien attcn- 
itnunOQjB iiynovitis occurrinK in cliil* I lion bu bctii Umwn to thn [tart by 
drcn flwijUiDt; !• fri^qumtly ob«crved si^ns of puu, swetlio^ i» at ouce per- 
bcfoK tvy vrmpltinu of pun ara per- ' oeivetL. 



246 



ffTRUMOCS ARTICULAR OSTEITIS. 



Cqap. XI. 



the joint with those of the fellow limh : thus no alteration can 
escapo him. I^e first intimation of change is nut bo much actual 
sweUing ; we have seen that the bone itself very rarely enlarges, 
or, as has been supjwaed, becomes disteniled, a« by si^me intt^miii 
force. ANTiat little swelling there may be affects the periosteum 
and the fibrous texturiis immediately around. It is at first but 
slight ; I have seen many cases of early osteitis, in whidi acairate 
measurement, by a tightly drawn band, has shown no swelling, but 
in which examination by the band could detect a subtle change 
m form, consisting in greater breadth of all the elevations and le«s 
depth of all the natural depressions of the part. Tliis condition is 
accompanied, if the bone bo quite superficial, by increased warmth, 
generally also by tendemesu. Such symptoms, corresjiouding to 
the changes described as appertaining to the lirst or conge^ve 
stage of the disease, may last for weeks, even for mouths, and 
may then subside, or indeed be altogether subdued. 

On the other hand, the malady may incxeaso ; the pain will 
become more severe, particularly at night, and the child wakes 
from sleep, partially or altogether, with a (-ry of pain. In this 
stage tbe heat of the part will be more marked and the swelling 
more perceptible ; the form of the joint-end of the bone will 
alter, or, to speak more correctly, the periosteum and the fibrous 
tissues In its immediate neighboui-iiood will become inflamed 
and swollen, and the tumefaction will concentrate itself more 
pnrticularly at certain spots, in which the effects of the disease 
will be most strongly marked ; thus the internal condyle of the 
femur will often project very much and pointt^Hly ; tlie enlarge- 
ment is not bony, but is elastic, and at first fiuctuatcs, although 
it is hard. The swelling is, in fact, protluced by effiision of fluid 
beucath the periosteum in the same way aa nodes ore caused, 
but over a much larger snri'aco ; the tightness with wliich the 
fluid is bound in between the tough fibrous membrane and tbe 
bijue producing the harduess. These sjHjts of effusion do not last 
long, but become dis^veraed and raei^ed into the general softer and 
difliised swelling, which goes on increasing until it greatly alters 
the anatomical forms of the boues, exaggerating tlicir jirocesses, 
and covering them with a swelling more or less pulj>y, yet Iia\'ing 
a hard fonndatiuii, with a sense, in point«i, of ol>8cnre fluctuation. 
Tliis swelUug does not spread over all the joints but is conGned 



Ckap. XI. 



CAKIES. 



247 



to ODO of the boncB that enter iato its formation. At this time the 
skia over tlie part will ofton nasumc a reddish or pinkish hue. 

At some iiidetemunate period of the boue-disease the joint 
will begin to i^ulTer. In the jjarticular caaea now under con^i- 
deration the synoviid membrane becomes very slowly implicated 
by ap;radua1 extension of the inflammation from the periosteum 
to the fiuUynovial tissue (see p. 241 ). At first no perceptible 
increase of inecretion takes place into the sac of the joint, hut a 
gradoal process of soft thickening commences, which, produced 
by the same granulating process as an ordinary synovitis, causes 
a similar <H)n<liti(>n of the juirt. The joint becomes romidcnl and 
ahapelcssr but never to the same degree as in the strumous, and 
pulpy pi-anulation of synovial membrane ; on the contrary, the 
place of origin of the disease maintains its pre-eminence, and 
does not become so covered but that its morbid condition is 
to bo detected till at least a very far advanced stage of the 
disorder. At this early period there ought to be no diiHculty in 
distiuguiahing ono form of joint-disease from the other — the 
following table gives shortly the distinguishing points : — 



OlAONOSIS DErWEKN SrKUHODS ABTICULAR OSTCITIS ASD StBCICOUS 

Synovitis ui the sarlier Stao£8. 



Strumou$ Articular Osteitis. 

Thti flrrt eytnptom \a Uvarj dull pain 
witii lim}>gn^ or uthur imperfection in 
tlio iMD of Uu' limb ; titin ctmiets on be- 
fore imj awulling it perceptible. 

TIio TMin is gcnenilly increaBcd in 
lioil, atia is 8iihji'i-t tn variiitiona; eome- 
timeB quite diaajipvariDg for a time^ 
outl ugoin rutumiug, 

Tlte sTclUne ot first is confinod to 
on« portioD of Ute joiut, for iiiBtoucc, at 
tho Kuoo, tbo nppcr wbon tbe r<.'miir, 
the lower when the tibia is ofll-^-ttxI. 
Aflorwanlfl tlieugh tJio whole joiut he 
cnlnrgcd, the tnmefactirin U more 
marked, hnrdcr uid Ivgcr over the 
bone prinrnrily afTectcd, arid is neiirly 
oln-ays on one aide of tlio joint Tho 
diriMOD betwoeu tha booM retDaiiu 
ovidemt to tho touch. 

In all bat tho dccpoBt pUwod Ixmea 
tho iutogumcnto over them ore aeoaibljr 
hotter. 



Rtrumoua Sjfnmfitis. 

The swfllling ia either Iraforo pain, or 
is diw:oTt<nMl with the pain. 



Pain Iv^tng ii Inter symptom as ro- 
ganhi TJfiililu ttH-L-lUri)^ yvt when it 
comes on is cuiutanL 



Tlie bonce forrain.i; the orticnhition ore 
blvntk-d by the awctling into uue rounded 
shupdeas uu^dd, wliioh overlies both 
porta of the joint ci]iuilty. aod eonoeals 
prt.'atly itr lUtofiiolber tlii; line of jooo- 
tiuti lK-twi;en Uio two bones*. There is 
no prufuroncc of plnrc : the flwelliug i^ 
oquahlo oTui tho whole joint. 



The integuments are not at oil, or 
scarcely. iucreosoJ in tcmpciuturo. 



248 



STltUMOUS ARTIOCILAR OSTEITIS. 



Ciuv. XI. 



Very soon after the commencement of inflammation, as con- 
txaaie<} with con(?*?8tion, certain symptoms euperveno which mark 
the commencomont of the aerond stage of the disease. Such 
are. peculiar aching:, wandering sensations along the course of 
the bone whose end is diseased, combined with spasms of the 
muscles, producing starting {)aius and permanent contraction. 
These starlings arc like those obw-rvable in the advauced condi- 
tion of synovitis, when the cartilages are ulcerated nearly 
through, and the hone cancelli immediately underlying the joint 
are injected ; but they are more violent, and as the bone is in these 
cases primarily affected, such spasms commence earlier in regard 
to the rest of tlie joint disease. Such violence and early occur- 
rence of these pains are almost enough to mark the malady as 
an indammation of the epi]jhysal end of the bone ; and they 
show, as stated in the first division of this cliaptor, that the osseous 
structure jnst beneath the articular lamella is injected, and, when 
very violent, that it is probably suppurating. But the surgeon 
must be careful in assuring himself that he has really to do with 
this sjTnptom, for when the disease occurs in young children he 
may often be misled. The ordinary hea^-y jwun of a commeuciug 
osteitis increases, as we knov^ at night when the patient gcta 
warm in bed, and the generally garbled and exaggerated report 
of the nurse will lead the surgeon to suppose the child's crying 
more violent than that dull pain usually produces. If he once 
stand for a few minutes by the bedside of a |)atient at night 
when the startinys come on, he will not readily forget the sort 
of movements and restlessness they produce. The jMitient will 
probably be found lying in the position which the splint enforces, 
breathing quietly but rather quickly : suddenly he starts, perhaps 
half round, perhaps into a sitting posture, with a very sharp |)ecu- 
liar cry of pain, but almost before he can be asked a question 
ho lieu down and goes to sleep again. Dr. Bauer says, that if 
tho patient be awakened he hardly remembers the attach of paiu 
at all ;* but this is doubtful, when wo know that he remembers 
it in the morning ; and I have found that on waking a child 
with this disease he always cried very much and was frightened, 
and could only with diiliculty be got to sleep again. One could 
not plainly make out whether he knew of tho paiu, or whether 
* 'Ituucr on Hip Uiitcasp,' p. 8. 



Cdap. XI. 



NECROSIS. 



249 



it merely raado part of a frightful dream of which our waking 
him was the dreadful climax. Older people, from seven xipwartls, 
have a very clear ideaof the pain ; but on watching a boy, aged 
ten, thus BuflFering, 1 found that he did not wake sufficiently to 
be conscious of external objects* and went to sleep again directly ; 
but ou questioning him next day he described exactly the sort of 
rapid shock nf pain, which tlie expression of face anJ gt^ure 
inclicatcti. We shall have occasion to recur to this sjTrptom, 
as it is most important in it« eflects as well as in its semcioli^y. 
Such is, in brief, the history of a strumous inflaniinatiou of the 
joint-end of a long bone ending in carieg. All osseous disease is 
alow of character ; but this form is of all perhaps the slowest, 
whose steps are least marked and definite, and whose commence- 
ment is ao gradual that the moment of beginning can be hardly 
fixed. There is another form of strumous disease which also 
may be situated in the epiphysal ends of bones, rather more 
rapid in it^ course, whos<j InHammatory action terminates in a 
necrosis instead of in a caries- Such cases occur as a rule to 
persons of riper years : the first symptoms, brought on by acci- 
dent or exposure to cold, are sufficiently sharp to be remarked, 
and are sometimes very severe ; perhaps there will be a shiver- 
ing fit, followed by considerable fever, and very acute pain in 
the bone. Gradually the feverish s}'mptoms diminish, and even 
the pain will be less severe ; but it reciirs with considerable 
Violence at night, und the affected head of the bone swells to a 
marked extent. The tumefaction is hard, inelantic, bony — is, in 
fact, bone rapidly formed beneath the periosteum — the swelling 
is not covered by thickened soft porta ; on the contrary, these 
latter become thinner, and are tightly stretched. The disease 
(necrosis) is more common in the shafts than in the joint-ends of 
bono ; but occurring in this latter, it is almost coutined to the head 
of the tibia, olecranon process of the ulna, condyles of the femur 
and humerus, and being thus situated in parts very superficial, tho 
form, shape, Imd consistence of the swelling are plainly made out ; 
the soft, parts are, ae said above, stretched tightly over it, being 
more adherent than usual to the subjacent luird tissue. The 
pain, viz. severe aching, with which the disease began, soon 
considerably diminishes, and generally starting piins will come 
on; but tliese are mild and do not form a subject of dread 



250 



aTROMOUS ARTICULAR OSTEITIS. 



Cup. Xf. 



to tho patient, or of special complaint, nor do muscular cwDtrao- 
tious form a part uf tho diseaito ; nor does the general health 
Biiflcr to any ji^eat extent After a time the poius of a necrosis 
will reoiir with greater violence and undergo some change in 
cheu^rtor ; but those are due to the eeocmd, the ulcerative stage, 
by which tho dead portirm is separated, and in which, therefore, 
wo should expect to find the symptoms approach m^e nearly 
tlioso of caries. Now, the soques-trum may lie in the middle of 
the spongy mass, or it may be chiefly situated on some external 
part ; or, again, it may lie close to or include some portion of 
the articular lanielU. All these diflerunt conditions make a 
got»d deal of difference in the prospects and termination of the 
case, hence it is extremely imjKirtant to be able to distingtiish a 
necrosis from a caries of a jt)iut^nd, even before an external 
opening sliall have been formed. The points of difiereutial 
diagnoses may be thus given. 

DUOXOSIS DETWEt^ NtX'ROSIS AM> CaRIES IS THE JoCTT-EKD OF A 

LONO Bosk dukinu tuk ejlklikr Stages. 



Syraj'tofM of Neero»it, 

Disease beciDB with a cmort nttack 
of piuci imd luTcT after an accident or 

BweUiag eqaably hard, ineliutic-, Uiii;; 
on exo^TKoranoa of uaCural form Hl-b 
clow to intcgumeata. wliicb on: adlio- 
root aod soiiu thiuiied. 

The paia with vbich diMue beaan 
flliurp and Kcvt-rc. bat soon diminisnca 
viTjr niDch ; then retnnts with otlmr 
icltiimuU:r~tluft.wio continaiug all tb<' 
Uue. 

If stortiDg pains oonir on tiivv will 
not bo v^i^J suvere, and du iiot wrui a 
great ffiibjcct of compluint. 

I'omuuKml coulmctJotiB are uuusiml 
as accom]iai)in)ieiit. 

Tlie genenU health does uot mffvx 
much. 



Sjfmptotnn of Cttrica. 

Diaeaio lo loiidioos m its attack that 
its actual oonimouceu(<nt ia difflcult to 

ax. 

Bwtilluig leas hard and not equably 
tio; l]uctuaU.-6 ubtk'uri'ly in placL-s; Iho 
parts bctveon bono and ^du puHy, 
Ihickeoed. 

The pain bogina kas severely, but as 
long as ducaflo lasts goes ou iucreusiug. 



TliO i>tartiug paiiui rury ecrvcrc, and 
eugriiaa Hit* [Jiiliciit'ii a(t«uttou from 
utitvr jniiuu uf diouwHi. 

Poricuueut ooutntctioDtf oonatsntly 
accoQipauy eariuB of a Joint oud. 

Qeneral health very much h^urod by 

disease, uli'vpU'SS ulgUts, &c. 



It is not a necessary sequence of necrosis, situated in a joint- 
I'lid, that inflainniation of the artieulnt ion should follow, because 
the dead bone may be situated so favourably, that its separation 



Craf. XI. SEQUESTRUM FALUNO fNTO JOINT. 



251 



can be secured without interfering with the joint ; but it sometimes 
happens that a neczosis will include the articular lamella, or 
that pns produced in the process of separation, will find its way 
into the joint In either case it too frequently sets up an acute 
suppuration iu the cavity, which, as tbe irritative action still 
continues, in not to bo combated by any of tlie general or looal 
means within our reach. In such cases the symptoms of the joint 
malady are very urgent, and, usually beginning with inflamma- 
tory violence and great fever, end with a typhoid condition; 
thus, when such bony swelling with the syntptoDis as already 
described have lasted some time, there will suddenly come on 
violent and frequent rigors, followed by excessive puiu in 
the joint ; the pulse bocomea quick and hard, skin hot, face 
liushed — in fact all the symptoms uf considerable inflammatory 
fever. The joint swells, becomes hot, fluctuates, and cramps 
frequently arise in the neighbouring muscles. However the |>ain 
rapidly becomes more severe, the power of tlie symptomatic fever 
in a very short time gives way ; occasionally, it is so ephemeral 
as not to come under our notice, and it yields place to syinploms 
of a low typhoid character. The pulse becomes very quick and 
small, the face anxioiis, the tongue brovra, the thirst extreme^ 
tlio skin burning. At last the swelling is no longer confined to 
the joint, but spreads over the whole extremity, which becomes 
red, and perhaps oodematous. If the joint or soft parts around 
be cut into, still more if they be left to break, the pus which 
escapes isofa dark colour and putrid. The patient may die, from 
the mere oppression of the disease, in delirium and pain. Even 
when it is attempted to save life by amputation, it too frequently 
happens, as in such a stato of constitutional disturbance we must 
expect, that purulent infection ucTorthcless puta on end to atro- 
cious tortures. Fortunately such coses are of rare occurrence, 
and it is a still more rare circumstance that the pus and dt-bris 
uf nernwis sliotdd tind their way into a joint before having jiro- 
dnced an opening through^Jie skin, whereby a probe may be 
introduced, and tlie extent and direction of the sequestnim suili- 
ciently ascertained, eitlier to ullow us to prevent such a breach 
into the Joint, or at least to moke us prejiared to combat ita 
eflectA 

Caries, however, which is the more common disease of the 



252 



STRUMOUS ARTIOULAU OSTKITIS. 



Chap. XI. 



end of a bone, does not oet up violent joint-inflnmraation, 
but rather a slow chronic attack, as above described (p. 241), 
causing thickening and granulation of the synovial membrane 
and eiilai^ement of the whole articulation, whereby, however, 
the part primarily affected retains the largest share of the 
symptoms, and the bone becomes very scnwtive to jiresfmre. 
The skin over tlie swollen joint, aud mpre jiarticularly over the 
diseased bone, becomes white and smontli, giving to tliis com- 
plaint, among nmny others, the name nf white swelling. After 
a time, the third stage of the caries commences by the formation 
of one or two soft fluctuating spots, which at last redden, point 
and burst, giving exit to some amount of pus. The formation oi 
matter among the soft parts is always accompanied by increase 
of pain and aggravation of the genuiiil symptoms, llicse are 
not relieved by opening the abscess ; on the contrary, they are 
rather increased. From the wound produced by the bursting of 
the abscess civp forth florid granulations, the discharge becomes 
thin and excoriating, and it discolours silver. In a little 
time tho cavity of the abscess contracts, but only partially, 
leaving a passage or siauH, which leads with inauy turns and 
windings to the deceased bone. The granulations which crown 
thpse sinuses are deep red (crimson), and bleed very easily ; 
round the opening for some distance the skin is thin, contracted, 
and hu8 a peculiar blue look. The surgeon will naturally pas^ a \ 
probe into tlie sinus, and endeavour to feel therewith the rough 
surface of disctased bone, but it is very hkdy that he will not 
come at once upon such surface, for the turns and windings of 
the aiuus, sometimes along a piece of fasciti, sometimes round a 
tendinous sheathe, may easily check tlte pasnugo of a 'probe ; tlie 
blue circumference to a sinus filled with bright florid gruuuln- 
tions is a sign eo positive, that the mere fact of not U'ing able 
at once to reach diseased bone should not bo allowed to negative 
it4( inference, A little patience and some ingenuity will, on 
a subsequent visit. Hud the proDer channel; but never for 
the mere sake of feeling the diseased hone should the probe be^ 
thrust violently tlirongh opposing stmctures. Ihe bune is found^ 
rough, but generally soft, and the rotten cancelli yield a little to 
gentle pressure with the probe, the supcrlicial portions breaking 
away. Ihia is very (Ufierent to the sensaliou of a necrosis, and 



Chak XI. DIAGNOSIS OF CARIES AND NECROSIS. 



253 



it is important tbnt thi^ two should be distinguished ; henco we 
will iigaiu coutrast tlieir ajijx'arancc. 

Diagnosis DirrwEEN NECttosis i.M) Caries in the Joint-emd or a 
LONO Bone durlnu i-he latek Staobs. 



8ymptoma of Varus. 

T>iirin!E formntion of piu Uic giinpral 
uid local spaptoma Izicrtiuu in iiitm- 
aty, aaA continne to iDorniae uvcu afkir 
»o extcnial opening has beoa made. 

The ninasca uo cxownoil by fii>ri<l 
brillumt criniKn gmniUAttoQS, wtiioh 
bleed extrrmoly caaUy. Tliey nr© »ur- 
rDnndcd by tUin blue contracU>d Bkin* 

The pui u plentiful, thin, and irribk^ 
ing. 

A probo flnda tho diocoaed boao-«ir> 
face vritb ditOcalty on account of tbo 
niDdingn uf the sinus. Tlio (ntTfa« U 
rough, sUgbtly yielding, not brittlt'. 
thdugb pMta give way— it giTCi on idea 
of ftuftztcfla. 



Symptom* o/" Necrotis. 

Wbvn pus fonas in the noft partH, 
Bitd tuuri! particulArly when it boa been 
lul out, the symptonu dimioiub. 

The riniues axe crovncHl by florid, 
but cot brilLinnt, ^raniilatioua, wtiiob 
do act Meed with extreme coac. Tbcy 
we fluroottded by nonual or sUgbtly 
altered flktn.* 

The pna ia uot loiga in qtunfity. aod 
ia in gcuonil ncorly Uudttblu. 

A probo pAdBod nloog a dmu to dc- 
crutic boiii) liudji the pMMgo tob-'rublv 
atraiglit aiul siiupltf. The bone U Itanl, 
Imttle, numotimcN movablo. Ofltui ouu 
may fihel the probe paw through a unu- 
oua opening (cloaca) in boue boforo it 
comet) to the dead portiao. 

Sni'h are the distiDgiiisluiig marks as for merely as the 
symptoms rolating to the bone disease are conoemed. Tho 
actions induced in the joint are also very different. 

Necrosis euffieiently near to implicate the joint> produces, 
when inflammation is set up, a more rapid action, with fluid 
effusion into tlie cavity ; tlie osseous swelling reaches however a 
higher point before such action commences. The articulation 
is moveable without pain, the muscular spasms form a haidly 
prominent part, of the disease, and permanent contraction of 
tbe flexors ranily takes place to any marked degree, until tho 
synovial membrane lias actually become affected. 

The carious disease lias on the contrary brought the joint into 
Uie following condition. The swelling is due to two causes, 
thickening of the subsynovial tissues, and of the deep fibrous 

health, win canoe tiie granulntions to 



* The mouth of n ^ua leadlDg to a 
necrotio boue puta on a for worse ap- 
peannoe when the aeiinGetnini, having 
beootne tooae. begins to pro* for exit 
against Uio soft porta, tho f^nulatioua 
then become criiuson, ami tho di^churF^ 
tliin. Even a droudng whiob cnnfluea 
the matter, or a paaamg ill atato of 



put on a worau opponxance for a time. 
Tlie bad appuonutce of tho ainosoa 
leuding to eari^ never changca till the 
dineoso begina to sret woU. Stromeyor 
' * iiiimlbucb dor Obirurgio*) nmkva n 
atDiitsr obaemition. 



254 



BTRUM0U8 ARTICULAR OSTEITIS. 



Chap. XI. 



toxturcB around the bone ; it is liardly at all due to efiiision 
into the joint cavity. It is soft, and more or less pulpy through- 
out, but it liaa a foundation of very considerable hardness over 
the diseased bone, whore the tumefaction is most marked. Tlie 
anatomical osseous points project abuornmlly, and the bone is 
tender on pressure. The swelling is white, the skin looking 
sodden and unwholesome, and it is marknd by the moutliH of 
Hinused, whence pout floi-id, crimson granulations, bleeding with the 
least toucli, and secreting thin acrid pus ; the limb is firmly con- 
tracted, the joint more completely and rigidly flexed, than in any 
other disease. The patient is pale, worn, anxious, and any 
attempt at movement is dreaded in an extreme degree. Some 
of the symptoms, as those ha>'ing reference to the shape of the 
swelling, are modilied by the sort of joint bones, in which the 
disease occurs ; thus in the carpus and tarsus no snch strong 
demarcation, can be felt, the tumefaction is more general, and 
much effusion into, and thickening of, the tcmdinous sheathes 
occur. Again, at the tarsus, if the lower and anterior part of 
tlie astragalus, or the other component bones be affected, it is 
not so easy clearly to define the original louility of the swelling, 
the whole foot becoming thick, clumsy and puffy, from great 
alteration of the tendinous sheathes of the other Ebrous structures, 
so abundant in this position. When sinuses liavc fonneil, their 
position, and the direction in which a probe strikes on diseased 
bono, must guide the surgeon in forming an opinion as to the 
locality of the disease. Kven in this stage accurate diagnosis 
is not always easy, and it must be remembered that, bt>th at the 
wrist and instep, one of the small bones will not long continue 
ulcerating without involTing others. 

The muscular spasm which plays so important a part in this 

.disease, sometimes produces dislocation, as has been already 

pftinted out (See p. 244.) It is unnecessary to ent^r into the 

symptoms of spontaneous luxation ; every surgeon will recognise 

such as soon as ho sees it. 

Dislocation, however, although an occasional accomponiment 
of the disease, is neither a constant nor necessary result of 
articular caries ; when it does occur the symptoms very much 
abate, and the patient recovers (if recovery it may be called) 
with a distorted and probably a usoless limb. If the diseoKp 



Cbap. XI. 



ABSCKSS AMONG THE MUSCLES. 



255 



oontinuo to get worse, whether di^tlocation have or have not 
t)ccurred, the j»iu and sleeplessness^ increase, hectic is set up, 
and the body becomea frightfully thin. Abscesses form 
one after another, at first in Ihn neiglibourhood of, afterwards 
further and further away from the joint, and among the deep 
muscles ; the {Mriostenm of the shaft itself becomes swollen and 
way be felt through the mnsclcs in that condition. At lawt, 
exhausted by dischai^o, pain, &c., the patient sinks and dies, 
unless the disease be removed by the knife. 

Sometimes, thouj^fh rarely, the malady becomes checked rather 
suddenly. Wlien the symptoms ap|>ear all tending to the worst 
termination, some increase of constitutional vigour may give 
hopes, which a subsequent visit may increase until the surgeon 
becomes justified in forming a more Cavoujable prt^osis than 
he could have done shortly before. The first eigii of this im- 
provement hi amelioration in the general health, diminution of 
the painful starting of the limb, better sleep at night, and return 
of appetite. The local signs are, gradual decrease in the swell- 
iug in the limb and of tenderness over the bone, decrease of dis- 
charge and improvement in its quality, gradual diminution of 
the ubsceascs among the muscles and closure of the sinuses 
without opening of any others, accompanied by return of the 
tissues to their firmness and normal resiliency. It is sometimes 
curious to observe how the mouths of the sinuses close in regular 
order, beginning at the one farthest from, and gradually ap- 
proaching nearer and nearer to the discaso. 



Treatment. 

Fir$t Stage, — In no malady is the command vem'ente ntccuriU 
morho more advantageously obeyed than in this. If the jMiticnt 
come nnder judicious treatment in the earlier stage of the disease, 
wliile yet the svinpttmis are those descrifn^d in the beginning of 
the second division of this chapter, he should have a very fair 
chance indee<l of being cured. If he have been neglected, and 
only have recourse to treatment when the second stage has 
commenced, he will certainly have to undoigo a very long and 
painful illness, and will be likely to recover with a permanently 
injured joint, or be obliged to undergo a surgical operation, 
or porliaps he may uover got well at all. 



256 



STRUMOUS ARTICUIiAn OSTEmS. 



Cbap. J.\. 



Sir B. Brodie, from whom no writer of the present day wonld 
willingly diflTer on tho subject of joint disease^ has discussed the 
Buhjept of treatment too gonemlly, and his remarks refer, I 
belio?e, to a further advanced period than the early one, 
now under onr congideratioQ. The earliest condition (marked 
by mere pain, reluctance or inability to move tlie joint, and 
Bomo not easily j>erceptibIo swelling, while yet there is no 
miificnlar eposm or starting pains at night) shoidd, in all but the 
most feeble constitntions, bo treated. I am quite sure, more 
actively than he has advised. Two clasBea of cases come under 
our notice — the one very chronic, the other less so; either 
may ck'cut in delicate and puto, or in fut and florid, children. 
Such circumstances muke a difference in the kind, but scarcely in 
the vigor of the treatment (o be adopted. At p, 120, two forms 
of struma were described ; at p. 139, tlie treatment best adapted 
to each. Now, although either strumous state may light 
up an inflammation in any tissue of tlic body, the slow, long- 
pending osteitis belongs especially to the coarse clumsy condition 
of struma, as a deep sluggish ulceration of the comcn, with 
congestion of neighbouring parts, is an accompaniment of tlial 
form of the disease. But inllammation of an cpiphysismay also be 
developed by the struma with fine connective tissues, yet such 
disease is more rare, more active, getting either well or worse 
more quickly. It is comparable to the superficial, rather 
ephemeral and non-congestive inflammation of the cornea, 
which leaves a thin but expanded nebula on the surface. 
Let us take our example of treatment from what we see 
of its elTccts on the eyes. The patient comes with the eyes 
watering and discharging a thick Meibomian secretion, holding 
down his head, and dreading light beyond everything. A brisk 
bnt not drastic purge with mercury is atlministercd, and when it 
has acted and brought away the thick mucus that hangs about 
the lining of the intestine, he is able to look at the light without 
much difhculty, and the brunt of the disease is luissed. It has been 
my fate to see cases, that had hung about for weeks, and whoso 
treatment had been judicious, except that from want of a clear 
intestinal surface medicines could not bo absorbed. Such a 
purge has been always productive of benefit^ and allowed the 
medicines, perhaps the same as were previonsly useless, to have 



Chaj*. XI. 



KAULY TRKATMEXT BY MERCUIIY. 



257 



their proper effect If, llien, a child bo brought to the surgeon 
with the early symptoms of articnUr osteitis, if he be gross, 
somewhat Cfwrsrly moulded, and have llu' disoolorations of 
rtUin described nt p. 121, ho slionhl Ik* trentcd by an immo- 
diAtc pTirge containiug^ merciin.', which is to be repeated if 
necesaary. 

Tliis simple means, though strongly insisted upon, is not in- 
tended to bo held np as a cure of early osteitis; it is the mere 
initiative. 5tuch has been said apiinst the administration of 
mercury in strumous disease: prol>ably the wholesale condemna- 
tion of the medicine is intended only to apply to its use when 
pushed far iMiou^h to tonoh the gums. Let me u^ain il1uNtriit4t 
tho applicability of the remedy by referring to stnirnuus 
ophthalmia in a later stage than when it wiis before uiiKMi as an 
example — when the cornea hiis begun to be didl in one or more 
spots ; beginninnr in fiict to ulcerate. I have seen trt'ate<l, and 
formerly have myself treattHl such cases, with iodide of potjiss, 
cod-liver oil, iron, quinine, and other tonic mid antistrumons 
remedies witJiout avail ; then, by the administration of a few very 
mild mereurials, huv<^ stopped the t<.'ndency to ulceration, or 
have healed ulcers already produced. In the same way as btaore 
we may apply the remedy found useful for serofultiuu intlumma- 
tion in one place to the same <li8ea8e in another. Hie prescription 
which I generally use in this form of epiphvsal inflammation is 
one grain, or, for strong children, two grains of grey powder, with 
one grain of (piiuiue, night and munung: :JUch a dose I etmtiiiui' 
during two, three, or even four days, then give the quinine 
atone at tlie same intervals. The mercur}' should never be 
pushed beyond a slight alterative efi'ect, and is iml to be repeated 
unless the skin and eyes again become muddy and thick in hue. 
Very many early inflammations of a joint-end in tills pHrti(>ular 
constitution come under my care iu the coui'se of the year, and 
I have no hesitation in reeommeudiug tlie above mode of treat- 
ment as eapaltlf (combined of course with suitablif Iih'uI means) 
of checking; tin- diseased action in a large number of instances. 

Strumous persons, with thhi skin, clear bright complexion, 
and finely-cut features, are not l>eneiited by mercury, even in 
sbght alterative doses ; neither is a purge, as above described, 
required so constantly, a*; iu the course-conditioned strimm, and 

H 



258 



bTSCMOUS ABTICULAK iWIVmA. 



Qw. XI. 



mcli nmedf mast be of a wxHrntatm^ Aemextftia^ Ombs 
in which ft booe mfiftmmatiaii ta d«rTdopediatlie<ie)ieftte-fcnBpd 
atnunsare mariced bj ft higher liegtee cf pallor ftad 6M3Sty 
ihan it prawot in ftnj odier fcrm of cnmmwnriag acnAdooB 
diieaae— except perhaps, ia a rapid speciea of phthiaii. The 
inflftaaronti'^/n itsnif is leaa chiociic' in cjoalitTt and tendi to pas 
man qu'wkiy inti^ mpparation than the sloggiah inflammalioa 
of the othor form of stnunooa d iac a ac. The local treatseat 
sh«Hild ^>e more decidedly and actxrelr conntfr-uTit&at, but aa 
litUu detiliti&lin^ aa poanble ; e. g. blist«ra alkived to lu?al at onpe, 
am) repeated on varioos parts in the neigfabonrbood of the 
dsaeaae, or tho actoal cauterj ; while all snch rcmediea as iasnea 
or aotona, that keep ap a coutinaons aod debilitating diicfaarge, 
are inadmiasiblc. Of cod-liver oil, qninine, and steel we net^ 
not Kppok more espocially h»re. Their great ralne in this form 
of fttntmouB <liMeaiM was pointed oat at p. 135. 

Iiriliiic simple, or combined with potassium, and its action on 
Htrniiia, wer« disciwaed in the Utter part of Chapter V, : we need 
only ol)serve on the present occamon, that it is reputed to bare 
a powerful effect on osteal iiiflammatioos ; but my obserration 
leodii me to conclude tliat its action is more beneBcial in thoee 
kmDB that lead to tlie profluction of nffw bone, than in those which 
tend to necrosis or rapid caries ; and the results of some cases 
that hare come under my notice seem to show that its odmini^ 
trationhas increased thn tendency to suppuration; at all events 
it is not adapted to coses of this latter kind of fitnimous disease. 
Many persrjns have, on theoretical chemical grounds, been 
Icinptcd to reeoninienil the administration of some remedy 
4'iintainiug uii osseous tronstitunnt, or coiigtitnents. Phos- 
phoric acid, lime-water, hyiKiphoephitc of lime, have been thus 
advised. My experience of the first is, that it acts like any 
mild mineral acid; of the second, that it disorders the stomach 
u'itliout prrHliicitig any eHect on the bones: and of the last, 
that it has no influence on the system or malady whatever. 

I^ocjilly, tlie first an^ moHt important indication is the main- 
tenance of entire rest. Heynnd this lirodie condemns all local 
troivtmcnt as positively injurious, and more especially the 
repeated application of leeches; whih^ Stromcyer* says, that in 

* ' Ilnriilliucli iIlt Cliirur^<-,' p. 490. 



Ckap. XI. CONDITION BKSKFITED BT BLOOD. LETOXG. 259 

all but lenco-pliIcg:matic nearly chloroli(% oluldren their use, if 
frequently repeated, is very great; and ho adds — ^*' Until 1 
became a hospital sm^^oju, I mys<^.lf had Imt a small opinion of 
thc-ir valnc in scrofulous joint-disease ; but afterwards I became 
persuaded of their u»e." In my experience only one cam has 
occurred in which I deemed it advisahle to apply leechea. On 
that occasion T ordci'ml three, and the effects were bfucficial. 
Tlio inHamination followed a fall, and was rather mure acute 
than in the generality of cases. But the truth is, that Biwlie 
and Stromeyer differ because they do not aufficientJy define the 
particular cases of which they speak. In the very chronic 
malady, when the joint^end is not tender nor hot, iu fact only 
snfters those symptoms wluch indicate congestion, all local 
treatment beyond rest is injurious. Sucli cases depend on eon- 
stitutioual eauses : iu all probability every one of tlie joint-ends 
will be lar^% and tlie one which a]»pears painful is only a little 
differently circumstanced to the others. Fresh air, sea bathinju: if 
possible, good food — in fact, tlie best bygienic treatment and 
tonic regimen, afford the greatest probability of cure. Any irri- 
tation to a part thus circumstanced ixiuld only tend to change 
the congestion into an inflammation. The limb must be kept 
at rest, and this in a manner, if the nature of the joint allow, 
that does not altogether preclude exercise — and certainly not 
fresh air. If any local treatment at all beyond tliia be used, it 
should be soothing and tonic I have seen Itenefit from a cold 
douche after the ordinary ablutions of cliildliood had been 
finished ; but to debilitate by the abstraction of blood, to 
irritate the part, not as yet inflamed, by blisti^rs, &c., is decidedly 
Injiu'ious. 

But on the other hand, there are not a few cases in which a 
quickly growing child acquires from some accident or undis- 
covered cause, inflammation of an epiphysis, which is much more 
decided and rapid. In such cases, the part, if superficial, will bo 
tender and hot, the sjTiiptoms in fact mark im active state, and 
require a more decided plan of treatment than the above ; per- 
fect r«6t by means of a splint must be secured, and counter- 
irritation at some distance from the inflamed part be used The 
form of countcrirritant must depend nn the patient's age, strength, 
and irritability : a blister, the liquor vcsicaforius, or other prepa- 

a 2 



STRUMOUS AilTICULAR OSTEITIS. 



obak xr. 



rations of the Spanish fly, occasionally prodticn unpleasant effecia 
in very young children ; a repetition of rapid sinapisms is, in snoh 
instanceft, preferable ; sulTicient distanee from the inflamed spot 
is already procured by nature, when tlie joint Wos dt-ep, as tho 
hip or tlie shoulder; but if the attack be at the condyles of the 
femur, the eountor-irritant should be applied above the inner 
condyle, which ia the [Mirt most frcqu^'iitly inflamed; wheu the 
akin has been acted xipon, by whatever irritant tlio surgeon lias em- 
ployed, it is judicious to keep up the action for Bome time, by 
means of a stimulatin;,' liniment or otherwise. It is unaeceeeary 
to mention any particular means oi inflaming the skin, even' 
surgeon who is olive to the resources of his art has n dr^zen such 
at Ids lingers' ends, uudwill take care to adapt the i)ower of his 
remedy to the violence of each case. It is always to bo bomo 
strongly in mind, tliat during the stjige of congestion, or early 
inflammation, it is very genendly |Hjasihle to proeuri* resnlutirm 
without further minchief, but that when once suppuration haa 
begiui, it is barely possible to prevent caries, and moro or lesef^ 
injury to the joint. 

It ia at this time that the diagnosis between oaries, necroaifli 
and central abscess in the bone, becomes so important ; for if the 
surgeon can decide from the sort of pain, tho quality of the ' 
swelling, and the condition of skin over it, that he has to do 
vriih the two last, and not the first, ho may, by prompt interfer- 
ence, save not merely a great di?al of pain, but perha[w the 
joint. It is useless to interfere before the necrosis have formed 
and separated, for even were a good deal of inflamed bone to be 
cut away the action woald not thereby be limited ; bnt as soonoa 
the ap|>eaniiice of surface leads us to conclude the bone loose^ or as 
soon OS an extenial o])euing has formed, it is well, bo tho 
object to find an alwccas or dead bonr,t*i trephine, and to search 
for what has l>een expected. If the necrosis include some of 
tho joint surface, a very rare circumstance, the treatment 
would no doubt, liasten on a suppurative synovitis ; but in u 
large majoiity of instances, the disease only skirts this locality 
which would, however, becomo inTolre<l in the future ului»ration 
and suppuration around the sequestrum. The surgwui, Jwforc 
forcibly tearing away the necrotic imrtion, will carefully examine 
the extent of that part, which nms towards the joint, and adapt 



CHAP.Xr. STARTIXO PAINS AND DIFFrBIBLESl'IMDLANTS. 2«1 



his procedure to the circnnistanccs of the Cflse. When tho 
dist*a.se is an al>scesa in thn hvad of a boue, uo hesitation should 
eaiuc delfty; iw soon as tlie ost'i'al aud [KTiosteul tliickening, 
and the jio^nliar pains which uceompany that malady appear, 
thv tivphiuu Bhcnld bo applied, and tbo nearer thu disease be 
to a joint, the more rapidly and diH:idedly should we act. 

When those pfculiar starting pains ronie on, whieh mark the 
commencement of tlio second stage, the surgeon knows tlmt his 
Mtnif^^le with the disease becomes more serious*, and that his 
utin<>it skill will be needeil to save the joint. These pains, 
wliieh. as already stated, I believe to supervcue wlieu the inilam- 
matiou attacks the bone immediately benejith tlie articular 
lamella, begin by degrees; in the first week nr two of tlioir 
appearauee, they may not form a subject of special complaint, 
and they may not bo jireseut every night, but oidy ocoasioually ; 
they gradually, however, become more seven' Jind constant, 
until tliey are, p<tr excellmee, the great horror of tho disease. 
As these pains iuoreaso in severity, so does the tonic contraction 
of ihe muscles (eliielly flexors) increase in [xtwer, and the mal- 
position of tlie joint become more decided and lixed. Under 
these circnmHtanees, the ]irojier plui^ of treatment is to fight 
against the irritation, and to counteract the muscular contraction. 

Medicinal SedtUitvs are all but useless, I liave given opium 
in a sulhcient dose, and have heard the next day, that the 
]>aticnt slept uo better, and Was not freer from the dreaded 
starting. I have then given a larger dose, and taken the oppor- 
tunity iif seriiig the patient at night. It was not {M)ssii)lc to 
judgi^ of the depth of the sleep during the quiet intervals, but 
the starlings were of the same sort as already de8crilH?d (p. 127), 
I (»hu*e great ixdianee ujkju opium in many foruis of {Jtuuful 
disease; some sui-geons have eontideneu in its action upon the 
pain now under eonsidemtion, but among the multitude of eases 
in which I Imve u»c<i it and seen it used, not one lias gi\en me auv 
belief in its eflicacy. Indeed, were it here affirmed that tho drug 
inereaswl s]»a.si)iodie shirtiDgs, ihc statement would have great 
support from uimlogy, and Kuoh .in idea has certainly not been 

• Irfl md again wurti Uio ■Uoiidniil i my ilfKciiplioiu uTI Hint liiu particular 

iigRiiutt plui-iiiu iMiiiitlriKH' in a ntir&t-'s rffintifc tu tlir )iip. to wliuw ili!t«iis<>a 

ri'iK'H. « illn'iil diiljnlinc hir to 5lrii'( it BptriiU *'lui|iU r i*. ilrvoli il. 
cro«fi!xainiii;iti>Hi. I tuivo cxuludoii fruni 



202 



STRirMOUS ARTICULAR OSTEITIS. 



Cbat. XT. 



contradicted by tho action of such remedy in any one case 
that bas come nnder my notice- HyofKyamns \» for too feeble 
tu ut't agaiu»t so violent a symptom ; the same may be said of 
couium. The Tincture of Sumbul, as prepared by Messra. 
Havory and Jloore, seems to me more efficacious, but the whole 
dafis uf remediee is not to be relied on for thiH [>arttcular 
objects Much more faith may be placed in a difTiisible stimulant 
given at night Sulphuric aitber, compound (Spirits uf sulphuric 
lether, chloroform dissolved in alcohol, are all valubble ; ft 
pleasanter and perha[»i quite as elKcacious a moans, is a little 
sodded port or sherry, and tliese in my experience have done more 
guod tban tiedativett; but if the latter medicines are to be 
ndministeredf they should bo condjlncd with the stimulant. 
During this period of the disease, tonics should be of tho 
bfematic character, such as quinine, iron mineral, acids, bitten, 
rather tliau of the nutritive fonu as cod-liver oil, sarsaparillo, &c ; 
but if t]ie patient Im losing flesh rather rapidly, then the oil may 
be advantageously combined with tliem. 

T/te Local Meant of subduing the s]msmodic startings arc 
several. When these pains set in, the patient is usually treated 
with some mure powerful eounter-irriUuit, than tliose which have 
been at present advised, namely by caustic, or perhaps by the 
actual cautery, and nearly always with the effect of subduing 
the pain. It does not apparently matter what caustic be used to 
destroy the skin, as far as this one oflect is eoucfrned ; but tlio 
hot iron acts most decidedly. After any application which causes 
destruction 4)f the skin to the size of a fouri>enny-piece or upwardsj 
the starting pains, and the vague but distressing sensations along 
tlie shaft of the bone, will very much diminish or cease altogether. 
But let us not be blinded by this apparently great step: before 
the sore thus mode cjin Iw healed, the pain will return, some- 
times with less violence than before, eometimes with even 
greater. Unfijrlunately. we liave no power of looking into the 
joint, and fiiuling out whether the disease stood still during the 
absence of paiu ; but we see cases rim their com-se from end to 
end under the constant application of issues, and the occasional 
use of setons, so that thr ftkin action and the Itono ac4.ion are not 
iiirfiin|HiHble. Wiintlier or not any treatment has the power 
ni' I'lii'ckiiig St) sh>w iin uctiott as eari'^s is a point so dinindt of 



Chap. XI. 



SMALL VALUE OF EXUT0niE8. 



263 



proof, that one onght to be very circumspect in reiiising uU 
credit to a remedy which has been trusted in by some of a«r 
best mu-geons. ytill 1 must coufeas ^reat scepticism in the 
valuo oi' such means in this disease. When tlie starting pains 
finst commence, that is, according to our belief, wlien the bone 
eauceUi underlying the joint surface first become inflamed, such 
appliciition may he of avail ; a ease was thus treated by myself, 
whicli would apparently have gone on to carits, had not the 
cautery been used. On the other hand, there are a great many 
cases which have been thus tr^-ated even very early, and yet 
iiave run on to ulceration, &e. It is therefore viry doubtful, 
whether such treatment does any good even in the earliest \ieiTtot 
the second stage ; and under such circumstances, if the patit.ui 
be in pretty good health, 1 would give him the bemdit of the 
doubt; but issues should ucver exclude other treatment, nor 
should so blind a reliance be placed on their value that one 
after another bo opened, while the patient loses strengtli, a]ti>e- 
tite, and sleep. 

There is no doubt, however, about this remedy later on, in the 
second or in the third stage. When tlie starting pains have 
lasted some time, when the {uitient is worn, and shows marks 
of debility, when the face becomes expressive of suflering, the 
use of caustic, even of the far more painless cautery iri>n, is not 
advisable. Such applications are made, we know, very frequently, 
and will always be tempting, because their tirst effect is to quel) the 
starting pains; but they return at this time much more quickly 
than at the first part of this stage. If, in the beginning, we could 
subdue tlie s^Mums by these means for a week or a fortnight, 
we can at tlu) latter end hardly stave tlicm off over two or three 
uightf>; they will, in fact, begin to return Ijefore the slough has 
separated, and then the treatment will have added an open sore 
to the other cjuist's 4jf debility and irritation.' The application 
wJifMi pus is formed in the soft pjirts is to bo still further de|ire- 
cated. Our i«Uient is by that time in a sufficiently weak and 
irrituhlo conditiun to ren<ier such means worse than useless. 

By denying all but a small value to exu(4>rie.<i, tind allowing 
that value only in the earlii-r stages, we do not affirm that there 



* TIiu wliulo [jf Uiuac rt-tiiiulu uro strictly liniiti-d \v cnm-a ws 
o(UH! of ■ jiiiiit liotie. 



prtmory (lis> 



204 



STRUMOUS ARTICULAR OSTEITIS. 



I'UAI-. XI. 



is alwolutely nuthing to be done in these casee. The truth is, 
tiiat it is doubtful vrhethiT, eiciijit in very few inRtanccs. we 
ever can cure a chronic diseuso: nil thiit we can ilu is to put the 
patient in the bfst (^totstjiblf [vueitiou for getting well ; or, in other 
words, remove as mucli as possible tlie tnvrbi causa. We oaunot, 
ill tin- prosf'ut iii8tAuc(% rapidly romovo the en use of the disease — 
it lies deep rooted in the original coust!tnti<in ; but we may ronove 
the eoiulition which kee{m up and aggravates the morbid irritation 
and which, while rontiiiuiiig, prevents any real improvement. 
These conditions are, as we liave seen, the continuous pressure 
which the muscular tension causes one bone to exert on the 
other, the deformity and forced position thereby produced, and the 
short sudden ujmsms, wliich seem also \a\ originate in tlmt pressure. 
The first treatment necessary for tliis cvmdititm \» Xa \\wm and 
keep the limb in a proper position (the proper posture for eacli 
jitiut has already been discuj^sed, p. 143), and if the ease Imve 
come under skilled treatment &o lalt! tliat a fiiW |KjidiLre have 
already been iLssimicd and maintained, it will be necessary to 
I'liange it for the true one. This may bt- done suddenly, and by 
lonre, while the patient is under chloroform — the contructions 
being stretched, and giving way; or it may be effected, also 
under cldoroforni, with sulfcutaneous Hection of all those tendons 
which oppose the change of jxjstuiv. Again, the stretching may 
be brought about by degrees, either witlx or without setttion of 
the muscles. It is olYeu Hst<)ni:jhiiig to fhid how much this mere 
change alleviates pniii, if tlie right means have been used ; but 
if the wrong ones have lK>eu practised, tlie stretching of the 
muucles and filiroiis Htrurtores |)nidueea viulent sjuism and cou- 
iraclion, to wliich tlie splint jirevents the limb yielding, and 
which pniducey intolerable pahi. In such cases there is no 
duubt but that the tuntlons ought to have been divided ; and 
even after the limb have been straightened, division of all the 
llexors (si.>nietiines of ono or more other muscles) subdues at 
once tlie consequent {tain. XevcrthclcRS, tliere is no doubt that 
we ought to choose our cases for either measure so fairly, that we 
neither use mere force, tuid bo subsequently obliged by the 
patient's sufferings to liividc the Umdons, nor, on tlie other 
hand, ought wo to cut unnecessanly a single muscle. The 
success, then, in our choice of means will dej>t'ud on careful 



CiiAr. XI. METHOPS OF 8ECUR1KG PROPER POSITION. 205 



judpnent of the wiwlition of the parts. If the contraction of 
tUe muscles have cciisod to bo ac'tivu, but hav« become passive 
uoQtraciure, not sufficient to eanse much deformity by flexion, we 
neeil uot divide the tendons* When the contniction is active, 
the inuiieUvi will only Iwar very slight stretching wilhuut pro- 
ducing great pain, iind tliis condition uiust lie judged hy tlie 
sensation which the flexor side of the Umb ofters to the touch. 
Very little practice will i-imbli; the hand to distinguish pretty 
jieuuratrly between the corky sensation of n contracted and the 
cordy one oi aconti-actiired lausclo. However, more weight may 
bo laid upon tlie amount of the olooic spasms : when thtve are 
present to a distressing extent, it is unwise suddenly to alter 
the jiosition of the limb, save to a very small extent, witliout 
dividing the opposing tendon or tendons. I have seen this done, 
and formerly have, on one or two occasions, done it myself; but 
will not again, unless under ver)" [Kseuliar antl exceptional cir- 
cunistaoces, quickly straighten n joint without tenotomy while 
active spasm continues. When the limb has been placed iu a 
proper [xisition, and opposing tendons divided, the sharp starting 
pains ceusa nearly or altogether, and no local treatment beyond a 
well-adapte<l splint is necessary- 
Many cases como under notice in a condition when it is not 
advi»ible to have recourse to sudden alteration of ptwition* 
8uch are the earlier stJiges, while yet the deformity of limb and 
rigidity of muscle are small ; or later stages, in which, owing to 
treittmcut, the deformity may be slight, but the muscle is i>as- 
siviily contiuctured, and starting |Miiiia form uo very prominent 
symptom. In such casi^s a spUut, adapted with a sc*rew, orutlier 
means of tension, may be applied, an<l a grmUial system of 
straightening nmy lie iwloptud. Tliis may fail, however, in cer- 
tain instances, by hgliting up a return of clonic 8i>asm, 'or pro- 
ducing great pain, even some inflammation of the joint ; it is 
then mlvisable to leave oft' tlio splint, and to have recourse 
to the more rapid means of overcoming raal-jHjaition. Another 
splint, presently to be described, wherein india-rubU^r springs 



• Tlio term " much <loformity " in rho 
li-xl ift n-Iutivo — itM vdIik; ixioiiistfl iit tl\e 
»ytA- of Ili« ati^It' tliioiigli witicli W1-- 
iniiHl ilruw liir liiiil) ill onlur to get it 

inlt) thii (Iiidirt'd (Hwiltuii. In niiMtt in- ' «tiftt'li it viiUi iui|iiiuih'. 
M«nv««, whctt thi>t \m nlMtuI, ot leu tlnut. 



UaJf n rij;Iit (ingl.,-, or 23-, we wuiilil (ay 
Uiu <k-t(iniiity i» uul t;rcut; Imt it mn«t 
\m rfuiemlKii-il ilwt Uu' lunger titc 
uiiiscic Uii^ ^reiik'r ilmtancc nifty w« 



266 



8TBUM0U8 ARTICULAR OSTEITIS. 



CHAP. XI. 



r^ 



form the active extendinf; force, may, in such cases, be need vitb 
advantage. It is better thajt the screw spliiita, bocause the 
power is a cx>tist«nt and cquuMo qimiitity, while that of the 
screw IB a quautity which increases by sudden and uncqaal 
inc-remeota. 

If the joint have been straightened with the help of tenotomy, 
littlfi more, as uJrearly has been rtoid is ncrcseary to sabdao these 
pains ; but if it have been tliouglit advisable not to divide any ten- 
dons, or if tlie case have been seen before any deformity has gome ' 
on, other means may bo adopted to overcome the sliarp .stflrting i 
pains, and with them tliat action, whereby they are ncooni|>auied, 
rapid ulevmlif>n of buue. It has been said that these are greatly 
aggravated by, and at last probably alt<^^ether dependent ujKtn. 
tho pressmti of one bone on another, increased I)y the muscular 
contraction. To coimteract such force I have invented a form of 
splint, and find much advantage in its use. The principle of its con- 
struction is tu make a strong india-rubber s{>ring, 
or uccumnlator, act as both extending and comi- 
ter-exteiiding force. For this purpose it is fas- 
tened by each end to a piece of eatgnt that pla}-6 
round pulleys, at tut*hed to either end of the splint. 
I will describe particularly the arrangement f<ir 
the knee. A long Desnnlt's splint is furnished 
at its upper f«irt with a loop of strong wire, 
or of steel (a), wliieh carries a small pulley, 
and which projerta outwards about an inch 
uud a half Tlie lower part is provided with a 
bar running across the space of the notch, and 
also carrying a pulley (d). Fmm the lower 
end of the splint^ projecting inwards an inch 
or an inch nu<! a hidf, is another loop, carry- 
ing a third [luUey (e). A iwrina'al band (h), 
jiassing round the upjK'r part of the liml) and 
spUnt, has a piece of rather thin calgut (violin 
string A or />) attached to it, wliich going 
tlirough tlie upper loop of wire runs round the 
pulley (a), is brought down on the outside of 
the Bjilint, iind is attached to one end of the 
india-rubber accumulator (c). Komid the foot and ankle aro 
fastenoii two pieecH of webbing (f), which lat^-i* over the in8te|), 




Cbap. XI. 



VALUE OF EXTENDING FORCE. 



267 



Biul to both BiJi'S of wlijcli is sewn tdpe, forming ft loop below thfl 
sole of tbo foot* This tape nllbrds uttachnu'iit to unolhtr pieco 
of t'tttgut, which plays over the piiUoys, in the lower part of the 
apliut (e and D), and is tied to the other end of ihe owjumulator 
(o), with the lilting anioiml of tension. 

This splint may, by fitting modificjitioni^ very easily applied, 
bo adapted to any joint,t It is very useful when it is desired to 
produce* grtidual extension of a joint, an of the kueo ; or, when 
properly adapted, of any other articulation. The ordinary plan 
of attaching a weight to the end of the foot, for extension, and 
fastening the patieut by cords to the upjjer part of the bed for 
counter-exteiuiion, does not answer, as it produces such wcari- 
nese, that no person can Iwar the constraint long enough to 
allow of much benefit. This rao<Ie, of getting extension and 
counter-extension on the spUnt itself, confines nothing but the 
joint, and even that to as slight a degree as may be desirable ; 
for instance, in the case of a sliglitly bent knee, it is not absolutely 
necessary to bandage the apparatus to the limb — the force of the 
spring keeps it sufficiently in place. It Is important only that the 
anklet and pennJi^al liand slunild bo duly jwddcdand kejit dean. 

Besides the mere power of stmighteiiing a l:>ent joint (nidy a 
secondary nse of the s^ilint, and not that for which it was invented), 
the india-rubber spring counteracts that force, which presses the 
bonus too violently together, thereby producing the spoein, 
keeping up the initatiou and the caries. I have se<tn the most 
violent pains yield gradually to this contractile force: it apj^eafw 
by its unvarying, constant, and yet not unyielding power, to 
tire out the muscles, to ovcrcomo their spasm, and to keep tho 

* A Itnxul wi;ll-[Kidilw] katlur ctnip 
going roniiil llii' iiiilck> i* nd [;(hhI, iinil 
stnippitig plaiHter, na iluwrnbt!!) m 
Cluiptvr XIV., it* livltiTr ttiiui uither. 
A Tvw littlL' oDiilrivajiiit-ii will Ih.' Aiuutl 
ti> liii] in Uii! ciim^ wirli wliirli l}ii< up- 
jKimtm iiuiy l>i' iiilitpu-il. Fur iiintiuiiTt>, 
t:xtriufum iicf'tl not bo nifuki nii the 
IK-riitiotl 8triit> wlii'ii Lliu ajtliiit 'm tiiiiii]- 
ugL-iI uti till) hiiib : but Ih** »r?riimiiliitnr 
limy bf< liv-d Uitliu upjHtr purt of the 
wuoilrii sfititit. Tliira will \w Huinutt;n- ' 
tlcii(-y to rkli> iipwiir<Iuiriiig tu UmntoUt) 
ill wliirli tbo catgut puwi'H ruuuU Uiv ' 
biwir piiUi-y ; Iu'Ik-d iUo- |veriiiiuil Uidi) 
tilHmlti Im) r)itit>itu><l tn thnuplinl, mill llii> 
tviudot) nti ft will \k Tcry Hliiftit (Stfi' 



Uhapl<T Xr\'.) It wiil bo ffniid con- 
venient io haw the ttccrumnlatur nviir 
Uio upiMiT port of the fiplint, am] to 
f/iiitun to the lower cfttj^Ttit a pifCK of 
tAjH! which can bu rpudilj tiitl utvd an- 
lii-il fmiii tht< ring in Ihu iiHliti-nibU-r. 
This bi'iiig a lrriitf.-M' upon a ajitniul 
nubjt-t't, tlio Hutb<:ir tins no rij;ht lu turn 
l» aiiiitbtr, hill Uv nuint point out the 
vulno of thiif cxti'Tuiiiij^ forte iii fractured 
itt tlib iip]>vr pnrl of the tbich. lit ciiriea 
ufthr vi-rtrbm tatnc otodincntion of it 
tuny bo found UKofiil. 

t A Hpocitt) ih-nttiptii'in of it* fonu, lu 
api>)iriilik- t<» liip-j«iiit iliMtiM', is pvuii 
in the t-hnpl<.-rili-vi)tt<l t^ttlml ■iiltjvct. 



2(i8 



STRUMOUS ARTICULAR OSTEi'JlS. 



CaAP. XI. 



juinl BHrfoces, if not oeuuder, elill not preeging tt^lbor. It is, 
however, ue<:esHnry tliiit all liie strajw uni] bauds Ik- padded, and 
fitted with tlie iiicest care. 

'J'hesf? inonris, as for as my experience of them reaches, do not 
fttil in sutxhiing to ft great extent, or altogether, the dtstrcsb-ing 
starting pains, which so wear the piitieut with anxiety and fileej>- 
lessuetjs ; but there is anotlier more powerful and more heroic 
uieth4}d, namely, to cut through the tendons of the contracting 
muscles. This plan is adopted by Dr. Bauer of Brooklyn, New 
York, for cases of hip-joint disease, and he gives the most 
favourable report of its ellicacy. It has been objected to such 
treatment, that when the tendons reunite, the same set of 
s}'mptnms must reinir; but it should be recollected that tho 
muscles arc lengthened by this means, and would not therefore 
act with such power, nud that any extending force can be used 
with the greater enicacy. I have never jjcrfiinued tenotomy for 
the purpose o( preventing the starting jwiins, wlien the limb htw 
been quite straight, but have dono so to relieve them, when 
produced by fnrciblo exttmsiou, with the greatest advantage. 
There does not exist any valid objectinn to the operation, and if 
tho mei-e applieation of an extending foree docs not produce the 
desimd result, I, having seen tenotomy relieve starting piiiiiH, 
should not hesitate to use such means, since uo discoverable evil 
follows tho operation. 

Thcsi? remttdies a ud appliances are applicable to the second and 
tliird stage of the disease, but iu this latter, there comes on 
another symptom which indeed marks its destruetive course ; 
namely, formation and bunxnving of abscess in the periarticular 
tissues, and among the muscles of the limb. No titatment what- 
ever, is the best treatment of these abscesses; to open them is a 
very great error ; such interference always produces aggravation 
of all the syniptoms; this result, iudetd, follows their bursting, 
hence evjffy treatment that might haj>t4--n Hu<h rvmt is to b<; 
avoided ; neither poidtices, pressure, iodine, nor other application 
is useful, but ratlier the reverso. All that art can do to elTect a 
cure is. as bcfiire said, to place tiie limb in the best [wssiblo jxisi- 
tion for getting well ; to cnunteract^ by one or more of the me- 
thods laid down, tho mcrbitl miisenlnr contnit-tioiis ; iiiiH to giip- 
|)ort by all mi-ansinoiir |kiwit tbugcneml hraltb nl' Ou* jmlient. 



Chap. XI. 



EFFECTS OF TENOTOMY. 



2fi0 



All the best App]icnti<in of thn tugheBt art will sometimes how- 
ever fail, and if the surgeon's nfiVtrts be unable to cnrft the joint, 
thf>y loimt be ultimately directftl to save liPp, and some t»pera- 
tion for the removal of the disease mu»t be itsw^rtod to. These 
form the siibjwt of a sjK'cial chapter, and the reasons weighing 
for and against each aro fully given. 

Casib of this Diseask. 

Cask L.— William Butcher, aged 23, from Alfonl, near Ouit.lford, came 
into the Charing-Cross Hoepita] l.'tth March, ISfiO. with diseaae of the 
right wrist. Mr. Hancock, under whose caro the man oamo/kiudly made 
Ibe jiatient over to me. 



/?, 



L>^., 



:x, 



\ 



About ton months ago tha wriat b«oame painful ; be ihinks be spraint-d 
it, and triad pumping on it. At laMt. not being able to work, ho had to go 
to the Union : the medical man lancod the wrist once and applied liu»oed 
poiUtices. Starting pains came on about a mouth after the beginning of the 
disease ; the wriat is much swoUen and ahapeleHs ; the tendinous ahoathcs, 
both at the hack and in front, participate in the strcUing ; the whole 
ia puffy ftn<l doughy, with harder and softer yAris ; the end of the ulna is 
enlarged ; over the back of the metacarpal bones of the index and ring- 
tAhger bvhind, there is u greater tume&ctton, irhicl[ fluctuates; over the 
back of the unciform there is the mouth of a ainus, which atiU wue[>9. 

It was explained to him that there wu little probability of our being 
able to save thu wrist ; but before having reoouriHj to the iant rnHiirt ho 
vriNhcd to have some means tried. H was determined to u»e thu actual 
cautery, though without hope or checking the suppuration then going on 
in the bnnea. Accordingly, under chloroform, throe Unea were drawn with 
the hot iron. 

16th April.— ITio cautery linee are all healed ; but, aa expected, no im- 
provement haf< taken plaoe. 

5tb May. — 1 amputated about (m inch and a half above the wriat-joint, 
and aftbfwardM cicaniined the jiart. 

Eramiiuiiiou. — Tendons of extensors with their sheathw of thumb 
and index healthy ; cuiuniDn extensors matted together by soft tissue and 
suppurating ; an absoosa over commencoment of metacarpal bones of 
index and middle finger, which bail not penubrated through the skin : 
flexor londons also matted together and suppurating; tendons of extensor 
carpi utnaris sound ; i>ertaHteuro over the end of the nlna much ttwollon 



270 



STRUMOUS ARTICULAn OSTEITIS. 



Chap. XI. 



and puff/ ; the boDO its«lf caKous all round, studded witb holes aad little 
osteophytes. All ibu bones of tlic carpus surroundud hy pulpy tissue of 
Bjnovi&l membrane ; vticuliting surface of tho radhu deprived of cnrtilagn, 
rough, carious, and oovered witb pink pulpy tissue (■zraDiiIatiooa). Fmt 
row of Dietacarpal bouos on the aur&co, where tbcy articulate with the 
radius, carious, deprived of eartili^ ; on their oth«r urticulaiiiig fjurfaocA 
[Mirtly deprived of cartilage and carious ; in somo parU tho cartila{;e Ntill 
remaming, was thin and sodden, here and there detached from tlie bone : 
the samilunar and the scaphoid were quite soft, converted into a tloahy 
mAM with thin net-work of bone running through it. Tiie second row of 
hones wore aho earioua, but in a \esut advanoeil condition, mom of the car- 
tila^^e remaiaing than on tba first row ; the cartilage throughout could be 
stripped ufT like thin tough membrane, and left beueaib a pink pulpy 
material (graniilBtinii from the cancelli). 

Mie.roicopie. — 'I'he Kynnvisl inenibrane was oonverted into a stniotiire 
cousistiog entirely of round nucleated cells, bare nuclei, and granules ; the 
tissue ti[>on the Iwnen in the absence of cartilages, also that which uaH 
left when these were stripped away, was procis<ily the same. Tho carti- 
lage itself, thus thitnied, had, for the most part, undergone fatty degenera- 
tion ; tho cells were in some places full of oil globules ; in other ]>art8, and 
these next the free edge, the whole corpuscle was full of oil, the cells 
having, apparently, deUqiiescod ; in other parts of the section the condi- 
tion was one of atrophy, the corpuscle and the cells being very small ; the 
hyaline subetanoe is fibrous wherever tho coll» are fatty. 

The carious bones had tbeir caucelli filled with pulpy grouulatioa 
tissue, and pus ; tho bony walls very plainly laminated ; laounru ouIorgcKl, 
lights full of nucleated cells; canoIiouU large as a rule ; Canada balsam 
penetrated very easily. 

CaB£ LI. — Alice Blackman, aged 6, came to me at the Cboring-Croifs 
Hospital I4tfi Ilecember, If-t*^, with pain of the right knee. 

Tlie only chniigo in form about the joint is that the inner femoral con- 
dyle is somewhat protutiemnt ; ou examining it by touch the tissues over 
that part a-e found thickened : tbc child cries witli pain when the joint is 
niovoil ; more jiai-ticuliirly if it be either bent or straightened beyond a 
certain point, rrossure u|k>u the inner condyle appeared to produce mon> 
poio than equal force exerted on the other. 'iTie child was fat, dark, 
coarse- featured, with swollen hps, red edges to eyelids, and large joint-ends 
to the bones generally ; the left knee, sound, was inclined to bow inwards. 
She was ordered to take a purge of Calomel and Jalap: to have a 
splint nearly straight apphed to the outside of tho thigh and leg ; a blister 
obovo the seat of pain ; to be drensed with tlie Iodide of Potass 
ointment. 

3uth. — The child came back as directed on the Idtlt, and was ordered 
one groin of Quinine with Sulphuric Acid throe times a day. She bos been 
getting better, but to-day the complexion is thick, the breathing short, 
and throat slufl'ed with mitciis ; there scorns, also, more pain in the joint. 
Ordcri'd another purge of Calomel anil Jalap; when its action is over, to 
take tho following, in pill, night and muniiog : — 



Ghap. XI. 



CABEB. 



^, HydtBTgyri c. OrotA .. gr, ij. 

<}uinn! diiuil}ih .. gr- j- 

Mist. AcaciiD .. q. s. M. 

To lei the bluter heal. 

6th Jan., 1B60. — She took the piU* for four days ; is now much better, 
leu heavy, complexion clearer. R«tuni to the Quinint' and Acid ; to [laint 
the in-iide of the joint with tincture of Iodine. 

Feb. 17th. — Tlio child well ; the joint hnn not lieen innomed. 

June 8th. — Alice Blackman fell down etwni and csmu back to tho 
hospital with a cut on the forehead, the skin 
Kcmped off her nose, and other little injuries; 
hut she at the same time hurt her knee, and the 
[tain in it makes her cry a good deal, especially 
at night. Tlie inner condyle is altered in shnpo, 
lui can he detected by the eense of touch ; but it 
is hardly more protuberant ; it ia tender on 
prassure and hot. She cries when the knee is 
moved moi-o violently tlian Wforc. A nearly 
intraight [last^hdard Hpliiit to Uie outside of the 
thigh and lo;; ; a blister above tho inner con- 
dyle ; to be dressed with zinc ointment; Iodide 
of Potass mixture to be taken throe times a 
day. 

20th.— She has had another blister over the 
seat of pain : there is leas tenderness, but the 
ohiltl cries at night a good deal. It appeani 
that Hhe does not w&ke up suddenly, but has 
some difficulty in going to sleep : ' when aha 
does wake, she does so with effort, and criei!. 
It was evident that thmo wore not the starting 
pains, but only the dull aching of tho earlier 
Htagea. Ordered to iiaiut tho joint wiUi Tra. 
lodinii ; to ooniinuo tho mixture, and to tnko 
for a week the following, in pill, night and 
momtng : — 

9- Qoinn-' disulph . . gr. j. 

Uydrarg. c. Crcta .. ,. gr. ij. M. 

BUi. — lliero has ap[>eared over the most prominent port of the inner 
dyle an increased tumefaction, which fluctuates -. the 6uid is deep. 
There are at present no jmiiui which apjiear like starting of the limb. 
To take one grain of Quinine, in pill, ni^hi and morning : to leave off tho 
Todino. The joint was drawn at tliis time. 

July 3nd. — ^Tho whole joint is swollen and puffy ; the enlargement does 
not depend upon fluid effusion into the cavity, hut on periarticular 
thickening ; the tenderness over the inner condyle rather te». The child 
lookn better. Apply bUster round lower part of thigh in front. 



* The abourroal projection of the inner condyle is mmewbat inrreaacd liy a. 
seroiiB cflVuIun muter thi- |icrioetttmti. 




272 



SXnUMOUS ARTICULAU OSTEITIS. 



PtUP. XI. 



6th. — ^TbeptunoTerthe condyle, and the flnottiaiiiiKHweliing, appear leas ; 
but an tiovr tbe periarticular tiMuca are irapUcated, 1 de«irc to treat, also, 
that condition. Gave the child chloroform, and a])plied the oautery-jron 
in one line at tbe outside, two at tbe innide of the joint. 

20th. — Child is better; the voiinil from cnuier}- almost healed, and 
much less tendoniost) about tbe joint. To take oae tablcspoonful nf 
Quinine Mixture three times a day. 

17th Aug,— The joint hos been strapped tightly for the last ten days, 
and the apUct removed ; the child does not now cry at night; the inner 
oondyle seema scarcely, or not at all. more susceptible of pressure than 
that of the other side, and the periarticular fiilness has disappeared. 

Sep. 19th. — The child's joint perfectly sound. 

Case LIl. — Jane Dickeiy, aged 1.3, a thin, weak-looking child, having 
finely-cut features, small houea, and veins plainly marked about Uie 
tiiouUi and temple, was brought to me aoth May, 1800, vith the left 
shoulder painful anil swollen. 

Thi! swelUng is very evident ; it makes the shoulder look rounder, 
larger than the other, and somewhat pointed in front, and a little to the 
outer side. This is best visible when the i>atient sits upon a low scat and 
the surgeon looks down upon her from above ; be tlien getfl much the 
same view at* is given in the accompanying drawing, whidi wits UiVvn with 
the child lying on her back. The shoulder is tender on pressure, and hot.- 
She was ordered a tcasixMHiful of Cod-liver Oil. and two tableapoonfuls of 



# 



E. 



'V 



»rKUJIOU6 (WTBITD OF TMB HBAP OT HUMERVa. 



Chap. XF. 



CASER. 



273 



Quiiiino Mixture, three times a Hbj ; a blister to the Iront of shoulder ; 
the arm to be bouiid to the oido. 

9th Juoe. — Appetite improved. She has had, since last report, a blister 
behind the shoulder: there b a superficial abscess forming over the aoru- 
mion of the other side. 

li3th.~Agaiu a blister to the front of the shoulder; to bo dreBsed 
with Oikido of Zino Ointment. The following to be taken with the 
Cod-livor Oil thrice a daj : — 



Quinie disulphatis .. 


■ BT.y. 


Ferri suJphatb 


gr. U- 


Acidi sulph. dil. 


mx. 


Spt. i'Ethens chlorioi 


nivii. 




iSi- M 



30th. — Better : the alwoeas over the right acromion has broken and left aii 
ulcer; it is quite superficial: to let the blister heal ; the arm need not now 
be bound to the side, but is to be kept in a sling. 

Julj 13th. — The abouldor has dimiDishod in size very much ; it is not 
now tender, nor hut. Passive motion and friction. 

Sept. 7th.— There was some trouble in overcoming the stjffneas, and 
difflotdty in moving tho shoulder; but it is now as finely movable as a 
healthy joint, though the head of the humerus has not regained its normal 
sixe ; it is but little larger than normal. I procured on admission for her to 
the Walton ConTalosoont LIospitaL 

Ca0B hJU. — I waa asked on the 28th Jane, 1860, to see Master F., 
aged 13, who hfui been sutTering four years and a half from knee-joint 
disease. Ho is polo, tliiu, and dark ; has slight ashen discolouration about 
upper lip. 

'I'ho disease began, the mother and boy both affirm, by a fall, though 
they acknowledge that the fall was not remembered till afler tho di.'U.'ttae 
had begun. The first commencement was pain at tho inner condyle, 
which provented the boy's walking in tho day and sleeping at night : aher 
a time this pain, under treatment, disappeared, and came on again three 
years aga As nearly as I can determine by questioning, startings oume on 
nine months ago; they are now so bad that hu hnrdly goto any sleep, and 
often when he is reading or otherwise amusing himself in the day, thuni 
cornea one of the stArts so violent that it iiicnjmcttfltee him for n time from 
all employment. Ue has been taking a ^rain uf Opium, of late, every 
night ; it does not make him sleep better, but renders him more drowsy 
in the morning. 

Tho knee is swoUen and puffy ; the swelling does not, however, hide the 
form of the bones altogether : it is the must prominent over the inner 
condyle, which projects oousidoralily, and where hard effusion can be felfc 
nearer the ftkin than elsewhere ; there is an abnonual amouut uf fluid in 
the joint, but the swelling is uot due to that cause, but to periortioular 
enlar^Qmont. A aUius, near the lower and inner edge of the patoUo, leads 
into the joint ; no rough bono con be felt, but there is no doubt that the 

T 



274 



STRUMOUS ARTICrLAH OSTEITIS. 



COAP. XI. 



inner p»rt of tbo femur, at loasl, ia carious. The leg in bent at leu tlun a 
nght &Dg1c. 

I gnve All uuCnvournble prognosis, but agrveil to do what was posstblo. 
The BoHd opium was omitted, and inntoad the foUomDg draaght at 

night : — 

B. Chloroform n^j. 

Acid Uydrocyan. dil. oiy. 

Tne. Opii m*. 

Tno. Aurantii jij. 

Aquni (IcHtilbtA ^iss. M. 

Two tabteapoonAik of the Mixture three times a day : — 

V. Quinic disutphatia ., .. gr. vj- 

Ferri aulphaUa Er< U> 

Acid Buli'h. dil i»t«. 

• Tne. Aurantii sj- 

CbloroforiD ny. 

Aqu» dcstillatae .. ^, M. 

The joint wan strapped and the leg tightly bound on a nplint, with a aorew 
fit the liock, thnt it niigbt, if posHible, bo got a little straight^ir. 

7th July. — He has ulept better of late, nnd the atartiug is )e«9 ; iliia mny 
bo partly ftltributod to the atrapping, but it in impossihlo to luake the 
knee in the Hlightfst degree straighter by the screw without producing 
great pain. To-day ctiloroform was adiiiinistored : I divided the ucca'^uory 
tendons and funcin*, nnd Ktroightcnod the joint : ordered oold lotions to 
bo kept on the joyit. Let him, immediately (S V. h.), have ten dropo of 
Laudanum, and lot the draught to-night contain twenty dropa, instead 
of only ten drops, of that tincture. 

lat Aug.— Not a bad symptom showed itself after the opention ; a 
Hplint was applied throe days aftur its performance ; the slight awelUug 
that o&me on disappeared under strapping ; the starting pains have re- 
turned uiid are now severe ; they did not conuuenco to increase till a 
fortnight after the joint had bceu straightened: the extending splint 
waa carefully applied and bandaged to the hmb. 

Sept 14th. — ^The starting pains began to decrease from the time when 
the extending force was applied : in five daya thoy had (juito iliNapjiearDd. 
On the 14th of lost month, a fortnight after tho applicntiou of the ex- 
tending force, the night draught was discontinued. Thti sinuH is closiog: 
I bogin to hope that tho oariea may be subdued. The boy's health ia much 
improved. 

Oct. 2Ut. — I have now applied another means of extension by mcana of 
splint, consiaUng of thigh and log piece jointed together with a hinge (aee 
Chapter XVII.), and have allowed him to move about on crutohos ; at 
Tiigbt this is removed, and tho extending apparatu.^ as before applied. 



Ciui-. XII. 



NODOSITY OF THE JOINl^S. 



275 



CHAPTER Xir. 

Chboxio Roeuhatic Artiihitis. 



pATHoi-oay. 

Tnis disoaso, sinno Dr. Haygarth described one of its ap- 
pearances as nodosi^ of the joints, has been re^rded with 
nuicli intorost by a hir;^ number of careful observers. Among 
the most zealoue and trustworthy of the authors on tliis subject 
may be reckoned my coUeagvie, Mr. K. Canton, of the Charing- 
Cross Hospital ; Mr. l^obert Adaras and Dr. Smith, of Dublin. 
The malofly is, lu general, either a Boquola of acute rheumatism, 
a result of exposure to cold, a gouty diatlictiis, influenced by some 
cachectic condition of system ; or it may be traceable to uterine 
disorder, and is combined with either lu:&uriou8 or very scanty 
feeding. Sir B. Brodio observed it among the upper servants, 
hall porters, and tall footmen, of largo London bouses: Mr. 
Atiams, among tlie damply-lodged and potato-fed peasants of 
Ireland: it is also a viTy common disease in Holland. As far 
08 I am aware, it does not exist in hot dry climates. It rarely 
attiicks one joint alone ; but genemlly invades them eymmetri- 
cally , picking out tho same articulation on either side in succession, 
mitil a large proportion of the joints of the body are rendered 
fixed and useless. Sometimes the disease affects only one joint, 
buiug produced by accident or other cause. Such a eii*ciunstanco 
very rarely happens, except at the hip, whore it has acquired the 
name of Morbua coxse senilis, Coxitis sicca, &c.* 



♦ Tlic inirtiality oflhiii inuladv Tor th« 
lii|i it) unduuMcU, uUlwugh it ilo«s not 
upiiurt'iiUy tout] toaJ^t tfao largL*r tuorti 
tJutn tiw nDnller joints. Hr. Canton, in 
fl[K.-ulcing of tttis fact, mja "tlic mi- 
nateat euunplco in the imdr may, I 
bclioTc, rooomnb to the inroiwH of liua 
malady. 1 aUudo to tliOBc of tb« oui- 
fvia nudilit, ood hcnco the power of 
beaiing may be diminishod or loet. On 



tiifti latter (Ktiiii, liuwcver, I merely 
tninoiao : but anutojncal cooiddc'nitiuaa 
mmrart tho proI>anilit>'." (Ciuttou'i 
'Samcal and Tatholopcnl Obacm^ 
UoM^p. 9. 1 85.^.>— The justice of tUs 
tnirmisc is mngnlarLr sbowu in llio re- 
cent work ' On DeamcaB,' by Mr. Toyn- 
bcc. wherein lio huaddnoed o tituab<«r of 
exompU'^ of tbis dito—e oflfctiag tLooe 
KHiall jointa. p. 270. 18G0. 

T 2 



276 



CHBOHK BHKFlfATIC OfiTKmS. 



CteAF. XIL 



This is in aooordance with alt oor idefts of a constitatiaiial 
dlMMe, aod tb« peculiarity of the changes, which the pariB 
imdergov ■dcogflieu sdll farther aadi ao opinion. The morM 
acUom am nerer rocmd confined to one stmctare; bat are^ 
•nmiaed vp w ritortlv as poadble, theiie :-— the jotBt-booee are 
flattened, that u, increased in circtunrerenoe and lenened in 
eftpaetty ; the Bttrface* are void of cartilage ; the bone polidied ; 
the articular facets fmiroimded by lar;^ etalaotiUc osteopbytca; 
the inner surface of the synoTi&l membrane is hinmte, with 
hypertrophied fringes,* which contain fa]«e cartilages, or bony 
growths; the sabeynorial tissues are enormously thickened, and 
frequently contain semicircular pieces of cartilage, or of oeeeooB 
matter. 

It is undoubted, that the first perceptible symptom in the 
Uving subject is effusion into the synovial membrane of 
the joint, a coudition in its appearancc« exactly similar to 
hydrarthroms ; and if we hare an opportunity of eauimining, afler 
death, a joint in these early stages, we sludl, as Mr. Bobcrt Adams 
huH romarkwl, " (iiid the morbid aiip^'amnceB of the disease for^ 
tnnrly called IIydroj« Articidi." It nevertheless is a subject d 
little doubt, in my mind, that the morbid action does not begin 
ill the synovial membrane, but in tlie bones ; that it is in reality 
a rheumatic osteitis. The enormous changes whicii we find in 
the shape and condition of the joint-ends are more than conld be 
produced by a mere synovial iuflararaation; moreover, it is 
not merely the joint-ends which are changed by this disease, bnt 
the whole bone. I have seen the entire pelvis, the whole tibia, 
and otlier large Iwnea, altered by this malady. The much greater 
diilictilty and troublo involved in making out an inflammation of 
tlio bono tlmii of soft parts, is a reason why the first effect upon 
this texture should be overlooked ; yet, from comparing a large 
number of sjHHumens. several of which were kindly lent me by 
Mr. Canton, and by observing the difl'ereut conditions of parts 
in various degrees of diaease, I Imvo concluded Uiat the following 
is the true cause of tliu morbid action. 

l-'irst, an osteitis, which causes increased density of the bone 
from tliickoning of its external shell, and of all the plates of the 
eancelli, — the inflammation does not attack a surface in preference 

* The »hnvUi09 of nH^^hbonriug taii<10iu arc alao frequently tbaa roagboDcd. 



CuAP. XII. CARTILAGE AND FIBROUS TISSUES OSSIFY. 277 



to another part, but invades the whole mags of the bone ; its 
more frequent occurrence at a joint-end is simply due, like 
stnimous osteitis, to the more active and vascular condition of 
Umt part Very soon tlie textures in the ueighbourliood of the 
bone participate in the disease, the pfriurtiuular tissues become 
inflamed, and the action, like all rheumatic inflammations, tends 
to development of its products ; thus these parts become con- 
densed, and even converted into bone. IleJice, llie large stalac- 
titic oeteophyles, the loaie bones in the fibrous tissues.* For the 
same retison, although the cartilages disap]>ear, tliey are never 
seen ulcerating ; on the contrary, they ossify. In early condi* 
tions these structures ore found very thin and pink ; and uj>on 
examiuiug sections through cartilage and bone, tlie articular 
lamella is found to be changing in character, the black unde- 
vclo(>ed bone cells throwing out canaliculi, and merging into 
ordinary bone corpusrles, while osseous matter encroaches on 
the ojirtilage. Wlien the whole thiclaiess of this sid)atanco is 
converted into bone there begins a process of wearing away and 
polishing. The wear, of course, takes place chiefly in the lines 
of greatest movement, hence there arise ridges and furrows in 
these directions : those on the hinge-joints are all straight ; thoee 
in the boll-and-socket-jointa, curvilinear, and diverging from the 
centre, like the engine-turning on the back of a watch. The 
polidhing is in i>art due to friction, in part to a pecuhar change 
in the bone, which has been terme*l porcelUtnouB cUp<mt, ftlr. 
Quekett bos very aptly compared this change with the mode 
adopted by a French polisher to overcome the difficulty in 
|K)lisliing a piece of wood at the ends, where all the £bres abut, 
and the vessels open : he fills up the spaces with wax, or some 
resinous suh«tance, which gives the surface suflicient smoothness 
to accept a polish .t On removing thin slices with a saw, and 
grinding thi.MU down on the aide formerly attached, so as to leave 
the porcellonous surface, the Haversian canals will be found 
occupied by badly organised calcareous matter, which seems in 
some instances so rapidly deposited that it strangles tlie vessels, 
stagnating their contents, so that the wliole surface is stained 
of a yellow, or orange colour. 

* *AiI<1itan)(!ntar]rI)oiie8.* R.AtUiiu. gicnl Obaerrutioiu .-' uliw tu Mr. Qntk- 
t I nm indcbU>d for ttilfl nungmpU c-tt's 'Hlakiloipcitl AiutUini;.' 
Ui Ur. Cautoa's ' Surgk'iU ana Patbolo- 



278 



RHEUMATIC OSTEITIS. 



Chap. HI. 



At a certain period of tlie inflammation the thickened luid con- 
Uonficd bone becomes graduaUy lighter. It is the quality of all 
inBammntioDs first to canso induration, then, as nutrition de- 
crca^s, softening, or a similar act I'ho bone does not become 
soft, bnt rarefied ; when in tliis state it is dried and sawn 
through, it is found to contain a (jtmntity of a very peciiliar 
jwwder, each grain having a remarkably definite size and sha|ie 
— Uiese particles iu*c ossified cells. It i« imiiussible to trace the 
development of these bodies: they may merely be the cells of the 
metiulla that have been thus changed; but 1 rather believe them 
to bo tho cells which were contained in the lacunso. The ex- 
ternal shell of the bone and the walls of the cancelli have now 
become thinned instead of thickened, and examination by the 
microscopM shows them to bo very plainly himinated ; in fact., 
Ihoy look like a collection of oeaified fibres, among which very 
elongated and nan-ow lacunas are placed. The gradual rarefac- 
tion of the bone, and the thinning of lK>th external and iutornal 
lamolljB, are due, I believe, to the stow ossification of the bone 
colls, which starves the intercelluhu' osecous mnterial, and allows 
it^ gradual absorption. Henco tht« ijeculiar actiou, teimed 
Osteoporosis — enlargement of the Haversian canals — produced 
by alKorption of the bony lining of those cliaimels. Even tht^ 
osteophj-tes, which at first are solid and thick, become mere cases 
of thin bone, divided in their interior into spaces by slight catr- 
eellar plates. But wliile (his rarefying action goes on where tho 
osteitis is old, new indurating material is (as in all except diffuse 
inllammations) deposited around the focus of infiammntion, Le.,*iu 
the newly inflamed parts, and to these two simnltaneoos processes 
the change in shape of oU the articulating surfaces is due, tho 
heads of the bone become fiat and broitd, while a similar elumge 
takes place in all the cavities, glenoid, acetabular, &C-. 

It ia to bo observed tluit the immobility of the joints does not 
ix^sult from anchylosis, an action which dm^ not> us fur as I 
am awnro, ever take place in this peculiar form of disease. 
This condition is ]»roduced by tho great development of 
osteophytes, wliieh, Kjtrouting out close to the joint eurlaces, 
act as buttresses, preventing motion by the contact of those 
Hprinpiug from one bono with tliose arising from the other. 

There aru some luiuur but curious [>oiutH worthy of meufiou : 



Cjiap. XII. 



OSTEOFOBOSIS ANP OSTROrUY'J'ES. 



27y 



one of them is the ultimate alKwrpiion of certain parts of the 
fibrous tissues. This appears due to the pressure exercised by 
the new bony growths ; thus the capsules of the hip and shoulder, 
the ligiimeuti* of the knee, the i)iceps tendon of the ann, are 
frequently found aljstirbed ; this hitter is also sometimes dis- 
placed inwawU by the oeteophj-tcs sprouting up beneath it,* 
Another jwint which I desire to notice, but whoso complete 
inTostigation munt be left to suhsequeut examination, is tlio con- 
nection between a hirsute comlition of the synovial membrane 
and a rheumatic inflammatory state of the neighbooriug bono. 
In thoue autojsjies, in wluch 1 have found tho synovial fringes 
hypertrophied, tlio bono has been thus altered ; chietly very much 
condensed; tlie cartilages very thin (undergoing ORsilication 
from tho deep surface) and pink. Be it observed, tliat in farther 
a<ivanced stagos these enlarged processes arise from among tlio 
irregular chasms luft in tim changing Ix»ne. That there is some 
cxmnection between hydmrtlirosis, with change of fltmotu re of the 
synovial mombmne, and chronic rheumatic artliritis can hardly 
be doubtt«l ; but that the former is a mild and merely local mani- 
festation of the latter disease would bu, in the [irescut state of our 
knowledge, rather too hazardous an ussertiom 



Symptomb. 

The malady commences with pain, which comes on at night, is 
vague and uncertain, and with stiffness, chiully ft-lt in tlio morning, 
when the person begins to movo, and decreasing on continued mo- 
tion- After fatigue, a fixed pain is felt in the joint, which, ou repose 
at night, yiehbs to the more vague and uncertain aching. Soon an 
cfliision of lluid takes place into the synovial sac, uausing a more 
less amount of hydrarthrosis (refer to Chapter VII. for a de- 

riptiou of bydrarthrotic swellings), which in superficial joints may 
be distinguished by their peculiar shape as well as by tlie absenco 
of acut© inflammation. Shortly after this tumofactinn is mani- 
fested the surgeon will feel in certain parts of tlie swelling a pecu- 
liar rustling on pressure ; the word rustUug is the only one which 
appears to me proj>orly to designate tlw! sensation, which does 



* For the morbid anntoDi; of tliU 
cImcoiki us occnrring in xpucioi juitild, 
tbtf iviwlor in rrfuiTMl to Mr. Oiuiton's 



wiirk nlrtiuly quotMf. nud to Str. H. 
AdiuiuV uduuniblti tmd doUiilcd luoiui- 
gram, ' Ou Rhuuumlic Uunl.' 



S80 



lUIEUMATiC OSTEITIS. 



GaAP. XII. 



not amount to crepitation. It is, of course, only in siiperiicml joints 
and in parte of the 8)'uoviaI membrane, close to the skin, that 
Uiis feeling can bo detected. Thus, if the mahidy boattfae kneet 
this rustling can be felt over the inner, sometimes OTor iha 
outer, part of the head of the tibia, and unless the sac be very 
full in the gnbcnircal pouclu I found it once iu a fiu^r, and 
once between the inner condyle and olecranon; 1 liave two 
cases at the present time* of knee-joint disease nodcr my 
caro, in which it is found ; one is a case simply of hydrarthrosis ; 
the other has already advanced beyond tliis [luiiit. The secjuel 
of events may step here for many months, perhaps years. Even 
altogether, particuhirly if the disease be located in one joint 
only ; or it may go ftirther, and produce, besides the swelling, a 
very strange species of deformity, which is characteristic of the 
disease— a deformity produced by a peculiar twist of the bones. 
The hume rus, if the disease attack the shoulder, is projected slightly 
forwards, ovortc<l, and mlductod ; its head is very prominent in 
front, deficient, alwolutely leaving a hollow, behind. In the hand 
such a quantity of deformities are produced, that I will only 
attempt to describe t\w most striking. It is more frequently 
nttaeked than any other member, probably on account of its 
exjiosed condition. The first deformity, beyond mere swellijig 
of the Bynoviul menibiiuies, i^i a remarkable hollowness at the 
dorsum, about the base of the metacaijial bones, with a singular 
proniiutmeo of the ulna and radius, chiefly of the former; soon 
tJio metacarpo-phalangeal joint* an; involved, and, as each is 
aitucked, the finger becomes greatly adducted and bent a little 
backwards, so tliat the forefinger, generally tlic fti-st attacked, 
crosses the others on their [wsterior aspect The disease at the 
hip-joint causes sliortening and very great eversion of the limb ; 
more than is produced in other hip-joint diseases, more oven tlitm 
follows fractures of the cervix femoris. The tibia, when the 
knoe is affected, gets a peculiar out^vard tendency, nmkiiig the 
knee fall inwards and at tlie same timu it is rotated outwards. . 
Tl»! patella is tnrnwl outwards and lies on the outer condyle. 
It is curious that the wrist slioiild be t>o greatly, Uie ankle so 
little, subject to the disease. Air. K. Adams says, " The auklo- 
joiut is very rarely affected by chronic rheumatic arthritis."! 
• tSGo. t ' Oil Bhetunatic Uoiit," p. 250. 



Chap. XII. 



FECULIAU DEFORMITIES. 



281 



Whffli it is attacked, the tarsus is nearly always involved. The 
scaphoid bone and head of the astragalus rise up in tlie dorsum, 
while the solo of the foot becomes depressed and flat ; tlie toes, 
when the tarso-phalangeal joints are affected, turn outwards: the 
great toe is usually first and most implicated ; it lies crossed over 
and on the back uf tlie others. 

Combined with this deformity of portion is a change in the 
shape of the joint-ends : the small and superficial ones become 
irregularly knotty — nodose, as Haygarth called it ; the larger 
ones change in various ways it would lead us too far to describe. 
At the same time, there comes on remarkable spasm of tho 
muscles, accam|)anied with wasting ; this symptom is variously 
counccti'd with the deformities ulx)ve described ; both usually 
come on together and continue, /wn*j9a»*t/, throughout the diseasa 
Sometimes, on the contrary, the spasm and violent starting pains 
at night precede every symptom except the vague a4.'liiugalreaily 
mentioned. Again, hydnirlIirusL«, witli struetural ehunge of tlio 
synovial membrane, may last a certain time as tlio only 
morbid condition- After a while starting pains will come on. If 
this be the case, wo may rely njKin this s^-mptom as showing 
that changes iu the shape and condition of the bone arc about to 
follow. 

Wlien tho malady has continued in a joint for a certain length 
of time the surgeon will tiud that it crepitates upon movement. 
Wlien this symptom Krwl comes on, it is usually pretty dif?tinot, 
oven audible ; but il" the joiut be subjected to much motion it 
becomes leas and less niarkt;d, yet will always be present as long 
OS the articulation ia not altogether fixed. 

I Itave, contrary to usual custom, deferred speaking of general 
symptoms, until the local hud been discussed. There have been 
several reasons for doing this, clearness of comprehension being 
more valuable tlmn mere form. The general health is in tlicse 
diseases frequently remarkably good ; sometimes it ai)peara as 
though the malady arose IVom superabundance of animal and 
digestive powers : tho sleep is soimd, complexion fresh and rosy, 
skin soft aJid moist, apjietite perfectly good. We may liud that 
in some of these functions a little superabundance prevails — 
somewhat too much food and too little work — sueJi cases seem 
to littvo boon those iSir 1j. Brodiu duelly observed We find, on 



282 



RHEUMATIC OSTEITIS. 



cuAT. xn. 



strict inquiry, that there is somn acidity and flatnlence, and a 
great teudency to Bleep after meals, a loose condition bo^ of 
muscleB and skin, ii tendency to accumulation of soft tat, and n 
p^a«y, UQCtuous condition of eurfoco. Such Btate of comfortable 
functional |ierformanee may continue ' to the very end of 
the disease, even when the patient is set fast and incapable of 
moving any joint in the body. I occasionally am called to see 
a lady, the joints of whose lower jaw, one shoulder, and piThnps 
one or two of the vertebral articulations, are the only ones unaf- 
ffcted ; the hips and knees are perfectly fixed. In one arm luid 
baud there ia sufficient movement for her to feed herself ; she is 
every morning lifted out of bed into a chair, every evening back 
again to bed, without altering the angle of the thigh and Imdy, 
or of the kueea Yet she enjoys, a& far as the performance of all 
bodily functions, except muvemeut, is coneerued, [lerfectly good 
health, with the exception of slight acidity after food. 

Other coses present at their commencement another extreme 
of weak functional performance. The attack will have begun 
sharply, perhaps with an acute rheumatigm, or after long expo- 
sure to wet ; tiie strength will be a good deal broken, the health 
" pulled down." The acidity, which ia generally present, ia rather 
from an atonic than from an overworked condition of etonioch. 
The attacks are more painful in this form of disease than in the 
one just described : the starting pain ia more severe, and^the sleej) 
less good. The patient wastes more rapidly ; but even in these 
oases the amount of systemic symptoms is verj* small in propor- 
tion to the great local tUteration produced by the diKCOSO. 



Treatment. 

We have already, to a certain extent, considered tlie constitu- 
tional treatment of rheumatic joint diseases (Chapter VI.) ; but 
we then wore speaking of a malady which, although essentially 
chronic, sullers stages of exacerbation, rendering it altogether 
morn acute than tliis remarkably slow disease. 

80 insidions is the first uttjick, that the ])atient frequently does 
not come under the surgeon's uotice until nt least mio of the 
j< lints have become much altered in form, thickened, and pro-, 
Itably so far changed, that we can never hope to restore it to ita 



p. XII. TREATMENT BT METtCURY ANT) lOPIhTE. 



283 



noniml condition ; and, indeed, in such cases, wlicn the oonsti- 
tutiomil evii has Brmly fixed itself iu tUc hubit, any treutmeut 
is placed ftt a great disadvantage. Dr. Haygarth obserrea, that 
it IB in the early stages that we can hope to prevent the ravages 
of the disease, and exhorts the Bufforers to seek medical 
aseistauce at the first appearance of the malady. 

Wo are Ixiuud. however, to mlmit that the result of treatment 

is less satisfactory than conid be mshed. Sometimes a patient, 

during the use of a particular drug, appears to get better, to lose 

, many of the pains which are so distressing ; the joint, even, will 

' become lean nodose and irregular : such a medicine is the 

Iodide of Potasdum. In ono case that I saw in the early ]>ari 

of the winter 1859. this drug had tlie most marked effect in 

prucuriug ease ; afl«r the second day of taking it thu patient 

told me she slept better than she had done for years. In other 

, cases the remedy quite fails to make the slightest diflerenco, 

either in the progress of the disease or the cumfort of the 

patient Bichloride of Mercury alone, or with lodido of Potna- 

sium is often decidedly beneficial for a time ; it must not bo 

poshed far enough to affect the gums, or even to approach such 

affection. 

Colchicum is a two-edged sword of considerable sharpness; 
there is no doubt of its great power in checking gonty and ovon 
rheumatic pains ; but it is very queationable whether it does so 
iu a beuelicial manner. The late Or. Todd believed that it 
changes the common acute form of gout into an asthenic condi- 
tion which is less easy of management ; and tlu^re is great reason 
tu believe this idea correct Any practical opiuion which is the 
result of exj>eripnce, not uf mere A priori reasoning, deserves 
great attention ; and wo may be sure of this fact, tlrnt whatever 
tho modu9 operandi of the drug may be, it hastens relapses, 
rtind»r« eacli ouu less amenable to treatment and re<nuriug 
larger doses of the medicinu (if treated with Culclucum) than Its 
predecessors. Whetlior the remedy act simply as a purgative 
or (w stimulating thy liver, or as causing a larger excretion of 
lithic acid, is not certain ; but it is only permissible when the 
constitution is vigorous, and should not be givcii except when 
other means of procuiing ease have failed. I Ijive been led to 
belieye that the Liiiuor Colchiciun> prepared by Mr. Baslick of 



284 



IIHEUIUTIC OSTEITIS. 



Chap. XIL 



Brook-Btreet, is less potent for evil than th© ordinaty prcpo- 
ratioiis of the * Pharraacopccia.* The medicine should excite 
bilious evacuation, but should never be pushed so as to purge ; 
when it acts in that uiamior its injurious effects will soon maoi- 
(cst themsolvefl. 

Guaiacum is a far more reliable medicino> and the best effects 
may bo seen to follow its administration in such doses as shall 
prociU'O two free bilious motiuus tu the twenty-four Iiours, if ttio 
patient be strong ; and in a weaker person equal advaDtoge is 
pnHluced by giving the medicine iu smaller quautitics. 

The Acid stnte of the prims viae is in some way closely con- 
nected with the morbid condition of system, and this ought to bo 
combated by wjme alkali given two or three hours after fotxl, 
as Ammonia or Potusli (a combiuution uf the two ia better than 
either alone) ;* magnesia iu such combination is also useful It 
is desirable to act uiKm the skin, and to endeavour in that way 
to get rid of the matene% viorbL In truth, it seems as though 
want of cutaneous excretion were in great part a cause of the 
whole class of rheumatic disorders (j>. 65). For this purpose the 
James's powder, or better, the Dover's powder, or a combination 
of antimony and opium may bo used. Ammonia iu various 
forms may also have its effect. The greatest reliance, however, 
is to be placed on different forms of both ; and upon tho in- 
ternal and external use of certaiu natural mineral waters^ both 
Knglish and Continental. 

The mere hot-water bath is tho least efiic-acious form of artifi- 
cial batliiug. The vapour and lamp-ba^h for those who cannot 
conveniently be moved, or for whom the more active sort are 
too violent, produce great cutaneous transpiration, and, if persiv 
vercd in, have very considerable effect in recent cases, when) 
the alteration of tissue is aa yet slight. Tlie hot air and tho 
Turkish buthf are, however, more comLmendable as producing 



* Mr. U. Adanu ipeakg itrongly iii 
tiufftvuur uf Mitlu. because, us liu aara. 
In Uiu ulitU' of HyiiUfin tlie combination 
of litliii: ueid wiU> Oiu uuda would tuuil 
to ]iruduL'4! tbo ubiUk fltinit!. Tl iri to be 
obwcrvcd, liuwt-vcr, Uiut liUuiU.' uf hkIu 
In nut d(.'{>uiutud umiiug tliu tiinura iu 
thia diBcxui.'. 



t For some conndorebto time past it 
iinti bcim my Imbit to recomiucnd fOr 
ticiitit with gouty Mr rlii^uioAtio difleucv 
to uiw llic 'I'nrtdst) or otbor form of 
batlt. Latuly tlieso cetoblishmeiitA havo 
txtme a good deal into yognv, aud Mtv 
DOW bein^ osod iDdbtMiouiuitdy, oud 
in Mvenl aues, 1 bclioTc, Injuriouflly. 



Chap. xn. 



THE ACTION OF VABIOUS DATHS. 



285 



groater action with lean debilitating effect ; they ore neverthe- 
less to bo nseii cautiously. 

The mineral springs of England, which have the most power 
in altering the constitutionarconditions npou which tliia form of 
rheuinutism depends, are Buxton and IJath ; (he former is 
adapted to those cases, in which some febrile disturbance is still 
going on, and particularly if bilious derangement be present ; the 
hitter is more active and tonic (the water contaiuH iron) and 
must bo used with more rnutiom ; but when all febrile disturbanco 
has ceased, and when neuralgic symptoms also prevail, the Bath 
'waterB are preferable to these of liuxton. 

Of the foreign springs, those of Aix, Carlsbad, and Wiesbaden, 
niiik accorrling to the order in which tiioy are ennmenitrd. 
Afany patients cannot, upon first resorting to such treatment, 
hear tlie powerfiil waters of Wiesbaden, and should ftrst undergo 
a fortnight or so of the treatment at Aix. A case has come 
imder my observation of a gentleman, whose fiuger-joints and 
one knee were rapidly becoming stiffened, although it is prohublo 
that no (u:Uw.\ osteopIi}'te8 had formed ; for the affected parts 
have regained their normal condition. He has now spent six 
weeks or two months, during each of the last three years, at one 
or the other of those places, begimiing with the milder and 
ending with the stronger course. Another, who was extremely 
rhtumiatic, being confined U} his house generally a fortniglit or 
more ouce or twice during the winter, has avoided those attjicks 
by spending the autumn at one of the spas above mentioned. 

The use of all these means must bo continued regularly and 
porseveringly for some weeks. The artificial as well as natural 
hot baths frequently act, at first, by increasing the pains* and 
setting up a little febrile actioa. Such efiect should, however, 
be slight and continue only for a short time ; but it is well that 
the jMitient be mode aware of the fact, lest he should imagine 
that the treatment have been injurious. The] medical attendant 
must see that these first effects do not overstep a certain limit, 
and must be careful to modify the mode of bathing or to dis- 
cuntinuo the treatment if necessary. 

We cannot tell why natural hot springs should be so mnch 
more efficacious than artificial waters made, chemically, as like 
* Bomo, ru Wiesbaden and Ba.\h, pnxlaco a atiglit miliorr crapfioo. 




28C 



HHBDMATIC OSTEITIS. 



Chap. XI I. 



them 06 pofisiblo ; j>orhape cbaiif^ of air. scene, diet, and tnodo 
of life, may havo much to du with this fact. 

It Ls not, however, my doaire to place before the reader an 
exaggerated idea of the benefit such treatment may aAbrd. A 
epa supports a qnontity of hotels, attendants, gamblers, &c., Ac. ; 
we hear the successful cases quoted again and again ; indeed 
if we could believe all that has been said and writttm aliout 
many mineral nprings, we hIiouU oidy wonder why, with Riioh 
waters on the earth, diseasoR should continue to exist. Although 
it muBt be acknowledged that many who resort to such places 
with the hope of coming back sound and healthy, only bring 
away with them disappointment and regret; yet otliers are 
decidedly benefited. 

This thtt'osti is so slow, and extends over such a long period, 
that I refrain Stvm giving any hiatory uf cu^ua. 



Chap. XTO. TWO SOKTS OF ULCERATION OF CAIITILAOB. 287 



CHAPTER XIII. 



IntimYMMATION and Deoeneratiow op Oartilaoes. 



Most works on discuaee of the joints couttiin a i«irt devoted to 
those miilmlipft, wliinh hiivo their espooial so«t iu tho C4u1ilagefi ; 
ftnd yet nothing ran ho more surn than tlmt of allthejoint- 
disc»8es, which fall under the surgeon's notice, not ono onginatos 
in the cartilage. It lum been seen t]uit an infliimraatory action 
commenciDg in the synovial membrane or in the bone, will 
sprtMid to tho cartilage and aet up an ulceration of that Btnifituro; 
. it 18 also well known that in the dead-house and disjecting- room 
we frequently find breaches of continuity in various nrticuhir 
cartilages which were accompanied by no symptom during life 
Tlio joints in which such conditions are found have been perfectly 
free from any pain or any diminution of mobility, and the neigh- 
bouring tissues have been perfectly untouched by any disease 
trhutovor. Thus we come to the inevitable conclujaion, that 
diseaso ooniined to the cartilage gives rise to no symptoms ; and 
we must uflk whether disease, which has commenced elsewhere 
and passes to the cartUage, may give any sign whereby we can 
tell whether or no tho cartilage hedisoafied? To answer this 
question fully it is necessary to enter somewhat deeply into tho 
physiology and i>atholog}' of cartilage ; but aa the subject has 
occnpied s^imo attention in each division of tliia work, it will be 
only neceasarj' to revert to tho points already treated, and the 
present chapter will rather be a r^aumi than a full exposition of 
the subject 

The qaestiona resolve themselves into these : — Are thero 
different sorts of ulceration of cartilage ; one accompanied, th© 
other unaccompanied, by any 8)nuptom8? D' bo, are eitlior or 
both these ulcerations prtxluced by some action of the tissue 
itself, or of some other tissue, absorbing the cartilage as a 
pa.ssive matt^rial ? 

Sir B. Brodie has throughout all llio edition.s of hia work ou 



288 



DISEASES OP CARTILAGE. 



Chap. XIII. 



diseases of the joints adhered to his original view of active 
chaugee in t]ie cartilages; in his earlier papers he ascribed these 
to tho intervention of vessels; and he has oven in his fifth 
edition some difficulty in getting rid of tlio idea, since he nifirma 
that "in persons who have not yet attained their fiill growth, 
vessels ])cnetrate into tlie articular cartilage." BIr. Aston Key. 
however, in 1833, saw some reason to doubt the poesibility of 
any vital actions in cartilage, and attributed their absor^ition 
entirely to tho "villous processes developed on the synovial 
meinbrano during inflammation of that structure." Sir B. 
Urodie, nevertholt-ss, adhered to his original idea. In 1843 M. 
Itichet,* of the Hopital Bons-StK^ours, added his testimony to the 
idea of cai-tilago being a dead, an almost inorganic material. 
Dr. Ecker,-|- in 1844, published the first obetorvatious upon the 
actions and conditions of cartilage-cells in disease. One of Mr. 
Goodsir's * Pathological and Sui^'cal Observations * in 18^15, also 
mentioned the growth and increase in the number and size of the 
cells. In 1848 Dr. Kedfem published a series of careful and 
minute observations 'On the Abnormal Nutrition of Articular 
Cartilages,' carrying further the rescan-hes of Ecker and Groodsir, 
and discloRing many details which tliose antliors had not men- 
tioned. X ^^^ t^*® *^*** ^^^ cartilage is truly a living stjucture 
capable of vital action penetrated so slowly, lliat in 1853 
I^L Kichet, in a paper on white swelling, § insists upon the 
inactivity of cartilage, and is at pains to prove tliat it is inca- 
pable of any independent action, saying, although he refers to 
Dr. liedfem's paper, "that the only direct manner of proving 
that cartilages are susceptible of inflammation would be to 
demonstrate vessels in their substance itself.** Mr. Birkett || 
ceriHures the use of tho word ulceration, and desires to substitute 
" disintegration." 

Even 80 late as 1850, Mr. Bryant T of Guy's Hospital, fol- 
lowing too implicitly in this path, ascribed all the diseases of 



• Bichct'SnrlesTuiDcurBBlanQlic*.' 
Auniilea do CluTOTfjio. 

t ' Ucber AbniitBiing and Zf^retoninp 
derOeleukkDorpel.' ArchiT. fiir IMiynio- 
logiacho UcilkQodo. vol. ti. p. 'Ji35. 

I Sue lojr paper ' On the rolntioa bo- 
tveoa Synoritii and Ulceration of Ar- 



I iicular CjirtlUgw,' Eilinburgh HodJcal 
Jonmiil, Fi'bnittrT, 1860. 
I § 'Mfmoire* a« rAcudi-mio lmjt& 
rinlo,* tomn xnt., 1858. 

tl 'Gny's Uotfpitol Reports,' Sod bo- 
rif«, vol. Ti., p.'iST. 
^ 'DineuoaondltuufiosoftheJoiiitB.' 



Ciur. XIII 



INKI.AMMATimY tX)NUITI(»N. 



5i8»» 



ourtilrtpfo to atrophy ; 'le^^enemtion and hyportrophy In-iug (uily 
mt^iitinned in order to throw doubt on tlio ]K>Kiiliility of their 
occii rrence. 

I bfjlieve my-fielf to have b<«h the first i*» hiive |*ointcd out thut 
thoee disoartcs of ciirtihi*;e which accompany the inflamnmtion of 
other tiBsucs in the joint are, in reality, inflaniination.* Th« whole 
view of the subject, and the arguments which irroaistibly Ipad 
to thia conclusion, liave been ulrt^udy detailed (see C'ha|>ter II. 
and Chapter V.) lliBtolf^ically cartilago belongs to the con- 
nective tisbiies, and we have seen abundant yvidence of the fact 
thai their iiiflammation essentially cousidlH in u ru{iid ninttipliru- 
tiun of tlie cells, whii-h Ibmi an eaiential part of their structure. 
We find this to lie tbo case with the areolar, li^otmcnton^t and 
oKseouH^ tissues; iudeud, we tixid tJiat the action of ve«sel8 in 
inflummation is but eecondary ; they apfiear only as hearers of an 
increased snipply of nutriment to ttSAues making; incrciiKcfl «li-^ 
innnds ; hence the one necessary essential wbicli reiiderK it {>owiI>le 
for a tiumje to assume au iidlammatory action, is not tho presbncu 
nf voflt^els actually in iliat tissue, l>ut the jjresence of cells hhoimmi- 
pied by any material which mip;ht prevent tlteir mulliplicatiou 
and generation. § Titus, histolo^cully and pathologically, there is 
DO reason why cartilage shouM not iuflume. and in certain 
diseases of that struettu-e we si-e the cells assuming a generative 
activity, whii-h is the essence of tlie inttaniraatory act, as exem- 
plitie<l in all tissues of the connective class, || Wounds of the 
cornea, according to 31 r. lIowmun,1I pn^duce an abundant genp- 
mtion of cells, which lead either to reunion or suppuration aud 
ruction of the part. Dr. Kedfeni ptLSscd setons through the 
costal curtilages of dogs, aiul fomid that th^y invariably pn«duce<l 
uuiMidt'rahle geueratiou of cells in the part next the silk. An 
examination of areolar tissue in the neighbourhood of a wound 

" 8ee my paper ' On the Nutrition anil 
litatunmntioD of Artfcubir Cutilagcfl,' 
ill MtHl. Chi. R«Tiew, O^t l85'J. 

t S*X! my pftper 'On Oraoulfttiou.' 
£«ale'ft ArchiveB, vol. ii„ Nu, 5. 

X Im» my paper 'OitOsteitiB.' ill Merl. 

CIti. Beview. April. 1860 : uid Chnp. X I. 

$ Froiu tbu> tWct a comUATv luav lie 

dmwu : unc wtiicli ou tlic faoo u( it luny 

ppiMir ultyrlf falgc. for- fe toll rrt, and , 

I absurd ; bat whicli 1 iicrtrtliolcM 

tV(4 myHfJr iu a puailioii tu privi-, 

el}', tlmt iio9]H-cinl Uhuo is ■■apaMu 



of tnflanmutimi. i.e. tbat norre litume, 
wlietber the cellular or ttbrotu. that 
muBculu twae, &c., cannot iitflntnt^, 
bat that the ease« of »u cnll*\i influm- 
niation of thr bmiu aiul uf niuM-U's tie 
in truth examplos uf inUuDiijinUoii of 
tho vcoUr tisBOcfi nuaifyiit^; mnoD^ 
thcM otg&ns. 

II Se«mypaprr'OnGnu»i]Htioti.'^.. 
in Beolo'it Afctiivctf of Mcdicim-. No. 5. 

1 'Oil thy Stnu'liircii iiivotvcd iu 
OpcnilifffiB uu thr Kyr,' p. tfH. 



\} 



2B0 



JHHEASES OK CARTILAGE. 



ChAk XUI, 



vr ulcer, shows the cells of that stractore in an activ^ouadition 
of generation ; and the cells in the lacunse of bone are actively 

eiiifiloywl ill inflammation of that struL-ture. VTieu, then.*fore, 
on iulluuunatorv Aishasn of the synovial membrane spreads to 
the ntlicr coustitaoutfi of the joint> and wo find thf! cartilage and 
bone iuvolTt:d, we have no a priori reason for refusing the tenn 
inflammation to the disease of the cartilage, aimply because that 
structure contains no blood-vessels. 

A point of pathology cannot, however, be settled by mere 
reasoning : the morbid anatomy is the only true key to the argu- 
ment. It is found, then, that multiplication of cartilage cells may 
occur to such an extent as to eot up or absorb the hyaline BtxucturOr 
producinp ulcers commencing on thy free surface of the cartilage. 
Tills piDct^s take:i place when the surrounding structures are 
inflamed, and is similar to tho inflammatory act in thorn, 

But ulceralioos of, i. o. breaches of continuity in (;ar 
occur when the [>arts aromid are perfectly healtliy. Tlio cxiat^ 
ence of these lesions is not suspected during life ; they are found 
in the dead subject, whoso articular functions had been perfect 
Such ulcers look to the naked eye more fibrous, rough, and arc 
generally softer than those already dcBcribed ; sometimes the 
cartilage is converted into a set of parallel 6bres, dose together, 
and stajidiug from the bone surface as the pile of velvet from 
tlio woof; and often that port of the cartilage is yellow. If 
sections of this inateriiU bo examined microscopically, the cor- 
puscles will bo foimd increased in size, and the contained cellsj 
also are larger ; but they are not increaaed in number. Thof 
corpuscles, which contmned two, three, or four cells near the 
attached surface, still continue, on approaching the other edge, 
to possess only an equal number of cells ; the nuclei do not mul- 
tiply ; on the other hand, they become obscured by an accumula- 
tion of minute globules of oil around them, between the coll wall 
and the nucleus ; in a further advanced stage, and nearer the 
free surface, the corpuscle itself geU filled with the oil, which lies 
around tho cells. Tlic fibriflcation of the hyaline substance 
oommences by the api«?arance of thin faint striae ; in some in- 
stances there may be seen between these a row of oil globules, 
and the striie become more numerous and more open, until the 
subBtauee is split into fibres. 



CHAr. Xlll. 



DKOENKHATIVK noNPITIOK. 



2M1 



Thia ftttty drf^tmemtion is a pasaivo dwcase, and eonsiets 
simply ill tlir lat't, that the cni-filagp evils liavt^ imUlw^U jiiate- 
rial which untit« them for their nutrient function. There is also 
Another form of rartilaprinous tlegeneration — the grmuilar; it 
hiiH ttie saiiH* rffi-ct iijiun t)io hyaline HubstancM of Kplitting It 
into fibres. I^tiorcHCOpic oxamiiiation Khow8 that the eorpusclea, 
when thus affectwl, heciine miniiteiy sjwtted with a sultstaiiee 
more ojjaque than the Burrouuding material ; they, at the same 
time, become enlarged, but very shortly afterwards fihrivel, each 
corpuscle forming a thin trausverse «'&!« long before it comes to 
the free ed^o ; those lines, or scaled, appear divided, as though 
by tlic old cell-walls, hut tlie usual aspect of lite uOl and cor^ 
puicle is lost. 

I consider that thi* fatty degeneration of cartilage is similar 
to that degenerate state of the cornea, which Mr. Canton has 
shown to bo the essence of areu* (umilin, while the granular is 
comparable to the atheromatous condition of arteries. 

In neither of these oasefl do the nuclei and cells multiply, they 
simply absorb a morbid material and lose their nutrient power, 
hence the action in question is a passive one — a mere degeneration. 
The fumition of articular cartilage is so passive, and is spread over 
80 lai^ a Rurfnce, that vte have no means of ascertaining when 
these degenerative diseasi^s are taking place over a small extent 
of the tissue ; and, bring Imt |Mwsive clinnges, they are not 
accompanied by any hyperjcraia, nor by any pain. The ulcern- 
tion, then, of carlilngtrs may be divided into inflammatory and 
degenerative, and these latter again must lie subdivided. The 
changes whereon degeneration depends are situated in the cell, 
mi<l then'fore we must rh\ss them according tocon<lilion3of thai 
bo<iy ; hence the t*^rra tibroug degeneration is false, aud the 
mnre so as fibrification of the hyaline sul^tanco accompanies 
every morbid change of cartilage. We may therefore divide 
degenerative diseases uito fatty and granular,* and as these are 
mero passive change^;, occurring in a structure without sensibility, 
so they do not give ris** to any symptoms. 

There is anoth*!r form of malady resulting from deposit in tlie 
eartilogo of a morbid material, viz., urate of soda ; and it is a 

* There U do reoiiOD b> believe Uiat I tioa of rartilugo. iklUioiigli Uioro nu]' 
there oxmUhiiv other form of He^nef«- | be tvo rniru of the fi^ramdar type. 



202 



niKEASKH OF CAU'l'ILAGE. 



Chap. XIII. 



form that appenm fioarrMy to l>plong to tlie degenerative dasB. 
The chalk in dcpotfitcd actually in the cartilage, t.e., in the 
hyaline subjittiniv around the eorpnsclo; but the extreme 
ojmdty of the material renders it e-xtn^mely difficult to trace the 
cuunection between it aud the containing tissue. It soon splits 
the cartilage into tilircit and liett among them, and if the deposit i 
bo in any great quantity the fibres almi^mt disaj»|)ear before 
it, and the tissue is converted into a layer of ehalk-stoDe, held 
together by scattered tibres. Sometimes this dt'posit, or other 
cause, sets up influnitnatioii, and then the cartilage yields more 
completely, and the nmte is thrown oiT iutu the joint, sometimes 
en m(M*e, sometimes mingled with the pus, or synovia, to which, 
being held in suspeneiou, it gives a peculiar milky colour and 
gritty feel. 

Ijitlammat<:>ry diseases of tlie cortilago only occur when amy 
rounding structures aK^ inHamed. The reason thatinilammation 
of curtilage docs not form a primary joiiit-4iseuse is tu be fnund in 
the insuBceptibiUty of cartilage to mechanical or other irritation — 
on insusceptibility which constitutes its great value, — and also , 
in its shtggishness of action. Hence, many injuries or irritations 
may be insufficient to produce primary inflammation of cartilage, 
yet be amply intense enough to set up sjTiovitis, wliich may 
secondarily cause the cartilages to become inflamed. Or, again, 
an injury may bo suflicient to cause primary cartiUiginous 
inHammation ; but it must, at the same time, of necessity, be 
Bulficient to produce either synovitis or osteitis, or both, and 
the actions of either tiBSue being so much more mpid tlian 
that of cartilage, we find these infiammations preceding the 
cartilaginous disease. The question is not whether cartilage bo 
susceptible of primary infiaiomation, but whether, under the 
circamstanccs in which it is placed, such disease ever presents 
itself to the practical surgeon. It cannot, probablVt be directly 
proved that inflammatory ulcers of cartilages never take place 
unless some other port of the joint-apparatus l»e also diseased ; 
but wo know that tlie sympt^ims of joint iuflammatiun be- 
come greatly worse when the cartilages begin to jiarticijiate in the 
action, hence this inflammation is a painful and wearing disease ; 
but we never come iw:ro8s such symptoms nnaccfimpanied, or 
rather uupreceded, by inflammation (if other joint structures. 




Chap. XUI. ACUTE AND CHWWIC INFLAMMATION. 



293 



The inflammfttion may be, as wo have already aaiH. acute 
or chmnic. It consistfl esseutially iu the ra]>id generation of 
cella from tboso primarily exiHtinf; in the atnicture. WTion 
this generation is very qtiick, it absorbs the hyaline Ruifstanre 
rapidly, and an lUcer, with cleau-eut edges, is produced ; when 
the oction is chronic, the hyaline structure is converted into 
iibreg, which render the e<lge and bottom of the ulcer rongh and 
uneven. The changefl which the cells undergo have been de- 
flcribed by Mr, Rcdlem, who has nnt, however, separated 
degenerative from inllanimatory disease-s. The first appearance, 
in microscopic examinatiou of the iullaine<i tissue, is an incrt^oRC in 
tlio number of nuclei contained in the cells, and iu the number 
of cells in the corpuscle — heneo the increase of these bodies 
in size. In the most acute form of the disease the corpuscles 
arc CbDvorted into large conglomerations of cells and nnolei, 
lying very close together, many of the eclle containing two or 
more nuclei. In the meet acute forms this gn)wth is so rapid 
that it devotirs entirely the intercellular material, and thus an 
ulcer is left, with perfectly clean smtxith edgea. The cells, 
thus set free, fall into the joint-cavity, and continue to multiply 
afl pus cells (p. 43). A less rapid cell action leads ultimately to 
the same result; but the hyaline substance, before disapjiearing 
altogether, becomes converted into parallel fibres in the direction 
of the cell-force. 

Theclironic iuflamniatfon differs from this by the more plastic 
chnraeter of its results. A large number uf tlin cells formed do 
not simply become pus-cells, but being produced by a slower 
action have a more persistent character, and a more perfect life, 
lliey elmnge into futiifonn and into fibre-cells, and thus the fibri- 
fication of rartilage is, in fluch instances, not a mere mechanical 
splitting of hyaline structure, but \a also, in part, an actual pro- 
duction of fibred from cells — the material formed being a coarse 
sort of areolar tissue, or a fibro-cartiluge (p. 112). Much of this 
growth is not doomed to be persistent, but somo of it goes on 
developing further, while the action increases in area, and at last 
some of it cjjmes in contact with granulation from the synovial 
membrane, or Irom the bone (the articular lamella having in 
places disappeared). The two parts thus in contact are engaged 
in identical processes, the formation of fusiform colls into cell 



-V 



294 



IHSKASKS OF CAU'liLAGK. 



Ciur. Xlll. 



fibres and areolar liusue ; they therefore unite, or ruther grow 
together, so intiimitely (Iiat it is inipossilile to find the bonndary 
U^tu'eeii tlie two structniRs (p. 1 13).* When a disoaflo Btops ai 
ihi-s stage, we may tind. ii|x>n subsequent eiaminatioii, a parti»I 
and faUo oncliylosis ; timt is, tliure will be anchylusis in some 
ptrls. Bound cartilage in other* Sonietimos chnmic uleers, if 
jinuill, leave boUiud aiiuply a cicatrix, like a scar in luiy other 
tiasuo. These marks in cartilage are always the result of a 
very slow luHamuitition ; a more rapid action, iiistea^l of con- 
Terting this cells, their progeny and the hyaline substance into 
fibre- and Hreolar-cells, caii8L'.s tliem to disappear, leaving a 
breach of surface which is not filled up l>y any trar.t 

When the primary attack is an osteitis, tlie cartilage undergoes 
llio processes both of degeneration and inflummation. In arti- 
cular di^eatses thus commencing it is to be remembere<l, that 
genendly only ono of the bones forming the ji>iuts it* primarily 
uffectcd ; moreover, it is seldoia so uxtensively diseased tluit tho 
whole surface, whereon the (cartilage rcwts, undergoes morbid 
action at tlio same time. Now, the first effect of an osteitis njwn 
tho cartilage is, in most instances, a cessation of its supply of 
nutriment, hencu a rapid degeneration and detachment, with its 
artirnlar Ian»elU, from the inflamed portion of the boni_\ Around 
thes{)ot.'« whcro such degenemtiou takt^s place, the curtilage >rill 
not thus b*3 killcd,*as it were by starvntion, bat will become in- 
fiamed and ulcerate<l. The cartilages covering the Iwme, which 
still remains normal, will, whi>n tiie other joint textures become 
inflamed, [>articipato in the inflammation, just as they do in a 
synovitis. Thus, in articular diseases, commencing in one of tho 
bones, thero are two sorts of action going on in tho cartilages — 
inflammation and degeneration. The latter occurs over that 
portion of tho bono, whose inflammatiim has been so violent, aa j 
to cut off the nutrient supply, tlm latter over those portions !e« 
powerfully affocted, and in that cartilage covering the yet normal 
bime, to which the action spreads in the same way as it does to 



* It wiw thiit L-ditdituiii wliip)i led 
Mr. Ast«in Key tn cotioludo od t)m dc- 
Dtrtu'lioii of furlilugvA Ijjt gruwttui from 
«yniivia] mrmbmne. 

+ TIkti- IK, in (he Collejre of Suiftcans, 
u ['rffmnilitm liy Mi.tiiii tifan ult-i-mtiiiK 
CMTtilagu ill wliicli vpseels mmiry. 'I'hfw 
viianliiuumt! fium Uic'bonc^ bcnce Uieiw- 



bcnlnr lomoUamtut Lavu bc4.>n (terfomted. 
and if bo the cartil&gu would liavL> Iwt-n 
nlucratod. TIiutO'Iim:! wniild not gu per- 
fectly unat;rotuiHiiiiotI iutu u fhauuL'l in 
vartilagt*: it inunt liitve i^ntcrti) with u 
sjiroiiturgmiiiiliiliiMi lieDiii'. Tlic |>rr)Nt- 
niti<iuis(moJ,und itcouuotiiowSe iiuuli' 
oal ill wliul Btrui'tiitx' ihc vi-mk-I rctdly lies. 



tUAT. Xllt. 



UYPKUTItorUY AND ATROl'IlY. 



295 



the synovial membrauo. The cartilage which has sufforwl 
d^encratioD, and which hes over tho fociis of intluniiiiHtioii, is 
detached with the articular lamella by the ueteitid itself, aud in 
frequently pushed by a collection of pus, or a growth of graniila- 
tiona into the joiut-caWty. in which it is found lying loose and 
fatty, it8 formerly attached surface feeling gritty like eand-papur, 
from tlio ttdlierence of osseous matter. 

lu the examination of certain joints-diseases, viz., chronic 
rheumatic synovitis and osteitis, the cartilages will be found 
to have h>st tlieir opalescent appearance, to have become 
abnormally transparent, of a pinkish brown colour, and to be- 
very much thinner than natural. They have in sueli cases an 
even surihco, except rarely in a few small simts where th<*y 
may be ulcerated, the ulcers having smooth or nearly Bmouth 
surfaces; very frequently a pioce of eburuated bone will be 
found on the same plane as tlie cartilrt^intiua surface. I behcve 
tliis condiliun to be a slow form of inttnmmation, teudinjr, like 
other processes of rheumatic origin, to the completion of all the 
|>arts involved. The attenuation. I believe, takes place, n(»t frum 
the i'ree hut from the attached surface, by encniachnient of bone 
upon the cartiloj^e, and this opinion is much strenj^thened by the 
(act, that there sof-ms to be a solid case of bune thicker tlinn usual 
between tiio osseous cancclli uud the cartilage ; moreover, the 
articular lamella gradually assumes more and more the stnieturo 
of ordinary bone. 

It is certain, that any tissue endowed with nutrient power 
must be capable of both hypertrophy and of atrophy, but practi- 
cally we do not c(tme across such diseases. In young subjoi't;?, 
the cartilage may be found excessively thick, but I have always 
attributed this to delayed ossification of the epifihysis. In 
adtilts, the cartilages may be found slightly tlnckencd, but 
they are tlien likewise .sodden and soft, and their increase may 
result from mere passive imbibition of fluid. Still, as nUjvc stated, 
tlie [Xfssibility of simple hyftcrtrophy cannot bo denied toatisaae 
cajnible of both nutrition and iullamiimtiori. 

Atrophy of cartilage, as describetl by some authors, that is con- 
siderable decrease in its normal thickness, results, I believe, 
from encrortclinn-nt of bono upon its d(^'p surface, ns just 
de8cribe<l The granular an<l fatty degeneration ih the result of 
atrophy, and the only imduubted form of tliis condition. 



294 

fibrt 
togi 

bet 

r 



I 'I t, 



' '/„;; 



I!n*p. XIV. 



I'LACK OP COMMKNCKMENT, 



297 



liue thii disea»e has been miule to commeuce in the ligamontum 

eree, and iii the cuiiiluge as well as in the bone and synovial mem- 
Tlu' syin|it<iniB, viz., lengtheniup, shorteniiif;, jmin in the 

nee, &c., Imvo bei'U uttributiHl to ulinost its many causes as 

here have been anthorities Ut iwsign them, and thus the 
luhject la involved iu a hibyrinth of falsity and conjecture, from 

rhich nothing but a simple following out the lead of truth can 
fever rescue it. 

First, as to the structure in wiiich disease of the hip-joint 
Biay commenre : there can be no doubt that it may begin in tho 

^Dovial memhnme, and in the Ixnie, liko other joint diseases; 

hiere is no reason to suppose, nor is there the slightest proof, that 
Ht may commence in structures, in which diseases of other joints 
ilo not begin, for instance, tho ligaments. We have seen that 
when the siibsynovial tig«nes» in which ligaments are placed, 
inflame^ the ligaments themselves suffer, soften, and l)ecomo 
thickened or aljsorbed as the case may tend ; wo have wien that 
internal ligaments, as tlic crucial of ttio knee, which are sur- 
rounded by folds of synovial membrane, and wliicli are in the 
ixjeition of a subayiiovial tissue, are more apt to follow quickly iu 
this course, than external ligaments ; but the disease is not the 
Ic^s ft sjTiovitis, because there happen to be internal ligaments 
which participate early in the inflammation and become quickly 
changed or absorbed. How very frequently does it occur in 
tho knee joint, tliat tho crucial ligaments have entirely dis- 
appeared, even in cases of subacute synovitis, whero tl»e cartilage 
is liordly altered, and where the general change in the synovial 
tissues is but slight ! 1 have also seen the crucial ligameuts all but 
converted into g<^iatinous structure, their presence being only 
markc<l by a few white ligamentous lines, running parallel to 
ven'h other tlirough the pink mass. Iu the same way, tho 
ligameutum teres of the hip Joint has been found to ho much 
8t>ftened and inflamed, while the synovial membrane around it 
is red and hypera>mic ; but lliere is no possible reason for 
assuming that the disease begins iu an inflammation of that struc- 
ture more than in any other part of the sj'novial and subaynovial 
tissue.* Other authors have located the diseased action in the 



* Mr. A(>l>iit Kt-y unfcirtiinitli'ly luldn 1 litry : Itt- jfivrHRiiHcitouuLdfahift-i'imt in 
tLi* wui|;bt of liiit authority In tliix fuX' \ vrUidi )iu fimls tli« wIiuIp kytiovial an] 



Hir-JOIN'T 



Ciur.XIV. 



fiit which lies in the btrttum of the cotyloid cavitT ; bat this 
opinioQ is ttjo aittiquatod, oud too far behiud tlie ecienoe of the 
prosent day to need seriuus refutation. Again, the cartilages of 
the hip are not difron.>ntly situated tothoso of other joints in 
r^ard to tlieir uutritiuo and diseases; they are as often, or 
indeed inrty be more oftt^u Ihun in other joints, the i***ul of dege- 
nemtiou (p. 290) ; and in old sabjt<:tti, in whom duriu^ life iin 
symptom of joint disease existed, sach degenerative ulcer? vill 
very frequently l>e found ; but, except this condition, which doea 
not product) u dutectuble joint diiieajte, there lA no malady of the 
hip commencing in the cartilage, any more than there is a 
malady of otJier joints beginning in that structuro, 

Tliua we come ngaiii to the two tissues, viz., synovial mem- 
brane and bone, whose inflammation i^, as we have seen, the cause 
uf disea^ in other joints ; and I am iiurc of truth in assorting, tliat 
every hip disease commences in one or other of these parts. It 
is, however, a matter extremely difficult — often, I believe, in 
practice impossible — to decide whether a disease already some- 
what advanced may have been originidly synovial, or osseous; 
as may U* supp.isetl from the fact, that some men of great ex|)e- 
rience and Cfkro, have asserted that ail hip joint diseases begin in 
the Ume (nust,, of Vienna, held tbisopiiuon). while others have as 
positively nftirmed, timt all tnich maladies comuieiico in the 
synovial membrane, in the earliest stages of the disease, wo are 
able to conclu<lo with tolerable certainty concerning the stnic- 
ture in which it is situated during the patient's life, and 
on examination, path<ilogtcaIly can always ascertain the fact ; but 
if the iiiseatte have advanced to the second jwriotl, the attempt »t 
diagnosis on the living patient will be vain, luid tlie tiuatoinical 
examination even will very frequently lead to no positive ctm- 
dusion. In oitier to p(^>int out distinctly the difficulties in such 
minute diagnosis, tmd to place tlio whole truth b€*fore the 
reader, it will he well to enter minutely into the symptomatology 
of the disease, and to trace where possible the cause of each 

ftubsynovial ti^uc inQoiucrl, nnd iLmonir 
It lliKt p«irttt'>n whirli ftivt'Kiposunit in 

iiart v(itibtihtU-8 Uu- ligauR-iiliim \vTva. . 
It* layt, " till! caflC'H whiili il haa f;iUt'u . 
■imlrr luy lot to cxamino Liivo iinliicM I 
nut to briii-vi' thnl ulceraliuii of the car- , 



Ulk(^* is pnwmlMl by inSiuiirumtiuD o( 



the lignmcDtnin ti>rc8." Mud. Olii. 
Trous., voL xviii., p. 230. Wk ric«t w»l 
lieri: tiit4.T iutu tlii.' {;;4^'ULTal ri-Liti<>iu<lirp 
iKtwi-eii uk-tnitiuii of ciLTtilu^*.- nud ill- | 
Ibiiiiiuiitiiiii of BViiuviiil nii'iuljniUL' : tito 
iwuiti wurdu of L'UUTBH' ni'I'ly U> thfa M t<> 
uthvr jninttf. 



CHAr. XIV. 



aYNovrric and osteitic. 



299 



separate Hjiuptuin : in tloiiig so, I will eu<leavuur, tu the best 
of my ability, to imilco a rlcar and brood distinction betwetfu 
what is absolute fatt, and wliat is moro conjecture. The patho- 
logy of the 8\'uovitLi or osteitis, will not be a^u bruachuti ; wu 
have now only to do with tlio ttyuiptoms nud their correBpoudiug 
morbid anatomy. 

Fint Stuge.* — The b^^inning of hip-jolnt disease is marked in 
children, who (Jo not imd oinnot express all their seuiiatioUH, by 
Hlight limping, during which the knee is somewhat bent, and the 
foot turned either inward;^ or more c-ommonly outwards. In 
atluUs, the diiH,'usc commences by u sense uf faligne, or of Hctunl 
jioiu, the more readily remarked, that it is only situatctl in one 
hip. At this pertoil, and for a short time afterwards, thcro 
ap])Oar certjiin symptoms in Mime ca£>eu, which are absent in 
others, and whicJi may enable the surgeon to define the synovial 
or ost«al locality of the disease. Tain, t^'uderuess. swelling, heat, 
more or Ktss immobility, arc, at this stage, all we cuu fix upon 
as indications of the disease, imd it is to the variations of these 
syinpt<3ra8 tliat we must look for our means of distinguish iug tho 
one form of malady from the other. 

StpiovUU. — Pain includes ull the different dolorous symptoms 
produced by the disease, whether thoy occur in the hip itself, or in 
other parts of the body. The pain of chronic synovitis may, in tiio 
hip as in other joints, bo absent during the first days of the disease ; 
but whoa it comes on, it is c<^>ntinuous, and more severe after 
exercise. Limping in children, which is produced by the paijs, 



* Brodic. iu hill ndinirfthl[> work 'On 
DiwoMW of Uio Joiiitii.' lull* not f^tvon a 
(poaial divisitjn to niorbust coxa-, liut 
'doiicribes it will) othi-r jnirit-<]iw'n.i<tH 
' ucordlng Ui tlic anntomiral »i\\a u( tliu 
laiilady. Fonl, whose * ObMTVutioiu on 
DUmik urtb<.- U![>-Jo:Dt.' 179i. luis been 
a Mirt ur uti&oknovlcdged totui-^Ilicf for 
miuiy au Iwiequeot writers on t]ic aulijct-t, 
1b tlie drat mrgooa wbo iu&kt-« tliu'o 
pericHls in uiorbun coxoriiis. He dood 
Dot ear lu so niatiT wonlu tbat tie di- 
Tiflca the malftdy inbi thrDo s1sji!Cil hut 
ho gives a di-Hcriptinn of ttiiY^c auccoff- 
UVD ptrifKlH. 'I'hit dinflioQ U of the 
gratitCNi iiiiporliiuov. IIU flnt atego 
extendi fnnu tUt commeneemont of tbo 
diML'UMi tu thf iir»t :ipp<wjuiicu of li-iijcilh' 
cniu^; of iU(3 limb ; tbu itvuuud mIaku 



reac)io« frvm this uccurr^nco to tho bq> 
pcrrimtitin of marked nhuriening, tithur 
fruin diHlfwatiim or uUicr cutuo ; Uio 
third, hc>gintiin|7 with this ihortcuiog, 
goes ou to t)ic> end of tho case. Iloynr 
and UuiwoaeuTQ take two BtAfroa. Uie 
flnt extending from tho comuK'tici^nn-iil 
of the disease to ditlocatiua of Uil- litwl 
of the fumur. Riut niukiD four : firitt, 
tlie commencement ; vecuud, iL-n^tlit'ti- 
ing; third, shortboiog; fourth, tiuupur»- 
tioii. Cheliiia (fiouth's I'miitflutiun) 
dividci tbo lunlAdy into tho iirat tlirve 
of Kost'i •ection*. Vfv will adhurt*, 
mare or If si cIoju.-Ij, to Ford's divi«on« ; 
but ho Juui hanlly made tli(-iii mu(H- 
cieotly dtfiuiti.-, and it in a di-fHct wbiub 
shall, u» far ua |HM8ible, be supplied. 



aoo 



HIP-JOINT niSEASK. 



CiiAP. XIV. 



may be observed to have tbe fol^wi'ng periods of greatest inten* 
Bity. Ill the morning, on first rising, there is some lameness, 
which gucs oil' entirely iu the t-arliest beginuiug uf, and only pir- 
tittlly a little later in tho disensc. Towards cvt'iiing, or alter 
any continuous exercise, liniiiing returns, and is more marked 
than in the morning, and becomes moro and more so as the day 
goes on, or fatigue increaues. In older persons, who can define 
their seusatioUH, stifiuess is complained of in the moruiiig, while 
in the evening, or after long exercise, pain moro or leas acute, 
with a sense of fulness and distension, is felt 

With this, there is tenderness on pressing at the back of the 
trochanter, and tendemesa at the groin ; but pressing the tro- 
chanter inwards, so as to bring the head of the femur and the 
acetabulum into close contact, does not cause jmiii. There is not 
in this early stage of synovitis any pain in tbe knee. There are 
iiont) (»f those stortings that wake np the patient nt nigl»t with a 
great dread. 

As these symptoms come on, they are accompanied and 
followed by a curtain amount of swclliitg in tjie groin, and 
behind the troclianter. The former of these tends to obliieralo 
the forfsu in that situation, or at least to render it narrower by an 
npjtoi'c'iit increase in breadth of (ho jK»st<'rior part of the tro- 
chanter. This, in its early condition, will only be seen when the 
patient, placed with the bnck to a window, permits equally oblique 
light to fall an Ixitb hipe. The swelling in the groin ie both 
more visible, and more easily felt ; it lies of course below Pou- 
part's ligament, is deep seated, has an even surface, and must 
not be mistaken for enlarged glands. Be it remarked, that 
when Ibis swelling in the groin becomes easily perceptible, 
sympathetic pain in the knee usually supervenes. Increased 
heat at the part, chiefly noticeable at the back of the troclxanter 
and at the groin, comes on with the swelling. 

OsUitis. — Pain, iu and about tbe hip joint, is of a heavy, dull 
aching character ; it is not increased by exercise, but is gene- 
rally most severe in bed at night; there is no stiffness in the 
morning. The pain is ollt?n irregularly remittent, lieing ctm- 
tinuous for tJiree or four tlays and night-s and then disappearing 
lor a time. In ohildron, a |mlc, worn, w^ary luuk will be ob- 
servctb before any limping actually come* (nt, and Uie child will 



Chai-. XIV. 



DIFFKHENTIAL DIAUNdSIS. 



SOI 



sleep badly at ui^ht, ory perhaps if laid od tho disfased. but 
as yet uunuspeoted, side. Ttie t^igiis of paiu, as well tLt tJie 
worn look in children, come on before any limping ; in older 
persons, pain is complsdnetl of before such a piwitive symptom 
is pwnxfived ; ihif limpiu<^, when it once does come on, ia eqimble 
throughout the whole day. There is uo tenderness while pressbg 
behind the trochanter ; nor, unless inflamed by otitcr causes, over 
the groin. We shall see directly that certain circumstances 
change this condition. There is early pain in the knee, startiiigs 
at night may come on in this, the first stage of the disease, and 
tenderiietw on pressing the joint surfaces ti>j^ther is not uncommon. 

With these symptoms, there is nu swelling either behind the 
tnx^hanter, or dcojt in llio groin ; the glands of the groin how- 
ever are frequently enlarged: this is a point which should have 
great weight in forming the surgeon's opinion, and is the cause 
aJiudod loin the hist jtaragrajih, ns inrtuencing tenderness of the 
groin on pressure, Ther.' is no increascil heat about the i>art. 
Add to these local signs, that a eliiid in a very cachectic condi- 
tion from sinnna is mans liable U> be attacked with osteitic 
than with synovitic hip disease, and the fact of the general 
hcmlth failing in u manner still more marked, before any lamo- 
Dess is peri'eptible. 

A long series of careftil observations have convinced me that 
tbiti account may be relied on wherever the semeiology is suffi- 
ciently marked. To render this more distinct; I will tabulate 
tlie symptoms of the first stage. 



Synovit is — Symjitomf. 

The paJD is a sense of ftalnen, di»- 
teiuion locrvucd iu oTouiag, and after 
oxoreise, but coofitaot. 

Sliffiieas ia reoming. 

Liininiig earner on with the pain. U 
is at lir«t Blight in morning, then di»- 
appears, and is mon* marked in evening. 

Pain ID kno© does not oome on till 
aftrr tlir dM'p ftwolling in the intiin is 
ptTcepiibU'- 

Starting of the Ihnb a late aTiuptom. 

Tondnrms behind trocliant«r, and :it 



Ostritis — Symptmni. 

Pain, doll achiiig ; muet at night in 
bed ; remittDai. 

No stiflhiOM in Uio morning. 

Limping does not coma uu till oftfir 
tliu puin \\aA exi«tu«I somi' time, then ii 
equable throughout the day. 

Pain in tl)o tniev an early srmptoiD. 



Btarting of the limb uu eaiijr Bymptooi. 
No tfiidi-rrutid on prewing behind 



groin: DoneoaprMsingurtieuhtmurlmtdfl tr>i.'lLiutli>r mid F^min, but tumvtimHH on 
iogtlhcr. prewintj; juiut tturfuoes togetlier. 

Tlie BWi'llin^; in the gniin is deep, Tht.- ghuitlx in the (^loin xwl>1I l>er<>rn 
and below Poupart'8 ligament; the glimds an; deepor swelling ib pi'n^eplibli-, if 
there do not avridl. I <*vennieh ronii* on iu the flnitsldgA. 



802 



HIP^TOINT DISEASE. 



I 'HAr. XIV. 



Nothing can tend more ofTectuallj to throw undeserved doufat 
nptm facte tluiu struiniug theni beyond tlicir legitimate applicih- 
tion ; and I would deprecate as stmnfjly as possible any attempt 
to press the above dia^osUc differenco into t-ascs, that liave 
advanced beypnd Ibe first staf^, or even towardi) the latti^r mid 
of tliat period. As the disease proceeds, the clearaees of the 
symptoms becomes obliterated ; the limping in cith(.^r cose is con- 
tiiiuons; tht^rc in tA^udemess U>th behind tlio groin, and on 
pressing the joint surfaces together ; and starting at night, if 
previoitfly absent, vill come on. The whole train of symptoms 
may have ccmtiuueil an iodetinite time, for morbus coxarims, like 
all diseases, has an acutt* and a dironie form : the acute malady 
uiuy ^lUop through all the variations of the first stafre in a few 
days, or even liuurn ; the rhrouic may continue for months as so 
slight a disease in ap[x>amnce, that it is scarcely regarded ; nntil 
the more serious symptoms which immediately precede and lead 
to tlio second stage 8U]>ervcue. 

1% Second Stagt consists of lengthening of the limb ; flattoning 
uf the nates, with a lateral tMrist of tlie spine; constant and 
strongly marke^l lameness ; a more or less dtutiunoun pain in the 
hip and knee ; spasmodic paius at night iu the limb, beginning 
about the hip and upjwr part of the thtgh ending at the knee; 
contraction of certain muscles and wasting of the limb. Fn this 
period of the aflbctitm wc hnvo no longer an)'thing to d<i witli de- 
tecting ill which stmcture the disease commenced, but have simply 
to observe the symptoms of the malady. Tlioso which luul l)een 
increasing towards tiio latter end of the first stage, viz.. pain, both 
at hip and knee, temleruess, swelling, and limping continue, and 
there is a<ldnd another symptom, viz., [K^turo. The thigh is 
constautly flexed upon the abdomen, more or less in difi<'ront 
cases; the knee is generally rotated oatward?, and the foot 
everted. If the patient bo made to stand up. he l>cara all tlie 
weight of tlie bixiy u[K)n the aouud hmb; the knee of the diseased 
one will be in a piano in (root of that of the other, in conse- 
quence of the hip being flexed, and also iu consequence of 
a malposture of the pelxij^, shortly to be described, it (the 
knee) will be also se|>aratcd from its fellow. I.e., abducted; 
the foot will rest witli the pole upon the ground, u good deal in 
front, with tlir to«» nsimlly turned out, though it will sometimes 



Chap. XIV. 



SECOND STAGE— LKNOTOENINC. 



ao8 



bo turned in.* At the same time, the knee of the offccted 
Bi'do becomes lower tlian tlic other; that is, the thigh apiiears 
Icngtliened. The buttock of that 
Bido is flatter, the folds of the 
uatos longer and less marked 
than notioal, the deproaaion at 
the back of the trochanter nearly 
oblit^n-ated. (See Figure.) The 
nppeoTftnce of lengthening in the 
liuib is the symptoin, par ercel- 
ktice, wliieh morksji thig sta^j^e 
of the malady. Much bought, 
and more writing, has been 
expended in endeavouring to ac- 
count for tlua apparent increase 
in the length of the limb. Most 
English, and some Continental, 
authors refer it entirely to posi- 
tion; others b(,'liove tliat a real 
leugtheuing may take place, tliat 

|iis to say, they believe that the 
bead of the thigh bone may, 
without dislocation, be projected sufficiently far fifom the pelvis 
to cauflo the whole distance between knee and acctabulnm to 
bo increased. I am, from the results of experiments, able to 
affimi, that real increase in this distance is without disloca* 
tiou downwnrds utterly impossible.f The position whereby 
a|qturent lengthening in hip-joint disease is obtained is a 
twist downward and forward of the affected side of the pelvis ; 
the tbigh is flexed upon the body, abducted, and rotated out^ 

[ .^Brds.; 



Hir.DuEUK— TuK PoBinoif or 
Apparent LicNututNtitu, 



I hare amn tbi»poritioti twloe,both 

Bt in yoimc <"hiWi*n. 

t Th«M«-xtKTJnH'ntB anil the opinions 

^of Cf^rtain autlinrfl atp, in onlcr to lr-«TO 

ftlift pourw' of our narmtivo nnintiT- 

rupU>d. plucRil tnt;ptlicr in on ojipendix 

tu t)>e pn AiQt Phfi{>t«r. 

I M. B»nnnt hns ffiTMi nt crnnt 
ten;*th an oiialvitis into all the Tu-i(?lic8 of 

ti>-itMiii whioli <ln* tliipli niajrnsmimi'in 
Ill-joint 'liMiuo . Imt not perccivitip tlit- 



pntcticftl Toluo of BQcli minute di«tinc- 
rjuua, I shBll not qnobi all his dtiSnitiom 
Mid argtiinvnts here. Ho fthowoby ilniir- 
iili^ frotfi tli4.'skcl«.'tnn i»ik1 nthcr mi-nns, 
tlint wIi(-n«'T<^'i til*' thiiili Hpp^an; Icn^jlh- 
cnfd.from ilt'pn tmion of tliut side of the 
pclvJB; the fviiiur miisl he nlHhictod : 
wIwnoTnrit i» ulinrtnm'ri t>y elPTntion of 
tlintttiiloofthufK'lvisiltntistK'iuIilucti'd. 
In this Bcasti tlie two worrtd oriJy rr-Intf* 
to thr )N'lvi!) itself, not to i\\f lucin of tin.- 



3(H 



inP-.T01NT DISEASE. 



CHAi. XIV. 



The wholp aide of the pelvis is alfto thrown fonviirds. This 
aida in increaging the apparent lent^iieninj;; of the thigh, and it 
dimimahes the pi-ojectian backward of the tuboroeity of the 
iscliium, thus proiriiriug a flattening uf the nates, r*vi»n thungh 
tliere be no wasting tif tJie glutens. These twisU of Iho |)olvis 
cause the rima natium to Incline from below upwards and towards 
tlio diseased siile. Tlie spine iUself will be thrown into eorrc- 
S|Kiuding curvatures all the way up, and thus a look of general 
distortion Ih} produced. These signs are all merely the result of 
posture, and may Iw imitated by any one who has an accurate 
knowledge of the appearance to be aiiBumed. The only luipro- 
duciblc ]H>int is the obliteration of tliu foiisa behind tlie great 
trochanter; this in disease is much filled up by swelling. But 
in examining a diseased hip it does not sufiicc merely to place a 
patient upright before us ; the examination must also be made 
under diffcrfnt conditions. 

In the fii-st part of the* second etage tho position is not so do- 
termiued, nor is tiic limb so fixed that it cannot be moved slightly 
and examined in the recumbent [Histure. Let the patient first be 
on the back, upon a hard surface, such as the paillasse of a l>ed, 
or a table. The j»elvis mu.< if possible, be placed at right angles 
with the spine, and the thighs at right angles with the trausrerse 
pelvic axis. In all probability these attempts at adjustment will 
be unsnccessful, but at all events there may remain so littln twist 
that it wonld re<juire a very acrnratc and pnwtised eye to detect it. 
The inner condyle of the femur ofthe diseased side will seem lower 
than llmt of the sound one, so will the tuberosity of the tibia, in- 
ternal malleolus, or other anatomical |>oints. Now, if wo measim-- 
the limbs we shall find little if any difference in their lengths. 
What (lifl*en?nco wo do find is, surprising as it may seem, contrary 
to ocular appearances. Thus, the limb whicb appears hmgcrwill 
(particularly if tike measuremcuts be taken rather on the onte.r 



body. I will explain tfau io my own Inn- 
guogo more lenely. I<et uh eiippoectlio 
tnuurrenc bxu of the pelvis lui imngin- 
kty line drawn iM-twpcn the two aetata- 
bula, tlto tbif^li jh nfither Bh<lucti>(I nor 
adduL-ted UB lunfr as ita axis is at ri(c)it 
antics with thiA line. Stippotw tbe pel- 
via tilts no tluit thv iiXLt) of tli6 tblgli« 
fuiuaiu Uio Baiuv, but Uiut of tbv pelvJB 
bi'comu oblique, tht* lutter will be at an | 



obtoao ani^If witli tlie axiH of one, at an 
acute tinglo with tliat of tbc other, limb ; 
tliB fnrmiT ia ab- the Inlter nd-^hicted. 
If thp ax(^ uf thv tluglui be of tbc flame 
length, it will U' at oneo soon that whilo 
the pi'lvis thus tilts, one will be drawn 
lip. HhortcDfd : tlie other deproacd. 
leagthi'ncd. Shortuniiig corri'siKMuls 
then with ndduutiun ; Icugtltouiutf witli 
abduction. 



CiiA?. XIV. 



FLEXION OF rELVIS ON TUIGH. 



305 



gifle) measure sliortor timu tlie other.* Various instruments and 
methods, of different degrees of complication, have been in- 
v«'nti'il. in ordtT to get acciimte niownrenjeuts of the llii^h in 
hiiMlisease. They areall futilo, its they have been invented to 
Cud out differences which are only ap)>arent. 

Another iv>int in this |H)sition should In* attended to. It has 
heon gaid that in the second stajje of morbus euXHrins the thi^li 
was lU*x<tdon tlui uhdomen, yet the patient muy lie with elioulders. 
buttocks, anil heels upon a plane surface. If nnder such condi- 
lioua, however, the ixtsition of tho pelWs be exaiiiln(,'<l, it will l>c 
futind to be abuonually pt:r[H-'iidi('uhir ; in consequence of which 
tiic lumbar and the lower dorsal spines are arched very con- 
eiderably. and the liand placed below the loiiLs will find a large 
gap between thera and the mattress or table. This, it need 
ecai-cely be said, is not the metJiod in which a healthy [ktsoh 
lies. In fact instcjul of tht- thitjrli lieintj; flexwl njxHi the ])t>lvis 
the pelvis is Hexed upon the thigh, and the n-liitivti [Hisition is 
tlie some. 

Next, let the imtient turn ujxni tho stomach, and let tho state of 
the nates, the inclination of the spine, and the relative apparent 
length of the thighs be examined, and it will be observed that 
distortion is not so great m this as in tho erect posture, but it 
still exists. In this imsition the surgeon will most comfortably 
and remiily examine the depression at the back of the trochanter, 
find any swelling or fluctuation, and the exact scat of tenderness. 

Such is the condition of the patient, as far as mere deformity 
tgoes, in the early part of this stage. The pains of which ho 
complains are several- One, a bursting, aching, gnawing, or 
burning ]wiin, situated Ijehind the trochanter, and in the groin, 
geneniUv both, and this is conibiiuMl with some decp-seatetl, 
perhaps fluctuating swelling. There is another paiu, uf a lesa 
defincHl nature, tho well-known •' pain at tlie knee," which is 
usually referred to the imier condyle of the femur ; but if the 
patient be told to put the finger on tlie exact spot, he will be 
rather uneertuin as to the locality. It is sometimes remittent, 



• Tliia curiouH fnci woh fret cxpliiiiii'd 

hv Oiulcclieiid (*lijU]iburgt'rZtitrt;brin,' 

]83<<'i, who allowed Ihat wlit-n tlic ilitirn 

f ]m'liiii»» to une »lil(*, iu criefai mitt^i np- 

pnHirli tliu IruutmLtbr of tho fomur: 



tliiu*, lliutiuh Uk' wliolu tliigli may idnk 
unil u]>pi>ar loni^pr, tho mtafinrciucut be- 
twci-ii amy point of the crinta ilii nnd 
of till.- llii^'li mii^t Ike fhorti-r thnn thu 
fttliiT liiiili. 



306 



inP-JOINT DISEASE. 



Ciui-. XIT. 



aometimes constant; it luay he Abeent for hours, aud tlien 
rctarn with a sudden stab, vhicli makea the patient start, and 
sometimes scream. It iK'iiisionally comnieiMvs befortr this «ovond 
stage oomes ou ; but cveu then it gets worse at thl^ tiino. m that 
it iH moru especially a symptom of this nu<l the subtiequent 
period of the disease. When it occtira early in the cane, for 
instance, before leugtheoing has cominenood, it occasionally 
leads di^nosifl somewhat astray. I saw but a sliort time ago a 
case of hipjoint disease, in which blisters and other treatment 
had been applied to the knee. It is nooessary, therefore, U* 
giuird against a too confident diof^osisnithont sufficient exami- 
uutiont more particularly as the chief scat of [fain in knee-joint 
disease eorn^spoiids pretty closely with tho spot usually pfiinfnl 
in morbus coxarins. 

Tho pain has been said to be of a remittent character. This 
ia fieuorully, but not always the case ; sometimes the remissions 
are quite free, wimetimes not sa WTieu Oio intervals are not 
free, it is observed that tho periodic pain gradually aasumes a 
difl'erent cliaracter, luitil, in the lutter jmrt of tliis stage, it quite 
overrides and conceals the urtUiuir}' lU^hing in the kne<', and yet, 
while still nut very severe, mingles with, and for tho moment 
takes the place of the other. The intensity of these latter nightly 
pains is very variable in tlie period of lengthening, but is never 
BO severe as during the next stage — that of shortening. More- 
over, when their severity during tin; second ])liase greatly in- 
creases, we may confidently expect that the third period is about 
to commence. The pains owe tlieir origin to different causes, 
although, of course, all derivable from morbid irritation.* 

Ist. Direct irritation of the nerves passing in close contiguity 
to tlio joint. These are the obturator nerves, tho sciatic, the 
gluteal, aud perhaps tho anterior crural. 

• It wouliJ IomI m very fur iudowl t» Itgnraent (IhiB hypothesia iB. htwcwr, 
give nil th« ditlieiviit «)latioiis. right or too frtr-felehcd, iind U fouadod upon no 
wou}?. wliicli Iiavo Ihn-ii rttt4UiiiU-d, y*-t focli. Riclit-t conceived It to be du.j to 
it w only pi>.'|icr lliat wiino should lie propagBlimi of the Uifiitmination along 
qufltod. Sir C. Ik-U uttriliuttHl Uiiti thu mcclnllary canul to the lower oiid uf 
pain to irrititiiMioflho oblumturiiorTL'. ~ 

Bir B. Urodic Apfu-nrii to cntinrtiiin a 
aimilar ujiiiiioa. Op. uit.. p. 123. Coiil- 
•ou, to cualinuily of thu iDflammalion 
along Um upoiiourosu of Uio reotna 
maaolu, one of wlioao heads iiruMi from 
tho bordur of thu ocetabulmn, aod ji 
olosoly connoctM] with tho ootylwd 



the lione. Bouui't a»nbut<--l it In miiny 
iiutaacefl to umlposition. whidi rausud 
conntaDt Ktraiii on thi< Ui^auiL-utii and 
muHttes of tlic kne4>. tttnuut'ycr lo 
opium of th*^ pscNU) mid ilia«'tui InU'ruus. 
WaltUuT mul Kriekf t-i >viii)qithy bo- 
twecn the two umta of the buiw. 



Chap. XIV. 



CAUSKS i)r PAIN AT THK KNEK. 



307 



2iul. An obscure sj'mjjathy lKJt\vi>t'ii Ibe two ends of the bone, 
or even direct propagiiliou of the iuilaiuuititiuit from one to the 
other. 

3rd. Spasm of n^rtuin muscles. 

Tlie firet cause is that which Sir C. BcU aud Sir B. IJrodie 
iwlvtM'rttc ; and when the close proximity of the obturator nerve 
and of the anterior crural nerve to the joint he considered, it will 
not be Burprituug that they uhoiild Ix.* iulluence<l by the prcs* 
sure or organic irritutioa of the dirieaae. ]{rodio reliiteR a cnsc 
m Ills cliapter on ' Ni'imil<riu of tlin Juints,' • which gliows that 
Huch referred Mens«tioii is j)Iiy&ioKijirical. — "A niau wa» admitteii 
into St, Georsiis Hospital, under the care of Sir Kverard Home, 
eompliiinin^ of j«iiu in the knee, aud of nottiing else. On in- 
quiry int4.i hiH ca>ie, however, it was also fonnd that he laboured 
under femoral aneurism. Sir E. Home applied a U^ituro above 
the ttunonr, wliicU iiiiniediately (liminislied in size, the pain in 
thu knee subsiding at tho Rame time. The patient died after- 
war<]8 of venoufi intlaTuniation, consequent u|X)n the operation ; 
and on examiuinj^ the limb I found (^mt some bmucht's of the 
cnnut nerve lay on the surface of the luuiour, which terminated 
in the exact spot to which the pain had been referred, and thus 
&\ oure explained the origin of the paiu, and the subsiding; of It on 
the tumour becoming reduce<l in size after ligatnre of the artery." 

TluB ease shows that pressure upon the anterior crural uerve 
will produce tliis peculiar paiu iu the kuee. The obturator nerve 
lies in nfl chwo a relation both to the hip and Uim kneo joint, and 
would doubtless be iullueuce*! in a similar manner by morbid 
pressure. 

The second cause is obsonre symjiathy, or propagation of the 
inftmnniation by coutignity of surfnce. There is no more tempt- 
ing method of cutting a difficulty than to refer it to sympathy, 
but thiri |>artieulur instance is supported by one fact, given by 
Wedenif'yer.f 

* Oti. cit., 5Ui (rdilioQ, p. 2S1. 

t W«JriiiLyor, in )*peii.kiii^ of nn- 
croHia, »i)A " All llu-m- nviiipiithi'tie 
piiJQH Wvi^ thix |KRiiliarity, tliut liivy 
liervr ps«» ulmij^ tjio tit-rw-x tiiiwords, 
tliat ^» towiirdx their ori};iit, am) tliiU 
tli«y arv nuvur incriiwi-i) by uutwoitl 
prcBWre, an<l Uii« lottor cirL-iimt«lunou 
should nlwujTft pro>laoc a Kiirtpicioti of n 



distant origin of the maliuly. Lutllj-, I 
miist nruturk Ituil tbfiMi puins Udiiidly 
follow the ctiur»t' nf tlic iitrvt' lyitig 
t^luM! to Uic ducuiM' ; lint tlint tht re ora 
coiiott til which th<:j aiv Inin^iailh^d 
alunig till-* niudullo, or olnnc' the jicri- 
tMU-uju of llu' lioue U> lis ouiL, TLuB, I 
liuTu noMi iinikT my cnrti an nafortuuuU] 
Ixiv Miflering from ooriev and Buppuim- 

X 2 



30H 



HIP-JOIXT DISEASE. 



Ciur. XIV, 



In otlribiiting ihn |Hiin of tin? knee to pmp»gmtiou of Uie in- 
flnmmation along a continuity of surfnce in the medoltary cazial» 
H, Uicliut only fullows riut liU mclJiiHl of accounting for mjinj 
Wttivleringf uncertain sonBatinn^, wliicli, he says, accomjfany joint 
difieaae. But thU wouM not l>o au adequate cause for the riolent 
pains, thoo^'h it may be so for the constant rlull aching. 

The third cause, viz., spasm of certain muscles, I hold to be of 
very irreut inijmrtance. It is ooonected with both tlie dull 
Itching and with the sliarp intermittent piiiuK. Thtttt? hitler ar» 
chiefly pn'valcnt nt night, when tlie |mtient is sinking to sleep. 
They arc sudden, both in their appearance and disappearance; 
coino with a great jump or start of tJic limb, wliich wakes the 
iwticnt with a cry or moan of distress. In the first i>art of the 
lu'^ht, K-^foro tho patient is verj' heavy with sleep, tlicse attacks 
wake him altogether, with the expression of dread and |«un pecu- 
liar to luB ago ; later^ when slunibfsr is i»rt-'tty sound, the pjiin.s only 
Khirtlu him for an instant, perhaps produce a sharp ciy, hut ho 
sinks to sleep again immediately.* Tliis is the same symptom 
that we olwerve in diseaies of otlier joints, and which we have 
utlriliuted (Chajw. V. and XI.J to inflammation of the bone close 
to the articular lameUq ; it is by no means so severe as in sub- 
Hetpicnt stages, but thmughout hiji-joint disease is more violent, 
in projKirtion to the organic rhange.s, tlian in nlTeciiona of otlier 
jointfi,| Kxaclly corresponding to the severity of this pain, is 
the amount of wa.Htiug which the limb midergoes. Such wssting 
is not men; loss of nutrition frt^mi want of exercise, for it is not 
only much more rapid, but is of a sort different from the emacia- 
tion wj caused ; ihc nmsr-IuH, instead of becoming soft and flabby, 
are tenso liko oonis, anil remain no, even while they grow thinner. 
In fact, we find, on examining the limb, during the whole time in 



tifin of tlit< hip-joint, ni ca[if<eqii'>iice of 
which till' cii]>ul ruDiuris ie» ditilo«iU'd 
npon tiiu ilium : luto piiTit.'trutc'<l, bv ul- 
ccmtiuii, UiixjukIi the tuAt purts una Um 
\mni, mcrvlv mvcntl Ijy di-liciitt- ;^niiiu- 
liiLiuiu. When I ptvtm vrilli mj iliif*cr 
ii[K>ii this iU<nucK>(l Iit.-iiiJ of tlio hone the 

Sitk'iit tli>c4 not ooiiipluiu <tf |iaiii ut 
tat «pol, but, hy ail invnluiitary uiovo- 
□imil, gfAi^ Uii) cuiidylen of Ibc femur, 
itiul coioitlftEiu of very iiitc-tiac- pcuii in 
Uicin, dlpioiieh pr(^>«<iiru uixiri tiwrn oon- 
•tytip* thi-iiiKclvtn u ciitiri'ly paiiiltwu."— 
Woituiiwywr, ' ll<iiH<ikitiit;<'ii tiU-r Carirs 



uml Vron^so,' (Jrofo mul WalUicr'a 
Jounuil dor Cbini7gi(>, 5tcr biuid. 3te 

ht-a s. cao. 

• Dr. UaiuiT, of Brooklyn, bai ytfeii 
u very ijnijiliii.' aixtjiint ui" this form uf 
pulu. 'On Hip mill Knot- •loiiit l>i^- 
L-am.;' u. 8. 

t Tbcn- i** iiuicb viiriL*ty in the «c- 
TCrrly uf tlk-*? iiioiid (Iuriu|j (be iK'COliil 
periixl uf hip-joint iliMtLM, wUH'h *h-- 
pi>ndii, I Mii'Vi.', pntiit'ly upon whether 
(IT no till' hiiiiifi hiivi' ur hiivp uut bocii 
pnnmrily iirtTii'lf*!. 



Chip. XIV. 



TltANSlTlON TO SHORTENING. 



3U0 



which t\\e.Afi stiurp [tiiiiis prevuil, timt theru is a constant tonic 
couirftction of the nmajles, wbicli is proportionate to the cou- 
tiatioiis wonrin^ \tnm imuaUy retbrred to the kiiou. and at the same 
timo produces the sort of uastinjt; |H-'culiar tu tlrnt form of coutrac- 
tion.* The reader will partJon the apparent circuity of my eoiirso 
in upiiD referring to lengthening of the thigh. We have aeeu tliat 
eertam of the femoral miLSeI<'S eoiitruet abnormally, and very 
little expc^rienee in liip disease shows that those first afteeted are 
the tensor Tagiueo femoris, the gluteus medius, and prulubly 
also the deeper abdueturs of the thigh. By such abnoniuil 
urtion the limb is carrietl outwards ; the patient while erect 
cannot keep the thigh suspended irco in the air, and hanging by 
its whole weiglit on the body ; he must place the foot on the 
gromtd, and, to <h» this, is ol)!iged to let that side of the p<,'lvis 
droop : thus producing the apparent lengthening. This is the 
rpal cause of that sympt-om. I^lie whole of it is an elTect of 
aliductiun from trontraction of the above-named muscles-t 

This sttige of lengthening lasts an indefinite time, it may tJien 
sliiwly Uyumn h'S-s miirkod — th<! spasm less, and with it, the 
deformity, — and the patient may recover without going thi-ough 
further st^^otf of the disease ; or on the other hand, he will get 
worse. The malady a^lvanees, not by regular increase, but by uneven 
exacerbations and ameliorations, yet as it grows, each period of 
ease bof^omes shorter, each one of trouble longer and more severe. 
The jjuliunt wastes (|uieker, eats h»«, sleej^ less, and suffers 
more. I have not uufrequoutly gone quickly to a i^atient's bed 
and seen him in a disturl»e«l sleep, when the weather has not 
been hot nor the Ijcd-clotlies by any means excessive, yet the 
uiMHtvered fm'e, chest, hands, and sometimes the amis, were 
thickly stndilml with beads of sweat. Here it must be remarked, 
that patients in this part of the disease never He on the affecteil 
side.^ The jwsition is variable, — if he have access to pillows 



* A« it will \ni lu'ccaeary lu n-fer at 
greater len^li U) (liuso rwirro -10118011 br 
RjrntptnmH, we iu this pluco onlv ^wtll 
uptm thctii long eiKin);!] to poitit out 
thfir ffft'cts and artious. 

t I nvvil only auk iknv mrgiviii ti> txa- 
tnine n niimlwr of hip diseti in tlii-i htijfp 
in the erect iwcl in Un> n*fniuljent lum- 
turci, ind, while doing m, tii pincc hin 
Angcn over the tm»or vagirur fmwri* 
BiiJ i^atiHf xnedtHM. TIkii t will iiaJt 
him to \i,v\ tonu- |)lth)ii uh<lt>ukiti-«]]y 



soiinil ill llii' hipH ti) hUuhI Wfuni liini 
tnvt, with liii?li> lu^i-tlu r ; h4 iiiu' t<^g 
be ah(lurtt.-il hikI nuTicd iiliglitly in 
fnmt, tliuii ptitrt-rl witli tliii Bi>U- ou tlio 
gruuiiil, uo na<UI}' wugbl btin^; llirunii 
iipmi tliitt liuiU, uikI tlie Hurgtoii nill 
¥*'v at nni'i' that Ihiu iilHlucttoti, aiiil 
Mt^'esKily »!' f^titif; llif linil>, givt- n»} 
tu IJic untirv uppuamnuu iif k'ligliieiiing', 
thti pelvis iauliiiitij; over iu umrr lu lut 
the hKit M)iuc t'f tlie trrounil. 
t S<.irae Aiitlion linvo nlUrmcd tb 



dio 



HIP-JOINT DISEASE. 



Ckai'. XIV. 



and ctishionx lie will 1h» Kknly to lie on tlio back, supporting the 
ktiee with a pillow. (I ani a&»umin;; ttmt the patient be left Uy 
litH own vlioi(.v.) If he liuve no Hiicli nieHita of sujijHjrtiiig the 
tliigli, and iu the latter (Uid of this stagi^ even if he have tliotu, 
his [lOBition of c-hoico will bo that of lying on the sonnd side a little 
over to his front, the affected limb erossinj; the other, the iii^iHe 
of the knee rt'Bting ufion Uio bed,^ — when we find that the patient, 
assumes thi^ posture we may be sure that tlie Beeond stage has 
eoascil and tin; third bcfriin. 

2%mi Stage. — Then} is, between the fteriods of len^heuing 
bud shortening, some neiilml tract of time, dunng whieh the 

painful ByuMd*'i»^ vory much 
abate or altogether cease. \i\\l 
this is only a treacherous vvUm ; 
there suddftdy oi-riin* a morti 
violent tulnjck of pain, and the 
spasms trom that time become 
more intense than dnring the 
second utage. If now we snbjpct 
our patient to a careful examin- 
ation we shall find the malformity 
in nearly every point the direct 
<(>ntrai'yto that already described, 
AVlxile in the erect posture he 
snjuiorts the weight of the body 
on the sound Uiiib, the cU)^4:tfl8vd 
one rests on the ground only by 
the ball of the foot, thi; hi^I Ix-ing 
elevated, and the knee is higher 
than tlmt of the sotmd side ; the 
thigh is slightly (in advaneefi 
cases considurubty) Hexed on tlio 
pelvis. The bnttock of the dis- 
eased side is shorter and more 
prutut>eniut ihau tlie other ; it 
is coiuuionly said to be moro 
rounded ; its form is to my mind 
better explained by saying tiint 

|itUiuuU <K!«ftflimuUly lit' on tin- diMwitcd | rmm iwnoiml nlwrvittimi, iinlcbK Uio 



7; 



llllMtlKKABK— -niK IV^tilTIOK Ot- 

SnoitTi:xiN(j. 



CiiAP. XIV. 



Tin UI) STAG ^;— SHOHTKN I NG. 



311 



H projecte backwards almost, to a iwirit. The diseasetl sido of tlio 
ptilvis 18 ntiseii, and tlic rhna natiutu slopes froia iHiliiw upward 
ujid away from that Kitle, The lumlmr spine is <:urvcd lutcralty, 
its concavity lookiDji; towards the disease ; the dorsal region is 
beat ill h contrary sense, its eoavexity Ijeiufj^ towards the aflected 
side, and the shoulder of that side slopes niore do\vn, is more 
depreat^xl tlian tlio other. Tho foot of tiio diseased limit nmy be 
'eitlu-r inverted or everted; tlie fitrmer is tliM moro t^ommon, 
but cases occur in which the contrary ]K>sture obtains. 

At tlie same time the temleniess behind tlie trochiuiter nnd in 
Flihe groin diminishes. Tlie deep fluetuutiiig swelling is ex- 
rhunged for a more difiuse non-fluctuating tumefaction, which is 
Hii]H'i*tIeia!, and a<'e4im|nmii'd by a certidn pnflfiness of sidtcnta- 
neoiis tisisues. Soon aiterwards abscesses form and burst in pbici-*;!, 
which vary in diifcrcnt cases according to ceilain eii'cmnstjinces 
to be hereafter considered. 

The whole series of symptoms indicate tho following patholo- 
gical elmnges. During Uie latter end of the second stage the 
capsule of the joint has been distended by fluid, generally by 
jms, and the alleviation of tho pain forming' an interregnum 
l)etween the two periods corresjMauls to the rupture of tho sac iind 
cosaatiou of distension, after wliich a more dilTuso action is set 
up in tlie ^rts around. 

It is nnt [NKSsible to siiy why, during distension, contraction of 
tJio alKluetors should predominate ; why, therefore, as long as 
such condition last t^ the limb slionhl be lengthened; nor why 
a change in tlieso circumstimces shuuld aftorwiu'ds sujHirvone. 
At p. 309 was describe<l a position which, at the end of the second 
stage, tlie |iatient tissunies, ui order, as is evident, to yield more 
end more to the eontriu>tion of the adductor mass, whose power 
at tliat time begins to prevail. A glance at the position of short- 
ening will show tliat the axis of tho affected thigh is at an acute 
angle with the transverse axis of the jKilvia,* the thigh therefore 
fiddu('tr<l. This liddiiction is the primary maljKisture in ** shoit- 
cning ; " for such condition, imlcss balanced by a compensating 
position, would cause one tliigh to cross tho other, — a [K).^turo 
which cannot be maintained while stjmding, and only to a. limitt'd 
degree while reclining. In order therefore to preserve a paral- 

* For vxplanntitfti tif ub- uhI udiltwtiuu lu tuMwariMl b; tlie iinglo* of Uic nxtt 
mm m>le ut p. ^13. 



312 



Uir-JOINT DI8EA8K. 



Chap. XIV. 



lelism between the two limbs, the patient must uIkIucI the sonnd 
one to the aame extent b& the other is addnetcd. This can only 
bo done by |irudnt'ing an obliquity of the pelvis; by raising the 
(ILseixsed and di^prfssing the suiuid side, thus ciiusiiig the aflect«Ml 
thii^'h to h)ok shortened, while measurement earefully carried 
out ahows no real shorteuint; whatever,* 

The9(i uervo-miiBcular pkoiiumena in hip^lisease are so promi- 
nent and remarlaibli^, tluit tlieir evident resultii as seen in tlie 
IMisture and apparent length of the limb have cinefly attracted tho 
iittenliun of siirj^eons, and yet, the peculiar influence which they 
have ui>on tlie continuance of the miUudy lias escaped notice. Bo 
it observed that tho constant and >'iolent contraetion does not 
merely produce ab- or adduction, occortliuf^ as one or the other 
set of actions may pn^vuil ; but, as from tJie dirwtiou of the 
muscles is evident, it must also draw the thigh upward and causo 
tlie hciiil of the femur to jiresH abnurnudly against the acetabu- 
lum. Tluis the pristine inHamnmtion having prtMiuced a con- 
traction, the head of the thigh tmne begins to press with 
:ibuonnnl force and <M>n8taucy in the upward direcrtiou. We 
might subdue tlie iuflammatiun but that the very prcHsure keeps 
up the contraction wliereby it was primarily caueed.t To prove 
this position we have only to look ut pathological museums: wo 
sliall find a few specimens in which the action in disti»buted over 
the whoUi jouit-surface ; a very few indeed in which tho inflam- 
mation has cliiefly attacked the lower posterior or anterior part 
of tlie acetjibubiiu and femur ; but in a pro]>ortion of castas so 
large as tu render tho above examples mere exceptions, tho 
upper lip of the cotyloid caWty and the corresponding part of tho 
caput femorw are ulcerating, whilt? all tlie njst of the b»me may be 
untoucbiid. Such constancy of ixrtion can only l»o accoimtod for 
by the fact that abnormal muscular contraction produces 
pressure, and thereby ulcerative absorption of these ])arts. The 
annexe<l figure, from Mr. llowship's collection in the Charing- 
CroHs Hospital Museum, is not taken from a specimen particu- 



* TliDt posturu prodacee iborteiiitiK 
in thu lutiji^nty ut cuses was uisu tliu 
opiiiii^n of IJii;mft 

t Tliis icirt of rttitrlivo tt^ntlDiic}- i» 
tlie ciiibtlont luw <if iiiiiHciilBr irritation : 



|truwuJ npoiO, tho more Tiolcntty docs 
tliu uutfclv contract. A mau's Oii^^ w 
ttrukii) liy eonic TiultjiKt; tliol cituscs 
llic fm^nenlit tn [>ic-rct>, ur otlicrwtMi | 
injure, wiinr- of tlio njusek-s ; coutratf 



if Ik nhni-p-curiKTiHl iitiiui he thruwn ' tint) in«tiintly oonimencca: tlic iiiorL- |]iv 
into tlif eye tlii; \U\n plow; np<jn it* luid. ' oryaiw lit- diiinugcd the mom i-piwiiiotti* 
if \\iis jmrt bt' irriUililo. tli.; murv it ouIj i cully ilu tlicy luit, uml llu- imin- Uicy 
the conjnncliva (tliiit it* tlie more it is ' cuutn^l tht- mwte will tlu-y In- linrt. 



CuAP. XIV. KFFECTfl OK AUTrcri-AH PRKSSURE, 



313 



Inrty choBon to pruve thi«u circuuistonces ; in fact, it prcfit'ntii un 
uniisiiul ttmumit oi' action »t tlie lower part of the octilalmhiin, 
evidently firoUuotMl I»y tho gnmtation of pus. Let it be observed 
how t}je cavity of tlie acetabulnni has been prolonged ubont an 
ino-li upwards; how the head of tlic femur lias been altered iu 
ftH'm ; how, also in the position which in lii'e they last assumed, 
the two fit acL'unitely t^tgether, and bow the traek left behind 
Iwciuuc narrower as the caput femoris wanted. It is plain froiu 



A^WOftCV. PKL. 

UuiKAilUD ACKTAlIUt.DX ASD UrAD Or PEKTIt. 

ibiH meiti phvrtiwil t-videiiee that tho head of the femur wiwusifd 
aliaoul lilce a enp|KT-pUter'8 graver, t^> furniw (Im- cotyloid mvity 



S14 



Hir-JOINT DIKKASE. 



Chap. XIV. 



Upwards ou tlic iliuin, mid has becu almost wuni out in the protiesu^ 
It has beeu held tightly to the Hoor of the cuvity hy tlic pyrUami, 
ohturatur and othor cajKiuIar musfik^s, while it was forced up- 
wanla by those jtreviousiy HiHx'itied aa abuormully coutructed. 
Tliu« the ttcetubuluni is made to travel upwards and nlwo inwards, 
wht^reby all opening throiijjjh the lloor of thn cavity into the 
peU'is is not uufrequeiitly produced, as shown by the tigure, 
1 say, that such evident yielding to the pressure upwards 
is not an exoeptionul cjisc, Yint is the nile: tliat when we 
tind a hip-joiiit ulcerating in any other way and iKwition, it is 
that some rare cireuutstauoe hai^ numcd a primary oHteitie in that 
purlieular spot. U muHt also Im? remarked that as the head 
of the femur travels upward, producing, in that part aguinst 
whieli it presw'rt so ubuormully, uleerutive obsorptiou, it causes 
beyond timt point an additional growth of Iwnc, fomnng a now 
lip to the new cavity,* (according to the law of incronsed growtli 
and induration beyond the focus of a suppurative iuilummutioiL) 
It follows, naturally, that the change in place of the joint eavi^ 
a» in the head and neck of tlie fenuu" produces a certjiin amount 
of real shttrtening, but this is Hbght — prolmhly doci* not eJtt-etMl 
an inch — yet ndds to the diBicuIty in appreciating the occuaional, 
later and more violent effeets of the disease. 

During this osteitis one;! the mutual compression of the arti- 
cular Burfm-es, we find the symptoms of tluit condition devc!opi»d 
in a remarkable degree. We have already seen, that when the 
bone in the neighbourhood of any joint becomes intlumed, . 
starting pains supervene. This symptom is very strongly deve<] 
loped at the hip, producing groat dread, suffering, restlessne 
and wasting. The shocks attack the patient just as he is sinkinjf' 
to sleep, and are in proportion to the tonic spaam. It seems that 
OS long OS the person is awake the contn>Uing influence of the 
brain is sufficient to prevent any irregular nervous phenomena ; 
but that when this ia withdrawn the escito-motury system exerts 
all its power. So constant are these symptoms to the |iai-ticular 
morbid chongc, that when a jiatient presents himstdf, whose 
limb is shortened, and who (suflers much from those starting 
pains, it may Ix^ confidently asserted that the head of the thigh- 



" TIiu itrodoftiou of new bono u 
liKwt marlcnl in rliL-umatip <wU>itis !jn 
which nuilntly, uloo, Ua- uci'lnbuluin 



(ruTt^ln a|)Wunl«J : ru LUoiUMtMu-hit'tio 
niwa uf «truiuiiU9 hlptlUian' vtry litllf 
or iK» tn'w rim iti pnidnritl. 



CiiAr. XIV. I.OCALITIKS IN WUICU AhSCKSSES OFKX. 



315 



bone 18 slowly pitnitrhinfj a groove fnna the ocetabuliuu upwards. 
Montovor, these |ittiiirt tir<^ so viohuit^ so much dreaded, tliut tliey 
deprive the palicut oi" sleep and appetitj?, plunge him into per- 
spiration8« render his whole nervous system extremely irritahle, 
and mhl ^'C^itly to the nipi<lity nnd destmctiveiK^as of the diseofio. 
The muscles which are afiVH-ted with contraction gradually 
Hhorten orponicftliy and j>emianently ; they Ixjcomo jMifiBively 
contractiiTed ; that '\a to say, their de<;reaae in length is nut 
merely a pasHiiig rtate, which, when the stimuhis ceases, will 
disappear. They Ijecome fixed in this shortened condition, either 
hy the glueing together of their eleuienls, or some like cauf*e, and 
they cannot of themselves resume u relaxed and lengthened 
[Kisition.* 1'hna, I Im deformity becomes more and more permanent 
and oi^;aiiie, while the active condition still going <m increases 
not only the deformity hut the morbid pressure. 

It was observed (p. 'MX), that at the end of the second stage 
tht! capuh' of the joint is distended by fluid, generally by pxw ; 

I that there follows rupture of the sac, after which a more diffuse 
action is set up, which is foIlowe<l hy (he fonnalion 4)f abscesses, 
niese pres*?nt themselves in various ItK'alities, according to cer- 

' tain circumstances, and chieHy according to the spot at which 
rupture of the ea{xsule may have taken place, and the |>ositiun 
in which the ]>atient has been kept. Tt is most usuiJ that tho 
first iippearance should l>e ftomewliere in the neighl^ourhood of 
the great trochanter, most frequently behin<l it This pus coraee 
from an oj>euiug at the bai*k and upper part of the joint ; an 
abec^ss at the outside of the thigh from the posterior and in- 
ferior asjHict, the pus travelling beneath tlie fascia lata. Absoess 
at the lower part of the groin, or iuKide of the thigli, shows that 
the capsule is torn in fnmt.t The appearance of an abscess high 



• U o|t|t«'arft Ut mi.' iVnm tliw Tcry 
fcli};lil ii]t|)itrtuiiily ftir t'Stiiiuiuulion ut 
mii'li ciiitdiiiori wliicli linit ]in!iionU'(l 
itM'ir. liiat llii» i*lutu};c.' is lui'iiUnI ni Wiv 
tJifUktliu of llic Bhrm nitliiir timii in tliu 
tlliri'M tlii-iitit(lv«-ic Kvt-ry fliitx- iif a 
tlilii«rUi in critupciMHl of a AarcuA utid of 
Hti iuvt'riliu^ wull : tluf ucUvit c'-Jiilrai'- 
ti«ti of n milKi'ln id produvvd b)i dburt* 
ooiag of Uiu fltwli ; iiiu^Tu L-untTttcturo 
•|i[iti)ni to tfiipenrent' attt-T tliu iiiUriur 
liuM bL>un fur !)onio tuii^ liin^ in lliiA 
ibortoiied cutMlition, wliuti the iuvt«l.iiig 
piui od^ifef il#;U j)«riUHnonUy to lliut 



ahap<>, ktmI ench wall of oTriry miupltv 
ct^H i^ fiscl ill ilM ablimviuUxl fiirm, 
3tur«nver vaoli (xtrUim of im'nlar tissuu 
iitvi-Miiig tilt' titiruiiH Ituinllc?!, usmiudui 
pcnnminuUy tW ni^w fonu imjiresBOd 
ii|>oii it bv ilio coctuMxi ami ooiitraote<l 
ei'ivoa. Soeh change dooa not forbid 
uoutiiiiutkinaf Mtivu oontnctiou, for Ute 
utatv (ountmcluru) dejKOiia upon chaogu 
in tlie {MiMVo |AJt4 of Uio organ, to 
which onlitmry nuimtitar contrmctioii 
luajr iKt Hil'hiil. 

t Thu Xvn^Xh uf tbiwe V>iuTowuig uti- 
Mx'bbM -iu ftict, tho cbbivf of a down- 



316 



IIIIMOINT DISEABB. 



CWA?. XIV, 



in tho gniin, i.i\, ininiijdwJoly bc'l*)w Poiipiu-tV ligameut, is of 
great iuiportiinco in diagnosis, for in such case we muy oon- 
clude tbat tlit» acetabulum has opened Into the pelvis, or 
that the floor of tbat cavity is perforated. There are two 
modes in which an abscese^ in this situation, may communi- 
cate with tiie hip-joint, either dirtjctly running backwards 
through the capsular ligament (a rare condition), or by 
entering thv jtelvis and jmssing tlirough the floor of the ace- 
tabnluni; indeed, u jhdvio atiseess, connerttnl with liipjoint 
disease, may occur before tho bono has Itcen ot^tually perforated, 
when the whole thickness of the floor of the acetabulum is 
involved. Some remarks on this subjeet by Mr. Hancock are bo 
pi^rtinent that I cannot fort)car quoting them. 

"We must osaure oureelves tbat thei>elvio abscess has \tcca preccilodby 
hipdisease ; is connected with it, and not with disease of the sptno, with 
|)S0A8, or iliac absouaa. Odu poiot, therefore, la this diagiioHis i^ the pro- 
existerce of htp-dinoaiio. Another is the locality at which ths ApontaD«ous 
OlMitiingR uKiiatly occur. Wbcu the matter is poured iuio the pelvis 
tbi'ough thti iHirfuratiou of the uctitabuUiiu, it falla, as we have aeea, 
bctneeD the obturator faaciaaiid the bone, and in coiiscquoiice of the Brra 
atiachmcut of tho former to the f&lciforto luargiu of tho great sacro-sciattc 
Ugament, the matter cantiot reach tbu skin iti that direction ; but bj gra* 
vitaiing posteriori; by the rectum it prescDtti itself by the side of the aiiu!«. 
aimtdatiDg fistula. It occaaionally bursts into tlie rectum itself^ or tho 
vagina ; and it has been known, by its pressure upon the neck of the 
bladder, to interfere greatly with tite procesH of mictiirition ; but the more 
frequent position, as far as my experience serrcs me, ia at the outer part 
of the groiu, near tho anterior-iuferior spinous procesa of the ilium, pro- 
bably induced by tho position maintained by the patient at this stage of 
tho dificabe. T\m is a (loint to which I am induoeil to attach »>me im- 
portance, OS affording a mcaiiii of diagnosis bviwi^n jmJvic and psoas 
abscess, atttfae latter tiaualiy prosoiita wort* intoruaUy nearer the middle of 
tho groin. The esistence of openings eKternolly in tlio noigfabourhood of 
the joint u-iU also assist; as pelvic aliecesa connected with bip-disenM 
very rtu%Iy, if over, takes place without having been preceded by suppu- 
ration about the joint itself. 

*' When the opening occurs in the groin, the existence or non-existence of 
perforation of the acetabulum may be ascertained by a probe, slightly 
curved ; by introducing it into the opening, and directuig Ita point down- 
wards and outwards it may bo pasavd through tho perforation into the 



ward dirt-otlon for harrowing at all — 
dijiuiida uixjii tfnivitAtii>n : liencc tliose 
wlio IihM' I'l^ii kojit III) tliQ IcsM while 
liip-ilibeaae ^ik* on will biivi- i»h»oci«f(( 



down the thigh altoott to tho Iraoo; 
thoau who hare bevit kc (>( in n r^fiuii- 

bonl pojiition luive iliijji uiHiiiin^' nboul 
the hip. bulttick, or groin. 



Chap.XIV. HARITY of HI'ONTANF.OUS msi/x;ATioN. 



317 



joint ; and I have also oliserviiil, thnt wlicreas in |»o<U) alwcess Uio prnbs 
cmn be more readily puwed backwards uid upwards, in these eaaen it takes 
the Dppoaito direction —backwiinls ami di>wiiwiird«. In some caaosof hip- 
diaeaae an abscess forms iu tbo pelvis before actual perforation of the 
: acetabulum ooours,"* 

JHalocation of tho lioad of the bone from disieafw, or sjiontaneoiis 
didocatiou, as it is ralU'iJ, la an octMin-em^t; so unusinil tliat one is 
fifltonishcd at tho gi.*ueral credence in its frequency. It is only 
abowt ten or tiftei^n yi-ars ago that every tii[>-joint (h'w'jLso was 
wtipposed to end in this way ; but if a search be made in tho 
Colh'ge of SurfieouB, St. Thomas's, St. Itartliolomew's, or other of 
our ^TOftt pathologicftl miiseimis, there will be found but very few 
8|x:'oimens exhibiting simnltanoously the signs of morbus coxarius 
and of dislocation. On tlie other liaud, it is by no means uncommon 
to find th(* lieiul and neck of the femur shrivelled (/> littU^monj 
than a Imtton-likt' projection, tbo acetabulum qnitc altered in 
fonn and pince, and yet the bone i-etained in it« carity.f 

Sir H. BrodieJ evidently attributes all shortening of the limb 
to dislocation; lie ealU it real, in eontradistincrtion to hmgtlien- 
inj;, whioh he very rightly considcTs apparent Unfortunately, 
this distin^shed surgeon quite overlooked the influence of 
position as a ojiuso of shortening, and has thereby abided his 
great weight to that fallacy, which producer a mode and habit 
of looking upon hii>-diseiiso which is not likely to aid in esta- 
blishing a rational and suneesr^ful treatment 

Liston, however, in his Lectures (Lancet, 677, p. 10), says 
that shortening does not often take place from dislocation. Dr. 
Bauer (Op. cit, p. 12) also insists upon its rarity. For myself, 
I am persuaded that spontaneous dislocation of the hip joint is 
uncommon in comparison to the frequency of its absi^ui^e. Tt 
occurs only" in cuiies of so cachectic a character, that new bone 
is nttt prfiduod'd beyond the focus of suppuration, as was pointed 
out at p. 304 to be usually the case.§ 



* Mr. Hanoodc ' Oa Exciiton of tho 
Uoni\ of the Femur/ I^oncot, April 
Wth. 1857, p. 421. 

t TiK'coiiilitioti flffurodnaddcforibod 
fit p. ;U^ u nut a distocatfon, for the 
heAfi (if tlic bono still remiutig in tho 
anebihiiluiii. tlioui^li Ixith may be altered 
in rtbii|M! liud iivi-ii in puaitiuii. Lttxa- 
tioii iu uiily to Ih> ufhriiK-il wliru tlic 



cATf ty, hoiceTer nttvrvd, uu longicr «on- 
toinii tbo caput ruim»riH. 
: Op.cit. 5th td.. p. 117, 118; tho 



pflMBgC is tot< luli<; t<i quiitf. 
S Tbf n-iimrks iijkiii Hpoiii 
location rrfeToulv l4iitrrtpla<.'<-mout upon 



t-iimrks iijKiii HpoiitjirKwmHfUB- 



the ilurxiiin ilii. Tbi-re aw oiu* or two 
iiuitaiic<un on record in wbiuti tbo thigh 
liBJt botii bixAtcd on the piibo« intu 



S18 



TIII'-JOIXT PISKASR. 



(iiiAr. xrv. 



Th« diagnosis in au nld vnso (if liip-clisiTflfie, U'twwni a tlis- 
locaUMl and n nou-diiiluruttid Umo, is not 8o diflieuU as it is 
siip[K<fje<1 to be, if the Burgeon will Ix^-ar in mind tJiis siitgidor nml 
iDi|Hii'taui fact Wheu the head of the lone btwomcs spun- 
taiieoitsly dislocAted ujxm the ilium the raalposture of the 
{>elvi8 gradually deei'ejises, bo that Uk* Uii^h is in such a case 
not shorter than the limb affected with crdinary hij>-difioase, but 
still with its liead in the ciivity. It must be remembere<l» tliat 
in a fuU-growTi porson, the tliigh rmiy be apjmrcQtly sliortened 
(hrou{i;h nicrt^ |»osition by thrtM? inches — that is to say, the kn«? 
la thut didtiince above the other ; if, in such a ca»o, a diHloi>ation 
u)Hiii the dorsum ilii were to shortou tho limb two more, the 
knee of the affected side would be very little beyond halfway 
d<iwu the thigh of the sound one. As bel'ure bitated, huwever, in 
those rare cabos in wlucli dislocation takes place, the side of Uie 
IwlvjH sluuly CODE'S duwn, since mutual pressure of the joint snr- 
faceti ceasets and even the jmlsjui ve eitntnu'ture of tlte muscles y iehU 
to a considerable extt^nt. Such haR been the condition in the two 
instimecs of old spontauecms dislocation, which I have scon during 
8 pretty extensive search of more than ten years. Hence, if u 
eurj.'e<m findthe pelvis in the ordinar)' oblique ^msture of hip- 
(lisijase. and only an nrdinary aniduut of shortoning, ho may con- 
clude with eohsiilcmble contideuce, that he has not to do with n 
case, in which dislocation had occurred. In the exiiniple frtim which 
the annexed plate was taken, there waa no ilisloc^tion, and it is 
given in order to sliow the amount of distortion which may prevail 
without such concomitaut. Anatomical oxaniination and nianipu- 
latioQ of the limb, must be u.se<l to aid Oie diagnosis; but to 
discriminate tlicactual position of tlistorted parts, among a mass of 
swollen and dibensed textures, is extremely (lilhculi, Nelatou's 
teat is ingenious and nimple : a piece of string is carried from the 
anterior-superior p]»inc.Mi;* process of the ilium Ui the tnberiwity 
of the irti'liium ; if the In^ne be normally placed, this line falls on 
the u]>pcr part of the troclianter major; but if the hood of the 
femur be ui»onlhe ilium, that pniceas will lie faral)ove the string. 
It is to 1k' remembc^rod, in using this test, and in maiiiptda- 



tlio furuuen ovalo lUid tiib> tlic Kiatjc 
□Dloh, but UtvM nrv «> rart' that it in 
liiinlly nueegmry lo nolici' llitiiii. itt 
Ukmu auuea of spuntmieDtiB (lulorution 
upmi tito iUtini wliJi'ti 1 liiiv<- kiy.ii. Uw 



jKMtnif «>f tho pntictit anil tbn fnrni mia 
K) (lift, rent to llmt of ortiinnry altnrti^if 
iug. Uiut it it wtre otiur pnint'-d oiil 
upon till* liviDK bDlijfH't it coaM iu»1 lie- 
iM^iin mintokcH. 




Ciur. XIV. DrAOKOSIS OF srnXTANEOUK PISIXtCATUlN. 319 



ni.R IIip-DlSKASE— SHOItTRNmr, W ITIfOl'T mSLOCATlOS. 



ting tlieeo iiartH, that (ke position of the tmirhaiiter is often 
I groatly chunj;;^!, in (he iiltsr-iKV of hixntioii. TIii> head, iw 
also tlip ntick, of tho thigli hone (a part which in all its injurica 
ami diseaaee Huflora from tlcfertivo nntrition), yields mpidly to 
carious disease, so that not anfreqiiently all that is left of these 
pirta in a little button projecting into the acetabulum, fmm be- 
tween the trochanters. Again, as we hare seen, tlie cotyloid 
cavity itself becomes altered, it« projecting rims wore or less 
eaten away, and the place where the button-like n'muinti of the 
heml are in contact with tlie pelvis, very much changed. 

Trtte AiwhyVisk is a mrc sequela of disease in the hip-joint: it 



320 



IIIP-JOIXT DISEASE. 



(;bap. xr 



ia pihinfly montioned here, in order to pulnt out the extreme diffi- 
culty of dit^osing the presence or absence of this oondition» ifl 
the {Mitii'nt be a child under twelve or fourteen, uiid the disease 
have lastefl a eonsidenible time. A certain umouutuf niuvemen^ 
in the thigh can be prmlueed, but a closer iuspeetiou will showthafl 
in all cases of advanecd hij)-dif*tMi.«»t' the nxi.sof motion is not the joint 
itscslf.but the sacro-iliac synchondrosi*, which becomes excessively 
fl(!xible. A patient was in the CTiarinf^-Cross Htwpitjil, at tho 
end of the last and beginning of the present year, in whom this 
mobility was remarkably developed. It was ]m[)osBiblo to romo 
to any conclusive judgment, until ehlurufonu was admiiustercd. 



TBEATBtENT. 

Firgt Stage. — The first Mgn of limping, the first complaint 
pain in the hip, shonhl, in yontig and strumous persons, attj'act 
iiwtant alteutiim j and unless it be the merest jsaSKing fvil, the 
safierer should Ih> subject to skilletl exaniination, so that any 
disease wUieh may be found to exist may be at once subjected tofl 
treatment.* In the commencement of hip^isease, we Imre* 
simply to do with an inflammatiou not combined with any mus- 
cular spasm or other eomplit'ation. and our i'flnrt>t therefore nre 
to be directed simply to combating this morbid action. The 
first indication is to render the joint motioidess, and to do this 
it is necessary that the jjelvis, thigli, ami lower leg Ix* fixe<i. hM 
large number of appartitus has l>cen devised for this purpose," 
The double inclined pliuio, Karle's bed, Heine's ctmiplicatcd 
couch, have all the disadvantage of conluiitig tho diseased hip 
too little, and the rest of the boHy ton mueh, Bonuet's grand 
appareil, and J-)r, IJauer'a Imitation of it, wliieh he ealls "wire- 
breeches," f have this great fault, that in rendering (he diseased 
hiji immoveable, they at the same time absolutely fix the otiier 
limb and in a considerable degive the vertebnd column. Ilie irk-_ 
Bomeness of sueh treatment, is something ineonccivable ; inde 
Bonnet acknowledgofi tliat it is impossible to keep a patien 



* Conatitutional treatment ii not 
O0naiiJ(,-ri-<l in tlic meacDt rlmpler. its it 
WM fiilly liandlbd in Clmptor V. On 
fltnunouA Hyiinvitia. 

t ThcK* tnu'htnoR coiuistof imn hant I 



connectcrl by vrJre pnnre, wliieli pnclo _ 
the pi^lvia, botik IliigliH, iLjrit, uml fwt: 
flxiii'i' immoTcably Uic wlit>li- luvrrr halt 
of tlic \ivAy. 



CilAt. XIV. 



MODES OP KtXIXa THE HIP. 



321 



longer than from three wneks to a month in siioh constraint, and 
rocommcncU that after snch time, the npHnt should only be 
apjdift*! at night ; indeed, hv relates the case of a child six years 
wf age, who was kept in liis apitamtus two muntlis. at tlm i-nd of 
which time ho Iiad very nearly lost the nao of his limbs 
alto;rether,» 

To obviat:* such ine«uvenienc*>«, and at the same time to 
obtain certain other udvanttLges t*i be preaently ex])lained, I have 
taktm mnch pain» in the construction of splints, whieh, whilf' ■ 
carrying cut a rigid principle of treatment, shall permit Hueh 
mw-lifieatJonH, as may br necessar)' or more ailvisabli! for particular 

see. In thiSf the first and early st-agc of tho disease, while 
^tbere is as yet no 8|)asm, no morbid contraction of muacles, nor 
any alteration therefore in thi! |><>sition of the limb, I use a 
Hplint of the following constraction : — one portion made of wire- 
gaui«», witli a border of thicker wire, passes niund the pelvis from 
one spine of the ilium to tlie other, it« upper edge correspimd- 
ing accurately with the crista ilii, and the whole boing of 
such breadth, that the lower border lies im- 
mctliately above tlie trochanter, .\nother 
]K)rtion on the cliseased side ruiis from the 
end of tliis ])elvic band down the outer aspect 
of the tliigh beyond the knee; the two 
parts being inimnvably joined together, or 
cut out of the gauze in one piftce. In 
order to secure a morn lasting tit of (he 
pelvic portion without making it too stiff, 
a little book is placed at each of its ends, 
to whii^h an india-rubber belt, pairing 
acrofiH the abdomen, ctui be atta<'hed at a 
proper degree of tension. (See Figure.) The 
Bnglo between the [lelvic and thigh por- 
tions mu»t be such as will cuui^e the 
femur to be extended on the pelvis (this will Ix? an obtuse 



ntaBUE 

IX ('lULimElf.t 



" Op. cit. Yol. ii.. p. 327. 

t Thu lup uf pullujrti ut cither eiul of 
tlie ttiijrli-pii'"'c will bo cxpliuu*^ ti<"re- 
nflvr, Fftr full sniwii ficraium I fiud it 



ic po, 
liiefi-l 



irliou. Beo fl{», al p. 327. Tlio 

unu « iKirt rumovitl to avoid Rivinfi tho 
ilgnn' loo nnioli Icnirlli. TIi"' txUmdiii" 



tliiefi-piccu IB ropreseDti-fl oa broken. 



LS- 



pr<-fi'r.i1iU- ti» luitki' tiie Itiigh-piece of appnniliu lutil )K:rin*eal biuu) an* only to 
woi.fl. which miijHt In: lixinl by Bc-rewa or 1)o UKwl in a later ttBt-v. 
other mcAUB iitniF^vably tu tlie pel- ' 



322 



HIP-JOINT DISEASE. 



Cn*!-. XIV. 



angle), as a flcxncl position feriresrinn in Miliseqiieiit stngeB to cer- 
tain embnrrfUHnif^nts, wlitch should be avoided. If the silicon 
intend to apply any counter-irritants behind tlie trochanter, a 
portion loay be cut away from the Uiek of the thifih-pifee, and^ 
lest this should weaken the ap]mratn.H too much, the litifk <if tlio 
pelvic band may he connected with a lower point of tlie fi'mum! 
portion by a pieee of strong wire, or better by a piece of flat 
steel, so curved a^ Ui avoid the trtK'hiuiter, and to (it tlie buttock. 
I have used all the«? forme with advantage ; they keep the liip 
quite imtnovable without irksome eunfmemont ofotherlimbe, and 
if well lilted. |>added, and fastened by means of a pcilvis l>iuidag:e, 
are a very wmfortnble form of splint The gauze, witli its edge 
of a thicker wire, can be bent to the requisite form, and by help of 
the india-rubber band across the alKloini'U, n^taina a very perfect 
fH. In the more acute ca»es, it may be dodrable, that tneanfl should 
be used for allowing the aduJt ]>ati£-ut to be raised, without pro- 
dncing movement uf the hij), so that a bed pan luuy Ire placed 
beneath him. This is easily arranged, by means of a pulley fixed 
to the ceiUng, or the upper part of the Ix-dstead imme<liately 
above the middle of his b(xly ; through the pulley ])a&se8 a rope, 
one end of which is attached to four cords fastened respectively 
t»i each end of tliepidvic jmrt of the splint, and to each leg by a 
broad band. The other end of the rope hangs wilhiu reach of 
the patient's hands. By pulling upon this part of the cordage 
the patient can lift lus whole bcxly, and tlie a]<{uirutus. from tlie 
bed.* A child too young to execute lliis uianuiuvre can be lifted 
BO easily that no such apparatus is neecesary. 

Upon the value or uselesaness of eouuter-irritauts some dif- 
ference of opinion prevails. This appeam to me to liave arisou 
from want of clear discrimination between the ditfcrent stages of 
the disease, and of the various pathological con<Iitions present at 
diffnrcMit times. My experience during many years of observa- 
tion and practice winvinees me, llint in thi.s, the earlier stages, 
much benefit is to be derived from a judicious use of counter- 
irritaut-s. It is unnecessary to re-enter into a doscrij>tiou of 
reasons why, in certain conditions, one metliod should be pre- 
ferred to another. Tliey have been am]>ly discussed in previous 
chapters; but it is iidviiudde to point out tltot such means must 

* TliiH pluu in boiTuwrd frinii M. Ikniiu-t. 



ciup. xrv 



VALUK OF KXimtRIF.R. 



323 



be utterly niiavtulinp;, althouph soiiiptimoa so t-mployed. when 
the (Hiticnt iH ullowt»d to ivinaiu witlunit any inoimsof oonfijiin^ 
tho joiut. It 18 siich treatment, such utter blind reliance U|h)U 
these means aAwie, which has brouy;ht them into discredit, 

liliich experience, and a loiip careftil process in summing up 
the results of pntotioe, are necessary to decide which combination 
of applications best suits a number of difi'oront circiuuslanceR; 
but I nevertheless believe myaelf in a |x>sition to say, tliat the 

[ eymptoras which have been described as indicating synovitis of 

' the hip, mor»?! especially of a snhacuto character, are best met by 
the more 8U|H.'rficial coiuitei^irritatioii, a. lilister kejit open by the 
application for two or three days of the savinc cerate, but never 
R(f long as to proihice constitutional irritation ; or the bh'ster may 
be allowed to heal, tmil then the skin kept inflamed by tuicture 
of iotUne. There are many other such means ; but it is unne- 
cessary to euumerute a series of r^edic* with wliicli every kih'^ 
geon is acquainted. When, on the other hand, the sjTiiptoms are 
such as indicate osteitis, a more )x>tent spplioation is preferable. 
An issue of |H>tassa fusa is a very fi*cquent application. Opinions 
concerning tlie value of tJie issue and moxa cla±<» liave already herni 
given : they arc somowhat cniel remedies ; but if tlio sore be kept 

I (uiive or irrilable, and be not allowed to fall into an indolent (Con- 
dition, it uill (luubtless have elTeut. The actual cautery is by far 
the most efticieut of these means ; its efficacy cannot be too highly 
extolled in the tirst stage of hip-joint disease, commencing iu the 
Iwne, ami when the patient is not very feeble. It is not only wore 
eflicient, but also less jminful in its ojH^mtion than the potassa. 
It is necessary, however, to Mtirn the uuaei'ustomwl hand ugainst 
dramng the strite too near together. Iii the commencement of 
my acquaintance with the cuuten*, a case occmred in which, 

I being over anxious lo give the remedy its full force, I drew the 
lines too close, Tlie patient was of feeble constitntiun, and a 
giiod deal of the skin left iKftweon the burns idenrated, produced 
a lai^ sore, which was verj- obstinate, and added^ 1 fear, to the 
jiatient's sufferings. The line, or lines, Hhuuld Ije dra^n from the 
trochanter, as radii from a centre. Of late I have made but one, 
or at the most two at least an inch apart, and believe tluit sueli 
an a])p1icaticm is as useful, and less ]>eri]ous, than one involving 
u gicater tuuomit of skin destruction. 



324 



UlP-JOINT DISEASE. 



ChakXII 



Immobility of the joint is to he preserved na loiig as 
8igns nf inflammation exist It ia m>t olwriv^ easy to ascer 
when it may be safe to allow mmeroent of the limb. As k 
aft thf^re b taidemeaa behind the trochanter fall ULstt^rs or 
raiit«'ry Rores being healed) th4< splint ntu.st be kept applii-rl : 
eTon after tendcmeas has oeaaed, p«in njKin flexion, «ven iipnn 
considcnible flexion, of the liip slmws tliat th** fimb mtist still bo 
fixrd. It must Ite remendicivtl, however, that when the t^plint 
is removed the joint is not immediately to 1^ flexed and twisted, 
timt wi* may judfje of its painless or painful condition ; fniclfl 
movcnifnt U sure to pnidace raoscular (>ain when all joiiitfl 
indainmation may have ceased. The limb, when releawd, mast 
be nibbtnl and shampooed ; and it ifl only after some himrs that 
we ran ju<lf^ of the condition of the articulation. Even wht 
the flplinl Is discontinued the patient shoald hf- kept in bed for i 
day or two before he is alloyml to get up ; all persons on fir 
gaining liberty arc very apt to abuse iL 

The Second Stage. — It will happen, even when all poesible skill 
shall have been employed, during the early condition of this 
difioaso. that the symptoms will increase ; but it rtill more often 
oecuni that the patieut does not come under professional obser- 
vation until the second stage has commenced. In this condition 
we do not find any symptomatic diflertince U^tween the two 
forms of the malady : the s-ynuvitis having produced nlcerution 
of cartilages involves the bone next the articular lamella ; or the 
osteitis in which the disease may have cummenced has attained 
tliat loeiility. In either case we have that peculiar train of symp- 
toms wliich follow such affection. Among the most reniarknbl^ 

' moftt painful of these are the clonic spasms, which come on 



am 



at ui;!;}it, cuusiug sleeplessness or dread. It is of great im- 
portance to annul, or at least to mitigate, tliesc spasms, not only 
on their own account, but also because they accomi>any lusting 



Bufllcieutly closely with the rapidity of destructive process. Nov 



eontra<^tion of the mnsclea, and because tlieir amomit corresjwud 

lel) 

no opiate wiiich unr art supplies annuls the^c pains: it has 
Iteen allowird me to watch patients, thussuft'oring. who have takei^ 
a lienvy dose of laudunum. and in one or two instancies it hojl 
seemed to n»e tliat they slept more through the |min; hut, that 
it was still there, was evrdencud Iiy their starting up mnmon« 



Chap. XIV. RKSTOItATKlN TO NOKMAL POSTHRK. 



325 



turily and falling back ogain to sleep, or by a sudden sharp cry 
or proan : in fwt, opium may dull the pc>rf^|jtiou a littlf, but 
d<H\s nrrt plieok the sjHugn, if, indeoil, it does not increase it ; for 
the limb, in the cases I speak of, boa jerked with mueh force, 
and while this Listed the putiirntH were l>athed in sweat. The 
pathologicnl oondiliim of the nerves, already de&cril)ed, is not one 
which could bo diminished by im opiate, or by any means tend- 
ing to decrease the contrttlling action of the nervous cenlres. 
A contrary remedy, namely, some diffuaible stimulant^ tis a little 
wint!, mtber, f»r ammonia, pven nt night, hit-*, in my haniK been 
prcwluetive of grt^ater benefit. 

IT the patient come to us for the Hrst time« when the diseatte 
IH Wf'i! tidvanecMl into its second stuge, when Ieiin:thciiing, witli 
abdui-tion and llexion, has hwted for a eertuin period, and there 
are nightly |)ains and spasms, we shall find that, by placing the 
limb in its proper position, viz., stniijrht, neither ahdncti*fl nor 
luldueted, everted nor mverted, and confining it in that posture* 
we may greatly diminish the starting pain as well as tlie cou- 
tinaouB aching. The n-ason that this change in pot<ition shfpnld 
.effect 80 mncli benefit is not easily explained. 5L Bomiut, who 
strongly upon it8 value, iissumod that it diminishes, or 
altogether jirevents, tension of the capsule. This, I can hardly 
conceive possible, since, in oi^er to put the limb in that [Kts- 
lure, he often used very coibfiderable violence, which muat have 
produf^d tension of some part of that stmcture. 

In this, the 8cc<md stage of the malady, there is no ilifliculty 
inputting tho limb into a proper jtosture: it may be done at 
once, eorly in the period, by jwlieious mimagi'iufnt, and by 
making the less violent deformities yield befon? the others. 
Wiiile tiie patient is Uing on the buek his lliigli ami Ifg will be 
flexed, tho limb resting on the Ijod by the foot mid buttock, witli 
the knee abducted and everted, i.e., inelinrd to lii' on its outside 
upon the bed. The surgeon places his haiul on the outside of 
the knee, and by lifting it away from tlie bed he overcomes at 
once Oie two latter mal[io£itures, giving, il" tho stage have recently 
come on, but vecy little piin ; he waits a little time, in order that 
the ]iatieut may recover from the first shock of this change ; he 
then, holding the knet; iu one hand, gra^js tlie anldc with 
the other, and straightens tlie leg uiwn the thigh, thereby 



¥ 



^20 



HIP-JOINT DISEASE. 



Chap. XIV. 



rolnxiiig the oxteaisors. and allowing him, with a little force, 
place the thigh in oxtension, i.c., tlul n]>on the bed. 

In most eases, however, indeed in alt thoso whirh havo coi 
tinned some time iu tills stAge before coming nnder treatnienl 
this method vtmld bo not only too painful, but would be all 
solutelv injurious. M. Itonnet* employed and reoommeBdc 
machines and manipulations of vast power for ttuH purpose, wl 
to me appear not only unnocentear)'. but dan^^rtms, and conceive 
upon false principles. Moving a diseased hip backwards on^ 
forwards, producing aueh forcible ilexion that the front of the 
thigli touclM'jn the abdomen, mmply in order to relax contra^Ti 
|tarts sufKcicntly to allow its being straightened, can hardly 
wise. During the whole of this second stage, the deformity 
due only to muscular contraction fn:»m nervous irritation, and 
vi-ry slight force, if eontinuons, will overcome this |)ower. Tl 
etuential is to ootain a eo7itintwus force. All tho various for 
of 'screws, pinions, and racks are not continuous when applied to 
H living organism ; the former are fixed, the other is moving : ad 
thjitrtt one time the power will be intense and rigid, at aniithe^ 
willnut IwcxerUxlat ulL A spring is the only force which, while 
it yields safticiently to the movements and struggles against 
continemcnt, winch a living part is sure to makr, yet exercises 
a constant. nVver-faiHiig traction, sure in the end to overcome 
muscular force, without painful rending and violent stretching oH 
parts. Any deformity from umacular contraction f at the hip 
may be rrstored ti^ the proper posture by mcjins of the extending^ 
splint^ with the pelvic wirc-holt I will not detain the reader bS 
dt^'ribiug the mechanism of pulleys, stra[»s, &c., as it Ims Iwcn 
fllrciuly dniic ([i. 2130), but tlic metliod of using the splint for thia- 
particular purixjse must be exphiined. Let ns suppose the patien^ 
lying on Ikis back, with the affected limb bent both at hip and 
knee. The surgeon begins by aiipl^-iuga broad piece of strap))ing 
on either side of the leg, from the knee to the foot, allowing an 
inch or an inch and n half of the matovid to project below the 
sole ; he then bandages firmly to the knee. The plaister ought 

'TmiW«li* Tliorapetiti()iio il6« Ms- ' refl're to an ncUVti ooDtlitioii ; wlii 



liiilior ArtimiliiirHH,' p. 41'! ct stH). ; lui^l 
' McdimtoH NoiiVfllft) Ag Tmiteitieut,' 
Ac. n (jrt. 

t Tlt« nquii^r nitiHt ho rpmtiuloil tlint 
tho wtinl conlniction in thiM suiuc onlj 



niiiM'lufi linro iwi-n fur M>tue iiinajila 
nbln time nturiiiillj coiitnirtetl, tlii^ 
dtijiorvfrtiTB B fiinii of iilrophy, mnjoin- 

Siiiivil by piwaive dlinrtL-iiiii^ luiil n^> 
itjr— ooiitnu.'tiiiv . 



Chap. XIV. 



TRRATMENT 1!Y EXTENSION, 



327 



to bo spread upon strong!; doth ; it is lor tlic purpose of making 
cxtoQBiou upou thu limb after tho Amerio.au fiiHbioit, iind is much 
more comfortable than fmy otlier mtKle. 
It is better to lt?a\-e the patient some 
hours before any forc« is exerted on i 
the strappinfi, that it may establish 
strong adlit'renL'e. When it i» 8np]X)seri 
to stick 8ufiiciently Hrmly, the splint 
is to be ])liieed in position ; the uppvr 
IKirtion will \nv^ round the pelviw, the 
lower lie along tho bt'd, quite out of 
reach of tho distorted limb. The «ur^ 
^con now bamlajcvs from the foot to 
the top of the thigh, inde|)eudout of the 
splint ; arrivtMi at the latter plaoe. he 
fausf'S tlie bandage to jwia mimd 
pelvis and thigh, iiitduding all the up- 
per portion of the splint^ thus fixing it 
with suOifient lirnintytn. Catgut in now 
Ut be fasti'iied to the ends of the plaister 
projecting btdow the foot ; the perinwid 
Iwnd, properly paddoil, is to be adapted, 
and both to be fastened to the aecumu- Sw-ist ron Hii'-uisbask. 
lalor with tho pro|>er degree of tension.* 

For llie fii-st ten minutes, or quarter of an hour, the strfttn 
shoiihl be slight ; tlie muscles myon atXer its applicntioi] si*t up a 
startled sort of resistance, which, however, soon snbsides, and 
then t!ie India-rubber is to bo pulled tighter. In a very few 
hours the foot or knee will have descench*d r»4> mueh that a nurst*. 
or oth<^r person in attendance, must tighten the spring, and in 
from eighteen to thirty hourethe limb will have come down, and 
may be bandaged to the thigh [mrt of the sjilint. lliis will have 



• Ilia iHil iilwujBflfainiMi- lutvuiliiiiii- 
• xtinMoii ii})!)!! the [K-ritifuiil Wml wlicu 
the {Nitirnt 18 u)iL In rhufL- (until Ihu <li-- 
fonnity \» cvvTcuuw, thi> fuieo mubt bo 
tliiw npplitMli : tilt' ii|)jiiT eml uf the iw-- 
curntiliilnr limy iht*ti hi- (aiU-m.-'i to the 
ti>|i of tho BjihiiL A (■luncp nt lln> me- 
chAtiJant win aliuw liinl tin' fiifcr netd 



jiut iliDihti* fia TiillL'ti iia tilt- tliiwttiirtui] 
pn-imiirc on ltic> i|iliiit. lluiit'r, tu pro- 
vottt tho fl|i|xinitiiii rkliutc up it i« uv- 
ccMury in n>it: a [tt.<riu:i.<ul')>uiirl, fiixtciiKt 
to tht' «|iUiit. hut tho tt'iuiuii uj'wanls 
wlJI Ik- o»|iml tit only nuf-lhinl n( tho 
pnwc-r of iho luviiMiuhitul'. — Mr. Ui}[tfi 
oi lA-iwatir S|iLiri', htu uiuUrtaktti to 



1«itli iipwnntx diitl itiiwiiwunlti : hut Ih*! I nukt- tltom «^luits itcainling tii my |utt- 
\owi-r puJley bvinj: in tlit* i>iliu(tiiiii iif u I U^rit. 
ii)i)Vnl»ti' ftiif, (.'nuiH.-9 tbe u]i«-unl ki he \ 



mr-JOINT DISEASE. 



Chap. XIV. 



been effected without pain or violence; indeed, the starting 
pains prcviouiily complained of will even abate under the down- 
ward tractioiL 

If, however, the mnlpostnre' be more fixed — that is, if the 
disetue be further iwlviinced into the set'onH sta^^, tlie thiirli 
ramiut be thus drawn down without produciiipf coiiside table pniu ; 
and in gnch case it will be better to give chlorofonn, and white 
the patient is nn<Ier it«t inllnenoe, to dniw do\m tlie limb Into 
the proper position — namely, straight, anti to Iwndugc it u])un 
the splint. 

The better to consider the treatment now to be udoptrxl, let 
us glance at the condition of parts. The patient lia» had an 
inflamtoation in the hi}>-joint, and tliere in HiiHicient renuuniug 
(be it much or little) to keep np a destructive pruct;t»; and at 
the Kuno time ho has morbid contraction of certain mnscloK. 
which nnder ordinary einrunic^ttinces pHxlnte a deforrnitv. We 
have overcome the tleformity, and by tiandoging can keep the 
limb in its place. This i& tlie wlmle lliat Af. liomiet's, Dr. Bauer's; 
and idl the other iii»trumentH at present used, profess to do ; 
bati in my opinion, thiH is not enough. Binding the tliif^h to an 
immovable iwMi fun's not annul the contraction of muscles, but 
simply i)rovi'nta the flexion or abdueliou of the thigh ; the 
muscles still contract, and they drag tJie upper part of the head 
of the thigh Iwne Wolently against the superior h*p of tlie 
acetiiUdum. I have already (p. 312) jHiiut+Hl out tliat tliis 
pressure is the cause that hip-joint disease continues so long. 
It follows that, to enable the disease to got well, we should 
prevent this abnormal pressure. 

Upon this principle, our plan of treatment is simple. We have 
only to prevent the miiscular st^asm from pressing these two 
iwjrlions of bone together, and the disease will decrease ; for in 
the majority of vjisca the pristine iulluinniation would he subdued 
by the time the second stage c<mies on ; but tluit it continues in 
consequpuee of the pressure. The muscular rontnirtinii whicli 
pidln the tlugh up must be met by another furci* which will pull 
it doMm. We cannot, nor do we wish, to separate the Iwuea, but 
wp can so arrange that the muw^ular fon^e jihull expend it*>lf 
uimu an external objwt, and Icuvc Iwtwi'cn the Iiea<i of the 
tliigh and the uoetjibulum no more, perhapH mther Ictw, than 



Cn.XIV. PDNCTUKK0FDISTENl)KI)8YX0VIAI.MKBlBnANB. 32l». 

their normal omouut of pressure. This can bo done by the ex- 
tending splint, oxnmples of the tise of which ahall bo given ; these 
means will not cure hip-<Ji8Cttsc,* hut they will place it in the b^t 
possible circumstances forgetting: well. The rest of tlic treatment 
mufrt be adapted to the peculiArities of the case ; thus, there may 
be taision of the capsule, evidenced by heat, considerable tender- 
nees, and swelling; behiud the trochanter and at the groin, atrcom- 
panied by dee]»-seated aud confined fluctuation. A few rare case8 
CK!Our wliosc rapiil course of events would Juntify our including 
them undi-r tlie head of acute synovitis of the hip, in which so 
much strong inlhimniatory fever is present that wt* may conclude 
the fluid to be synovia. By far the larger proportion of diseaw^s 
in this joint belong to the subacute or clironic form ; the 8h>w 
succession of 8)'nipt*ims, and th«; irritable hectic-like fever, rather 
warrant us in assuming tliat the fluid in the cavity is jiu& 

In the former instance. 1 would strongly recommend the appli- 
cation of the actual cauter)-, at the back of the trochanter, in two 
lines, so disposed as not to interfere with the appUcaiion of the 
fijdint. A short line of cauterization at the groin, intHde the 
feniuml vein, has, in my e.\|M:;rience, gi-eat effect in easing the 
jtain, and also, I believe^ in j)roducing nbsorption of tlie effusion. 
If, on thp othur hand, the fluid in the joinf-cavity bi\ judging 
from the sj'uiptoms, probably pus, we cannot hoj* to procure its 
nhsorptiou by such meaiut, and any counter irritation will be not 
only ustdess, but jMJsitively injurious, by adding to the paiu and 
irritable condition of the patient. 

We may, however, consider whether it will not be advisable 
to let out the fluid. It has Ix'eu shown that at a certain period 
of the disease the capsule gives way, and the contents are poured 
into the surroiuiding parts ; that a period of ease then supervenes, 
whick is generally followed by absceiss. We have, thertjfore, 
this warranty in nature for sucli n procedure, viz,, that if we do 
not empty the idiscess, it will evacuate itself; and by drawing 
out the pus by means of a canula, we prevent its diffusion among 
the muscles, and may even cheeky or ver)' much retard, the for- 
mation of external abscess. Surgerj* is, I believe, indebted to 
Dr. Bauer for tliiK operation, and it will, as far as my experience 

* Thi] poaibitUy of curing n cbranic inflmumatury diMaae biu been ulnuuly 
duuliteil. tscL- p. 2trl. 



330 



Hi r. JOINT DISEASE. 



Chap. XIV. 



goes, bo formd very valuHMe- IJi roy hnnda it has perUiinly 
relieved pain to a remarkablL* degree, aud tliu fornmtiun of ubscess 
bOB aeemed, to say the least, postponed. But the more extended 
experience of Dr. Bauer himstdf will afford a more reliable aoeoiint 
of its benefitB than my ^malltT number of oases can fumiHli. 

" But what shall we do with the effusion in the joint ? If it is 
of plastic ohanu'trr and small omount, we may hnvo it to resorp- 
tion, and if it should orgiinisi^ and uaiue fibrous adhesions 
between the corresponding articular surfaces, it would matter but 
little, since wo have it in our |»ower to break them up again and 
re-eBtnblish mobility ; occasional motion of the joint in iho pro* 
cess of their formation may even prevent them effectual ly; this 
flhfluld be (Ume, however, with grwit disi'^retion, and not beftire 
till! inflammation has libiited in some degree. A considerable 
qnanlity of effused matenal is not only a great im})cdimcnt to 
the restoration of the position of the extremity, but it is in some 
respects the means of coutiiiuiug iutlammation by keeping up 
the distension of inflamed tissues. With the quantity of exudtttion 
the detfree of malposition and the violence of ttyinjitomt eorretpond^* 
In order to relieve Iwtli wo Imve to withdraw it. We moy do 
this in two ways, with kuifc or trocar. A straight and poinLL*i| 
tenotome is ttatly inserted behind the joint, then so turned as to 
penotnite the cajwular ligament. The wound of the latter shoidil 
at least be a quarter of an inch long, so as to facilitate the 
eecape of the fluid. Whilst this is being done the extremity 
should be tuvert<;d so as to diminish the size of the articular 
cavity so as to drive all the liquid out. The puuctm-ed wound, 
in tine, should bo carefully closed with adhesive straits mid the 
limb fn.stenpd on the wire appiinitus. We should proceed in a 
eiiuilur manner with the trocar, with this difference however, 
llmt the cantda remains in the joint until the limb hfla»beeu 
inverted. The limb sliould be kept in tliis piisitiou until the 
canula has been removed, the wound cKvseil, and itself fastened 
down in the wire breeches, otherwise the formation of a vacuu/u 
would invite the air to riish in aud cauKo lubichii'l*. The exact 
place to enter is to bo determined by the fluetuation, mostly nii 
inch jHJsterior and superior to the great trochanter, where the 

* Tliia ttnti'ttioiiL (tliu JUiHon iirc Dr. t wliult* i'xt4.-ii»iiiii. Ut iimtiy jujutnlii 
OuULyd) ia liiirdly to lie iipptk-*!, tit itit | wiUi viulunt Hjmptoais. 



Chap. XIV. DIVISION OF CONTRACl'ED MUSCLES. 



331 



I 



joint is but littlo covered by aHtpose tissue ami foficia. We 
prefer a Sue trocar, of about a Hue thick, to tlie knife, as you are 
luort* eertuin iu iU baadliu^, and as you cau see the contents 
witbdrn^vn, wbich will not only perfect your diagnosis in refer- 
ence to tbe actual condition of the joint, but will afterivards 
guide you iu reference to the plan of treatment to be aftQn\-ardH 
puraued/' " 

TTiird iStoffe. — ^The rapidity with which shortening comes on 
depends very much upon the treatment during the second stage, 
uud upon the pu^ture whidi t)ic patient a«Hiimc« or is made to 
tttkc.t If the position which produces an apparc^nt sborteuing 
of the thigh be induced by the irritating pressure of one bono 
surface against the other,! wo may, by preventing such preaaure, 
Im- abhi U) postpone, perliajs oven ultogctber avert, tbe assumption 
of that attitude. There are cases which iu spite of every treat- 
ment will run ou to aljscess ; but even these will not get deformed 
to Bui'b a degree if extension bo applied early, and even when 
the third stage has lasted a considerable time the shortening will 
Ik' very much diminished, 

U' a patient in this pha.se of the disease be allowed to assume 
what position he chooser, or even if he have u splint upon the 
limb but not any extension be exerted, the ytarting pains become 
extremely severe in ciiaracter, — produce, even during litfulslnra- 
Itenj, profuse perspu^titm, wear out the health, and cause rapid 
wtLsling with hectic fever. M. Ftonuet was, and Dr. Bauer is, in the 
habit of performing myotomy pretty freely for the relief of theso 
s|iasm8. 1 too have found such operation efficacious, but do not 
expect again to be forced to its use for such purpose. The contrac- 
tion of the muscle is not prevented by its division, for it dej)eud8 
u{K>u nervous irritation wbich continues after myotomy ; as tbe 
itporation relieves pain it is evident that this is not caused by 
the contraction itself, bnt by sometliing that the contraction pro- 
■ilucea 'Hie posture caused by the contracli(.>n maybe overcome, 
but the paiu, if nothing e\w be done, will continue ; it is not, there- 
ore, the posture whi(!h is painful. Then; remains only the other 
Boct of the muscle, namely, tlio abnormal pressure upward of 
the thigh bone: by relieving this myotomy aunulfl the 6i>asm. 
Ihit tlivision of a mass of muscles like tbe adductors is not to bo 



* Oitaor 'Oil Ilip ttiiil Kutxr-juiat I 

IJIHOUM',' p. '28. I 



t Bcft-r ti> i>. HID fur Accodiit of )H)tf- 
lunt. I t^w p. »I2. 



332 



HIP-JOIXT DISEASE. 



Ciup. 



ondortaltcn lightly, not merely on ncconnt of its sisse. but also 
rnxoani of the position of tlie obturator vessels aDil 
ia true Uiat the stTtion is uot fi.iUowe<l by flaii^emms 
rhage or f^iralyttis; that tlic miiscli-s may i>r**n bo di 
without severing the rascuhir and nervous branches (p. 
but such on operation is ]»orfon»ed close to tin- c-ait^ule^ 
n(»t tv he recomnieuded during tJio active pluit»f oi' Iii]>-<ii 
although the imiDodiate relief of pain is gratifyixtg. Myotoci 
liuwever« is a justifiable pnwreiiure if the case come under tn 
moiit when the (h'snasc is ulrimdy fur advanced, when tlie m 
cular contraction has lasted a long time, and the deformity 
too consideruble to be overcome even by .a powerful extendi 
force under cliloroform : we shall be obliged iu such cases 
divide tlit* miiMcUts. The principles of such operations full 
another heading, but it may here be stated that it is not 
ni|)idly to extend a limb, iiarticularly ef u chUd, if tlie dcfi 
iiiity Ikj 8o great that the contractiu^d muscle must U? cousid 
ftbly stretched. (Chapter XV1I-) Hence, in h>ng-Ktaudii 
cases, myotomy may be used to place the limb iu the pro] 
poi^ition. 

The above mode of reasoning upon the cause of relief froi 
myotomy, and tlio examinJktion of a great numlKT of nmrftJ 
H[H>cimeiiH, led me tij tin; belief that the evil efi'ect.s of nnwcul 
contraction might be overcome by connteraetiDg their po' 
and inducted me to oonstriict the extending splint fur that j 
pose. The results have exceeded my hopes, and iu no 
whore it could be applied has it failed to relieve the starti: 
pains. In throe casea^ in which the health of the patients 
giving way rapidly under tlicir sufl'erings, sound sleeji and apfi 
tite were restored and feyer disappeared. In one instunee, the 
treatment of whiili 1 undertook when an absci'ss was present! 
on the inside of tlie thigh, the sliortening much (lwTefts<*d and tl 
ptis disapiwared. Kxtcnsion may uot cure a dironie nirii 
of tlie hip ji>iut, hut it follows out the most reliable of all surgi- 
cal indications,- — it removes a cause of the disease. It I 
already been questioned whether we can ever do more in 
chronic inltaniination than ]»ut the |>ationt into the l)est possi 
circuinst^uices fvr getting well, and this is done I Iwdieve 
removing the morbid preH^un- of iIk* one lione aguiittil the otlii 



:tio 

I 

i4 



CuAi'. XIV. CARE IN ALLOWING rX)COMOTIOX. 



333 



All cases of caries are so slow, both in tlieir morbid and 
rfipamtiv« act*, that when once this process has licgiin (evi- 
dnnccd by stiirting pain-i of some duration) the surgeon must 
arm bi>th himself luul tin* patient with much eudurance and [Mjr- 
wneriince, juid the fonncr must not expect tluit a few weeks' 
tr4!«doui from piiiu is an evidence that the j>aticnt is well. Slonths 
rather than weeks am n'<|iiin'd for t!ie cure ; when all jwiin, ten- 
derness, and swelling have ceased for some time, the ap(Himtus may 
Ihi disecmtinued by degrees : first, the oxtensioD removed for three 
or four days, then, also, during t)»e niglit ; if no pain follow, the 
fiplint niiiy be tnken off*, the limb and hip ciirefully rubbed but 
not Hexed ; after another lapse of time passive motion can be 
ejiri'fully emjihjyetL In a few days the ]>atieut may sit up, and 
after further interval, may move about on crutches ; but if at 
any time in the course of these experiments any pain in the hip- 
joiut or knee recur, the splint must be again ajiplied and atiother 
jmriod ela]»se before any attempt at its discoutiuuauce be re- 
peated. The extension need not be reapplied mtleas stortings or 
tenderness reappear, for that condition weakens the muscles 
more entirely than any other, save paralysis. Even if ])ain do 
not return, a long time should ehipse Ixifore he is allowed to 
place more than the mere weight of the limb upon the ground. 
It is to be remembered that the formerly carious part is now 
a cii-atrU, and like all new tissues, will fall most readily into 
disease until it*i organization be firmly established. 

A certain number of cases will, in spito of every treotmoutj 
ran on frotn bad to wtirso ; these belong chiefly to that leas 
common form of morbus coxsc, which began in osteitis. In such 
cases, although by relieving pressnro we may prt-veut the starts 
ing pains, abiieesses will nevertheless form among the muscles of 
buttock and thigh, or on the pelvis, or in lx>th sitiutions, and ulti- 
mately destroy the patient's health. In such cases excision is the 
ouly resort; thissubject id haudled in another Chapter (XVIII.); 
but it moy bo here remarked, that lliis operation is in my belief 
a'^ually positioned t'xt long, and that it should not be so ranch 
reganled as an nitimote resource to be employed only because 
anipntjition is worse than useless ; it should rather be viewed as 
a means whereby wo may yet procure for our patient a valuable 
limb. 



3M 



BITJOnST msKASK. 



Qur. XIT. 



C-uo or nm Dbkul 
<l|», <iy..^O I my OoffBcr, agBd It fom imo tke ChBiqe4>aB> 

ccK^) wHli bip iTwiw. 

Rn m«Ulw 100 aooM piin mil 4MnSkj m waXtia% enaa oa. 
IsatD «w in tba bip. aad it eaoMd turn to Uaqh. Tbc liaiaaai (ot 
«od, in abottt UarM ««efc> after iU Iknt eooung oa, b« eodi ttot ««B: all 
bai nawuDcd ncarij alvija in or Ijuig ou Um mUaide of Ibe bad ; i 
be eoaU ait vp> AA«r «k waeka or two mcmtha he vaa Mm atgun 
wift, bol nf7 toott got tired, umI AMU be «as obifHl to Basp » food < 
A fortaiglkt ago ibe |»tn becaaw nadi wona^aad be baa be^ bi bed i 
thutfciaw. 

Tho tbigl) baa now tbat poaton caOed langtbeniag ; aad it gtrea I 
imkii to etanil, altboa^ h« pQte no wei^t on the liaib. HMrt i» 
RwdUngr and a good d«al of leodcinieBa. bo<h behtiid the tradiaoier and < 
tha groin. It wan aboat a fortnight a^, as near on he can rnBentwr. tKat^ 
atwtiof; paina fint connoeooed. He aajs that they now waken bim up 
oflao wben be i> bSHa^ to aleop : thia doea Dot occur everj, bat vecy 
atmdy evny. nigbt. 

A bliater vaa ordered bebind the bi|i, and when thia beakd another i 
appTied to the groin. Koithcr application appeared to prodoee benefit,! 
th« alerting waa getting wonw. 

July 24ih.— 1 a]ipUed the aplint aa deeoribed at p. 327, aod gava tbe 
accumulator bat a alight degree of teiiaiou Ordered iodide of potaaa mix- 
ture three times a dky. 

ZImI, — The circular bauilage, vhereun extaoBOoi ia mad^ eeema "nry apt 
to gall tbe akin ; by changing it« poaiticn from ankle to knaa miw but 
ali^t inftaiiiwatiou haa been pre^-euted. lie has bad no etaxtin^ ainott 
tbe 26lh— (tloo]« and eate well. 

Aug. 13tb.— He haa had no eitartiug imioH ; in fact, no pain at ail, and ia 
inclined to be unruly, jumping up in bed, sometimes gottmg out of bed 
altogether to play with other boys in tbe ward. In conaequeiKM of this I 
faatened a bandage round the jMiInB and to tho bed on each aide. 

'J7tb.— iJtill free from all pain. On examinatioo of tho hip no swelling ^ 
imr toiidomeBs could be found, either at the gmin or behind the tro- 
chanter. Tho tension was discontinued, aud tho splint only employed. 

Bept. lOih.— The spllut was taken off on tho 30tli of laai, and he wna kept 
n« much u possibtu in bed till tbe 7tb of tho present, month. lie has 
ninco beoD allovrod to walk about, which he doua without liniping or anjr^ 
atillbeRB. DiBchorgod. 

Vauu LV.— James Tohh, aged bk, came Into Ctiaring-Cn»>s IIaHpit«)» 

under Mr. liancock'a cure, Ut May, 16*iO, with a dirteawj in tbe hi]>-joiut» 

wliii-h hiut oohtimicd ftince Jniuiary loHt. 

Mr. Ilnnt'ock treated the boy by ni^ana of a Reton, under which he tin- 

L'pruvud. Some tiuii; after it \mu\ takuu out hf relapsed, and ho Itatl on issue 

^■A,ipliud ; but in hpito of oil thin lie got wortte. Ou thf Uth of Juue, I, 



Chap. XIV. 



CASES TREATKT) HY KXTENSION. 



336 



linviDg xinttd for a month ihu oxteiuHng ttplint iiivoii ii cose in pnvat« prac* 
ticQ, requested Mr. Uftncook to allow mo to ft|Tply it upon tli'iB child. 
I With his usual kiitdnetts he cotiwuted, ood placed the cB«d unJer tay 
^care. 

Juno 14th. — Tlie following vtta the Btat« of the dt8e>ase at this datd : — 
The child complained of great |>ain over the inner condyle of the femnr, 
and could only rest with the thigh and leg anpporte*! upon a Btnull doulile 
inclined plone. Any movement made him cry violently. At night be 
alwayx Aeemed In great pain, and cried frequently for hours bufore he cotUd 
bo got to sloop, 'i'hcrc was much tenderness, and eomo heat and BwcUing, 
oth in the groin and behind the trocluinter. The limb had assumed the 
osition of shortening; but it seemed that this had only juat uomu on. 
)uriDg the lost ten days Uie ohild'» appetite and healdi have much 
Ideoliued ; indeed, all the more violent symptoma date from about a fort- 
fjiight ago. 

I put on a splint made entirely of wire-gauze ; tbe thigh-pieoe was &»• 
ened on the iielric portion, at such on angle as to allow some floxiou of 
the hip. Extension was made from a ncll-jtoddod str^p of webbing abova 
the knee.* 

2~ith. — 'I'be cbild api>ears better — be docs not cry at night, but hleep8 
well. I changed the angle of the thigh-piece, bringing the limb etroigbt 
with the jxtlvbi. Tlie child Ik still in pain if ilio limb be rniher suddenly 
moved, and there U still tenderness behind the trochanter. Putting the 
limb dowu Miused no jtain at all, as it was done slowly — no muscular con- 
traction. 

July 16th.— The child is better, can now bear the limb to be moved 
about )>retty freely ; the movement which causes; pain, when rather quickly 
douo, IB fluxion. It h-is once or twice happened that tlie fastening of the 
accum\Uator liaa slowly jieldod ; when it becomes louse tbe cluld isaJwu.vB 
in paiu. 

Aug. 13th.— Goes on well. One day lost week some visitors gave Uim 
unripe pears, and tbe bowels have been' much ivarged ever siuce, and be is 
oocftuonally sick. This lias made him pole and languid, otherwino he goes 
UD well. It ha» been diflicult to prevent his being galled. 

Hept. 17th. — Ue bos got much stronger and better ; is taking iron. 1 
have now replaced the wire thigh-piece by a woodeo one, and make exten- 
KJun from strapping ploisterapphcd along the leg. 

Oct. istb.— Exauiioed oarefiilly the bip and find no tenderness and 
Kux-lling, nor [ma on poshing the bouo upwards, Ltit the extun&ioa bu 
diKcoiitinued, and tliree days afterwards the splint was left ofC, and tbe 
child allowed to sit up. 

2(Jth. — lliu child has been sitting about for three days without sign of 
pain ; but to-day he would not get up, and cried with jwiD in the knee ; 
splint and extension reapplied. 



* Subftcqncnt cxTH-riuict; in llw uw niuy 1m? u|>{ili(Ml aa roUted at p. .'f/7. iiii- 
uf thii) 9|itii>L boa eliowii mv thut it 'le \ UitA, piirli»|i4, wlnii thu tU\^\i Utu lung 
iiul ui^-ct-deur)' thiL< to cliaii!:e the mtgU' ' \tom coiuidLnihly llfXtil. 
uf tliiflU iiiiil iwlvi^iortitFns, but tliut it 



33G 



n IP-JOINT DISEASR, 



rHAF. xt 



Nor, 14.— Ho is now up> can crawl about^ lift bia foot up to hia fore- 
head, but the limb is too weak to support weighL 

Other cae«8 might, ba af\dvd lo these, but they really preseut few potaj 
ou which to observe, as the sunplo luMlurv tit coniiMrative or ent 
freedom from paiu ; unprovemaiit in health ; gradual reduction of 
deformity. 

Tlie outline figure at p. 310 is taken from a boy, aged 1.1, who 
edocc been subject to oxtensiou of thv limb for the lost three moiiLlia. 
Starting pains have entirely ceaaed ; the deformity haa vorj- much yielded ; 
an abscctui, which had presented at froot or the thigh, haa disappeared ; ho 
has no paiu creu on bearing the whole weight of the body on the aflected 
limb. He is now, 20th NoTcmljer, walking about without any paio in 
the hip, but tho leg is weak ; there is hardly any malpo&turc. In unotfa 
ciwe, in which the paiuH at night were excestive, tbe health had xe 
much yielded, tho sweating was profuse, the emaciation very great, aud 
tbe discharge Arom abscesses and sinuses exhausting. The evtt appear- 
ancuH yitilded by degrees iit the order in which they are enuworuted, and 
the young gentleman now sits up for a few hours each day, without ] 
and only has the splint, with oxteoaion appUod at uight. 



APPENDIX. 
On the Apparent LENOTnENfNO of the Tjiich. 

Although moBt of our reliable KugUsh authorilles affirm, 
*■* lengthening of the thigh in hip-joiut disease, is merely the efl'ecf 
of tho position which patients thufl ai11ic;l4^d (uwime ; " yet wimo 
English, nndraany Continental (chiefly Gonnan) authors, fake a view 
ao entirely oppoeitc, and supjxjrt their doctrine by so manituld 
reasonu, that the subjeut hau a])poarcd to tdo as TBqiiiriiig furthtir i^^ 
Testi^tion. ^M 

Uiinter conceived the *' Icnj^heniug '* to bo duo merely to poeition* 
Ford held the same opinion, although he hafi not expressed it vory 
clearly, nor decisively. Bnidie nay**, " This a[>pimraiir«; is altogetliMl 
deceptive, and on a careful measurement l>eing made with a tape from' 
the anterior superior spinous process of tho ilium to tho pntolla or 
inner ankle, it is found that there is no elongation in reality. Tho 
{►elvifl is inclined laterally, so that it makes on tlie Hide of the disease 
an ohtnse angle with tho apinc." * Bonnet entertains an tdentii|^| 
opinion, and explains at great length, tho various poeitions, whore^^ 
thia deceptive uppeorance may l>e pirtduced. On the other hand, 
CoultKin conwiders that the limb may be really lengOiciiod "a little 
more than an inch." f This ia a point on which it behovea ut) 1 

* Sir a Brodie ' On DiMimi of the 1 t CoalaoD ■ On C^-awe of the Bk 
Joints.' p. 117. [p. 10. 



AfTWSVtX, 



EXFERIMENT3 ON LENGTHENING. 



387 



be accurate, and I will quote pasmgoB &om those whose authority 
8ian(l8 high in Kiigland, and on tbo Continont, in ordor that a full 
view of the subjt^ct may be before tho reader ; only promising, that 
tho6© who consider the tbigh to bo really lengtlioned, conceive that 
such elongation ia prodnced by Bome morbid change, which causes 
the hesd of tbo bone to bo partially expelled from Uie socket, and 
that then the woight of tbo limb causes it to sink down. Rust, of 
Vienna, aHcribed this lengthening to Rwelling of tho bead of the 
lione, wbicb forced it out of tlio auetubulum; ho *iuito overlooked 
posture, conBideriug the whole elongation to be real. Falconer, 
Boycr, BicKat. De^aidt, and other«, considor the lengthening due to 
ewclling of the articular cartilages. Petit was the first surgeon 
who BUppoKed that an accumulation of fluid in tbo aityloid cavity 
could separato the head of the femur from the acetitbulum ; and 
Sabatier seized upon thie notion, and attributed tho lengthening of 
the thigh to thifl cause. Fricto * assumed that a relaxed condition of 
the muHclea might cause real lengthening of the thigh- Sir B. Brodie 
says: '*ln cases of inflammation (acute) of the hip, if active treat- 
ment be not had recourse to in tho first iuRtunce, there is always 
danger of the bead of the femur being tlirofit outwards beyond tbo 
margin of the acetabulum, and then completely dislocated by tho 
action of tho muscles. Several cases of this kind of dislocation 
bave fallen under my notice."t Bo it observed, however, that bo 
does not attril>ute the lengthening to tbis cause. Boyor, Larrey, and 
others, imagined that the lengthening might be produced by swell- 
ing of the ligiimentiim terea. A number of authors (Boyor. Larrey, 
Morgugni, Kubt) put down swelling of the Haversian gland as one 
cause of tho lengthening, and many agree with them, that a solid 
swelling preHsing the bead of the bono out of the cavity, may 
produce such distortion. 

Upon the other side of the question, wo have chiefly Iluuler, 
Brodie, and Bonnet, who consider the lengtliening as due entirely 
topoailion. LelUBnowdiscuss, whether any of tho causes above enu- 
merated can produce a real letigtbeningor shortening of the thigh. 

In trjnng to determine this question, two poinU must be made 
clear : firstly, whether any one of the causes mentioned is capable 
of presning the bead of tho bono away from the acetabulum ; 
aecondly, whether, if tbe head of tbe bone be thus separated, the 
tbigb will be thereby lengthened. 

J-'irst Qiisstion. — That the head of the bouo is very seldom enlarged, 



• 'AniuUfuditCUinirgiiclic' Abthci- 
laiigilfH sJIk. Krunkenhausu lu Uuil- 
burg, 2'" ThoU, 8. 29. 



t Sir B. Brodie 'On Diecascs of 
Jotnti,' 5tii eilitioD, p. S4. 



HIP-JOIST 



cbat.: 



■MjbednwB tnm a»bet,tkM But. vtemtk 
■I I !■ Mill of tUaUea. eodd cnly q«ateaae cms, ia wUcki 
All ■ II to oeesr. Fri^ti, «ff "™**'|^ giw «■« ■& 
mv^dBgjbt calvgiHea* «M M»d to bare tdm fJbeau 1 1 
iamadtmy paiMopcal pnfMntMiB. io wiucfc tfekoadof l 
pnpar, i c the |iui onUnuilj oar? «ph1 bj cartilage, vac ; 
biiMu BweUtagof tbecaitilageitaBltamUat Un aoaC i 
onaor t«o fine*, and eoaU not tbeniora cm 
faidi or nan. ' EffiaaiaB, or gnmh in t^ aoalabaliiH, 
Im tks onlj caaaea laiaamhrg. It majr vefj uncfa be 
wfaelheraliqaidaffiiaediatotlie o^iaaie of tbo joint, woald i 
late at all between tbe boMi. T^ aort part, a« BoBMt ol 
oflkia iajoctioH in tibe dead mbj«ci gathered aboot the neck:! 
fastir. bat KMBe* be aaja» waa between the booee : thcn^i bow^ 
aaoertained that point be doca not aaj ; at all ereatB. while 
mnaclca maintain their integritj and action, liqoid weald 
nora earily diatend tho capiale, than digJatw the bone. A i 
tomow, aa a growth of grannlations from the bottom of the ; 
bolum, wonld be Ur more capable of making plaee for it 
between tbe bone mriaeea, but it ia to mj mind vety i 
whether it coald pre«B the bead of the bone the leeet ilifrtaitfe I 
aockut. Ivct the position of the two leaser glutei of the prrilbr 
the obtnrAtorR, gcmelli, qnadratua, aiui upper part of adduc 
magntw— the strength of all the upper and anterior part of the < 
■alar ligament, be oouudered ; and let it at the itame time be rcmc 
borod, that neo-plosnu do not push aidJe parte which are in i 
degree firmly fixed, hat simply produce their absorption. He 
it appears, that none of these caosen could operate in puahingthol 
of LtiL' boue from the nuckt^t It is rmlr dne, however, to the high i 
of Edward Wcbcr, of Bonn, to say that this opinion ia diametric 
oppnaed to hia. The cxxierimcnts, whertby ho scorned to show 1 
atmoNpheric preaHUre keepit the femur in its place, haro 
hln^nily dutAilvd («ee p. 17) ; a oorullary^ that he draws from 
Ih wuHhy of quotation. 

'* We hiivo flocn in tho experiments above described, that aa i 
aa air was allowed to enter tho cotyloid cavity over the capj 
fomoris, the head fell out of tho acotabiilum, no change in 
ligament having taken place. It Is not aecetutary to the prLtductifl 
of this eObct, that the subatanco should be air penetrating 
without. It may equally well he n fluid accumulating there 
aucretion from tho Teaflcls, or a solid sulnstanco growing in 
place. In tlio some degree, in which such fluid or other suheta 
forms and inc^rcaaoH in the ca\'ity, will the head nf tho bone sink 
StaowD weight, out of the acetabulum, without thonccesfiity of ( 



Appendix. 



EX^EBIilENTS ON LENGTHENING. 



339 



I 



presfliirc, and without encoantering the fnualloBt resutanoo &om the 
ligiiments." • Surely, if ovon this theory of syi^pvial vacuum were 
correct, such an ignoring of muscular action and lif^aniontnoB roaist- 
anco cannot bt* admissible- The presence of either fluid or now 
growth would nut dcHlruy the vacnuiu, if any aiioh exiHtod, so that 
the now material wuuld place itself where itenconntoreJ the least 
rosistancc, and that would certiiinly not be between the head of 
the thigh and the pelvis. However, this aasiimplion is beet reftited 
by some oxpcrimenttt to be dotoilod liclnw. 

Second Qttestiou. — Lot it bo Buppoacd for the present purposes, that 
in some instancea, however rare, the head of the femur may bo 
preased- outward by an iulemal force, will such change in position 
alter the Icuglh uf the lliigh? The direction of such displacement ia 
outwardB, and a little do^N-nwards, but so little in the latter direa- 
tion, that it may well ho queetioned, if a separation of an inch 
betwoec the two surfaces would cause any appreciable difference 
in tfao meaanrenienta of the thigh, con8idering that the limb could 
not bo draped down by its own weight, until the head of thu bone 
protruded beyond the lip of the aoetabulum. 

Kyrperiment J. — May 4, I8(>0. — On the body of a fiiU-grown man 
not emaciated ; all the viscera had been removed, the thighs were 
forcibly flesed, extended, and moved in eveiy possible direction^ 
until all rigor mortis was overcome. 

A needle was ilriven into the anterior inferior spinous process of 
the ilium, another int*> the femur, above and to the outer wide of the 
knr*e joint ; an inflexible wand of wood was then procured, and at 
right angles to its axis a needle was driven into it; this was 
applied against the one In the ilium, and a fourth n«edle was 
inserted at the point of the wand, where it came in contact with 
the one in tlio femnr. Most acciirvite rai^&ns i»f measuremfut were 
thus procured, one whereby a variation in length to tlie i ,1b "^f an 
inch could be appreciated.! Tlie subject l>'ing on its back upon 
t)ie table, a hole was rapidly bored from the inside of the pelvis, 
through the acetabulum ; the staft' being held aguinst the nccdios, 
ahowed no alteration in the length of the limb. 

JSscptrmmeb il. — Same day.^ — On the other Uiiib of the same subject. 



* * EiriicR Bc'incrkuDgrn CiKr ilio 
Mcclmnii dcrfiilt'iikii," He. Ed-WeU-r. 
MfUlrrV AnbiT. 1836, p. hi. 

f Tim iJinicnlly of mcaninng the 
thi^li <*iin hiinllT (>«i iindr rnt«od hy any 
wlio bnvc not (lir»_ft»Hl nnirh •tlontion 
to timt f«nhj*'ct Th*- nbt<tJw)rR whicli we 
WcoiiritiTril uti tlif living in c^mpmiiif; 
ODD aide with tlie olhtr, of fp-tting' ttio 
two tliigba in cxAf tly tJio aunc rt'tatjon 



to the pt'lviH anil at nerfwt ri^ht aoglee 
to tilt' Hiiduftliu Wly. n uttrr nicutiin»- 
mcnt (if limb ngatnKt Uuib most nnrer- 
taiti. Nl^fdU-ltw(!rocll(M(!nn» (tied points 
hecuunu all proceut-s of tim Imnos aro 
too lirund to wrrc cut sccunit^ obifct« of 
moBcnrumeiit, and they wrro flsnl into 
tba bono t>cca»flt' the mobilit)* of Uie 
ikin doftny* nicety of itjiprcotation. 

z 2 



340 



niP-JOlNT DISEASE. . 



Chap. 



liko moans of moasnrcment being adopted. Onboringaholothrongb 
HxG noetubulnin, qd di6foronoe in lougth ooald bo detected; thi 
noKzlo of a s^iingo was then fitted (o the opciung, and water wa 
injected. About three draehmfi probnhly found its way into th^ 
cavity; no moro could be forced in, although oonRiderable preastir 
wafinscd; there was no difference whatevttr to be deteqted in tli€ 
distaiice between the needle in the femur and tliat in the ilinm. 

KrperirnetU III. — May 9, 1860^On tlic body of a man who die 
of old age. All internal viscera wore removed, rigor mortis of lef 
hip entirely overcome by forcible flexion, extension, &c. Needlos 
driven in as for Experiments I. and II. ITio rcvorno snrfaco of tho 
acetabulum was pierced (mensuremcnt showed no eoni;eqneQt 
chau^ in tlie diHtanco of the nccdlefi), and enough nf the bono 
wiu cleared away to permit tho . CAsy intn>duetion of the tip of-^ 
tho little finger, wUorowitli tho smooth head of tho bono oonld 
felt : nynovia flowed. An iron screw-drivor was inserted betwe 
the acetabulum, and the hf>ad of th« femnr, and then turned, so ; 
to lie with its greatest breadth betweenHhem ; this visibly movedl 
tho trochanter out wards, but made no diQ'ereuce in the diatauco o£ 
the needles. A wooden wudge was then driven between the tv 
articular surfaces (the back portion), by successive blows of a' 
mallet, till tho mass inserted equalled ^V inch. Thiscaused visiblo 
projection of tho trochanter; it was Iiardly possible to obtain any 
BuflSoicntly accurate measurement of the amount of projection, since, 
from aimnltauoous roUition inwards, tho relative ^Kmition of ilium 
and trochanter was altered. At all events, it was known that a 
mass of wood ,% of an inch thick intervened between the head af 
the femnr and the aoetabulnm. The distance between the needlo 
in tho spine of tho ilium and that in the lower part of tho femur . 
remained accurately tlio same as beforo tho wedge was inserted. 
Tho skin seemed to drag a littlo on tbo lower needle. M 

Thia last experiment is far more decisive than tho other two, ■ 
but cortAin defects might bo supplied. In the fir^t place, the weight 
of the femnr, always supposed to aid in tho longtlH'uing, could not 
act. In tho next place, tho lower needle seemed a littlo draped 
on by the skin : this appearance was very slight, it may have even ! 
boeu fallacious ; but such draft might Iwvo been produced by one of j 
two oauscs : either tho thigh bune was really pressed downwards byj 
tho wedge, but the tension of the skin would not allow the ncodloJ 
to show that descent ; or tho projection of the trochanter hod puUedl 
tho skin upwards, and thus produced a drag upon tho needle.] 
Again, it cei-tainly would be advisable in tlic next experiment to 
obtain some measurement of the outwnnl projection of the tro- 
chanter. Moreover, in the preceding trial, tho wedge had been \ 



Appenoix. 



EXPEKIMENTS ON LENGTHENING. 



341 



drivon in behind, otitl a little below the trochanter, aud this potti- 
liun may have prevented the deeceut of the thigb. 

ExiMrrvmsiit i T.— May 10, 1800. — Ob tho right hip of tlio Bamo eiih- 
ji!Ct iw I ho hwt, placed upon \X» back upon tho table ; all rigor mortis waa 
uvui'coiuo by forcible dexicin, &q,^ of tho thigh. A meiwuriug tape 
>riut fastenc^l by a flat headed nail to the la»t Kpinc in tho Botn-um, 
BO that it would bo carried round tho ilium, including tho tro- 
chanter, to a Jieedlo in tho symphyBiB pubis : thiH n]0!i.<4ur*>nicnt wax 
cxiiclly twenty and a half inches- At tht* edge of tho measuring tape, 
another ueodle wan knocked into the ti'ochanter, wliich wiut to Horve 
unt only as an indux, but also aa a moanu of Huourtug the tsame posi- 
tion of ilio ta|>e at the noxt meosurouioiit. Needles were fastened 
into the inferior autiiriorHpiue uf the ilium, aud in the lower part of 
tho fuiuur aa beforo. Incisions were made down to the bone pi*CTious 
to iuaerting each needle, so as to leave them free on all Bidea A atrnp, 
fautened round the aiikic, held a ring which permitted a s)*Btem of 
pnlle^'s to be hooked upun tho lirab. Counter extension was made 
by ft roj»c' pa88c<1 under ihu pcriuteuin. W hen all things were ready, 
and tlie meatmremcnt by stall" accurately procmx'd, a f^stem of 
three pairs of pulleyu w^ui faui>ke(l upon the limb, aiul npon Its rope 
a weight of 28 lbs. was fastened; this procured an extending force of 
76U Ibfi, or Gj cwt, llier© was a gentle crackling in Uiu whole 
limb, but the nieasuremonta were precisely tlie saino. Ten minutes 
wore now uUowcd io oUp8o, and the weight was seen graduuUy to 
sink doAMi towards tiie floor; at last the stretcliiiig of some part uf 
the cxteubion and counter-extension (citlior limb or rope) was so 
giout, tliat it was necessary' to fasten the weight higl>er on the cord. 
The uiousuremeut between the needle in the iliuu und that in tho 
femur wiis now again taken, aud no difference was lound ; thus Uie 
weight had in no degree lengthened the thigh, i. o. it had not increased 
the space between knee and pelvis. The cotj-loid cavity'was now 
piercotl (rum the pelvis: moasui^imciit still showed no diUci'onco in 
the distance of the two needles. A considerable portion of llioiimer 
wall of tho acetabulum was gouged away, as in the last exporimont, 
anil a wedge, three quartora of an inch in breadth, was driven in 
above, and a little behind, the head of tho femur. This caused the 
trochanter visibly to project ; the measurement round that side of 
tho pelvis aud groat trochanter was within a fraction of twenty- 
one inches. There was found, in the distance between the 
needle in tho great trochanter and that in the sj-mphysis pubis, a 
decrease of nearly two lines; this was attributable to rotation in- 
wards ; but between the noedje in tho infeiior sjnne of the ilium, 
and that above tlie knee, no diQerence in length could be de- 
tected. A wetlge, just one inch broad, was now driven in directly 



HIP-JOINT DISEASE. 



Chap. XIV. 



behind tho head of the femnr; when it liad got nenrly bonie» 
conuidcrublu power was iised, tuid tho troclianter was seen to pit>ject 
furthor ut each blow uf lliu mallei, and t)ie neodlu wliicli had bti«n 
driyen into it, turned tike an index more and more towarda tho 
ilium. At ltt>it the trochaut4.M' projected so miuh, tlutt thir ibau foHt$a 
and belly of Qii' gluteus modius, funned a deep hollow ; the mcatmra- 
mont. round the ilium and ti\>cbftnier waK now 22i inches ; tho 
needle in the troohxmter wax a fraction of a line iwurer to the one iix 
the fiymphysiH pubis, fihowing how ^eat rotation inwaxda muKt 
havo beon. The moasnrcmcut between the noodle in the ancerior 
Bpiuoiis procoMi of tiie ilium, and that iu tho lower port of tiio femur, 
remained precisidy the some. 

The wudp* wan withdr»wu. The head of the bone did not rolum 
to it» old place. Tlie weight was removed from the cord. Ilm 
head of the boue fell back — not suddenly, but atill pretty quickly — 
into the socket, producing a remarkable sound procisoly like that of 
disartieuUtion. The moaeuremont in length, of the fumor, waa 
fomid precisely the same as before and during the trial. 

Those experimental set at rest the supposition of any real 
lengtheuing of the thigh being possible, witbautdialocatiuu, Such. 
roBults are consonant with reAtw)n ; but I should hai-dly have ooa- 
coived, that a separation of an inch» with such great proji«tion 
of the tiXMJiantor, could have made ahs-JiUely rvj thjr-trvnce iu longtii, 
although 1 expected to find that diJTereuco very small. Wo must 
tlion look entirely to position, as the causo of this important 
BjTnptom.* 

* This lu«t oxperimcnt iras referred to ia Chapter L, p. 18, by on oiror. aa 
Kxpcrimeut QL 



OUAT. XV 



ON Tim BU1(S£. 



343 



CHAPTER XV. 



On Affections op SynoviAr* SnEATHEs and BDitSiS in the 

NEIQnBOUBHOOD OF JoiNTS. 

The synovial mombraues which line tendous and their Hhcalh^ 
or which fonn fluid pads Iwlween tlio skin a»d bony j>oiiitji ex- 
poeed to friction, also between tendons ond the subjacent bone, 
in every case where the former pa£)&e8 over a tulKJi-osity to be 
inserted at iU further aide, are all subject to innumniatioti. 

The Bursfe, as these latter bugs of synovial membrane are called, 
arc thus to be found in certain points of the body in a normal 
condition. Some are sii|»erfifiul, others deep. To the former 
class belong the sac between the skin and olecranon process, and 
that between the same Btructnre and the patella with its liga- 
ment, Ac, &c. ; to llio kttcr, the bursa between the biceps 
tendon and tuberosity of the radius, between tlio ligamcntum 
patellae and tuberosity of tho tibia, between the tcndo Achilles 
and 08 caleis, &c. &c. But if, from deformity or other cause, 
any point be exposed to urusufU friction insnfHcient to pro«luce 
ukoration of the skin, a bursti in that point will be formed. 
Thus, one will arise on the outside of the foot in talipes vaniB« 
if ihi^i person wnik a}x)ut ; in angular cunature of the spine, a 
bursa is developed between eacii projcctinj;; spinous process and 
the skin ; and many other such instances might be given. The 
various facts and investigations ufiou this j>r(Hluction of new 
burssB show that they are formed from the common areolar 
tiHsue ; that there is no structural difference between them and 
the bursrc normally found in tho boily ; and, therefore, it may 
well be assumed that normal bursa} ore produced by tho friction 
which they ore develoi)ed to prevent 

The inner lining of these sacs is not smooth, but covered by 
fringes, like, but smaller than, those in joints ; moreover, fibrous 
bands, numing along the wall, project into tho cavity. Tho 
outer part is simply condensed areolar tisgue, and is continuous 
with that structure on all sides. If tlio bursa be subject to 



UTTLAlIlfmOK OP BURBA 



Cbat. : 



oonadenble imwiiie^ iIb ooter poriioiis will become more i 
denaed, till they mipiiiili a &Mm4Qce •ppefttance and 

Any baisa of the body a liable to become inflamed* 
attack may be either acote or dmmic; even the acntc 
may hi! sJmpIr 004.' which caoKa increase of normal 
and tliicktriuDg, or it may be anpfrantiTe. Fortii 
puratioD of a synorial busa does not oden arise spont 
exoept in the guhcntaiieoiUBaca. I have never been able clc 
lAaseertaia ench action in any deep bttrea, althoogb in 
ewes of deep-seated diiTiise snppuration 1 hare coDaidex 
synoTial sac the probable birthplace of the disease. The pamU 
inflammation is nsoally produced by a blow, or some ext 
riolencv, acting upon a much-delalitated oonatitutiou. 
aetiuu is uut confined to the bursa itaeU^ but is of a difluae fo 
and attacrks the areolar tissue continuous with the bursal wa 
The general eymptoms are precisely those of the " difi'use 
flammution of the cellular tissue*' — of what used to be 
** phlegmoaona iuflaiumatiou," viz., a brown, dry tongue, heat I 
skin, sleeplcsBiies^ and a weak, quick pulse. The local syniptos 
differ only in this, that iu the pldeginonous iiiflamaiiitimi 
pus can only be disused into the areolar meshes ; in bursal 1 
puration a caWty exists wherein a good deal of the pus is alimi 
collected, and thoa we have the local symptoms of a circumscril 
absoeSB combined with those of a diifuscd one. Tht? skin at 
inflamed part i^ uf a dujdcy red ; the colour has no^harp bou 
dary, but fades gradually into the normal hue of the surround 
skiu, Tlio HWoUinj^ is more or h-sa coiL'^icuous, according 
the size of tho biirsu, its superficial position, and the stage of 1 
inflammatioa. The heat is very considerable, and the pain 
great, m long as tumefactiou continues and tension be not 
lievcd- it' the case bo suffered to go on, as sometimes happen 
without any adequate treatment, typhoid symptoms devolope 
themselves, and tlie state of tJie ]>alieiLt muy become critical, 
absorbeut iiiilammution, greater and greater debility, ultimately 
prostration, witli low, muttcirjng deJirium, will shortly be followed 
by deatli from exhau^itiou or purulent irxfeetion. 

Free inetsiouit through the whole reddened portion of ti 
skill, [irufouud enough to include the deep side of the bi 
poultices, mixed with charcoal or yeast, or chlorinated eoda, is 1 



Cbaf. XV. 



SUPPURATION OF BUBS^. 



345 



I 
I 



I 
I 



fit local management. Tlie general treatment should be stimulant 
and tonic Bark and ammonia, q^ninine with tether, cldorate of 
potash, or other euch me<licme, combined with opium and 
camjihor, or opium and eldoric a-ther, at uight ; wiue, brandy, 
or, in those accustomed to it, gin, may all, in the woret cases, be 
needed. It is generally adnsable to give, before resorting to 
any of the above means, a bi-i^k purge ; but this is certainly not 
always desimble. Our jxiwer over the intestinal muoous mem- 
branes is often very much abused, and in few ways more than 
in first attacking uU patitfnfs with a drench. A little judgment 
in considering the condition of the tongue, the oflpect of the 
conjunctiva, and the state of the abdomen, will guard us against 
such errors. To pm-ge a patient with buraal auppuratifm, who 
does not need such treatment, in to iuJlirt upon him an absolute 
injury, by weakening his powers of resistance to disease. 

When the patient recovers from the depressed condition, the 
wound made into the skin and the walls of the aUtcess boinns to 
granulate, and to throw off any sloughs that may liave formed. 
iVmong these must ho included the whole bursa. It comes away 
in white souked shreds of dead material, not one portion retiiin- 
ing any life, and remaining behind. After a time, even before 
all the sloughs have sejiaratod, the poultices may, if the skin 
and wound look sodden aud inactive, be changed for a dressing 
of dilute nitro-hydrochloric acid ; and when the sloughs have 
entirely sci)aratc'<l, lint dip})ed in cold water; or if the granula- 
tions be flabby, and the discharge considerable, a solution of 
alum (from t«n to twenty grains in the ounce) may be advan- 
tageously employed. As the bursa, particularly when swollen, 
occupied considerable space beueatli the skui, a cavity will I>e 
left, in wliich matter will collect, unless its sides be kept together. 
It is, therefore^ necessary to apply some pressure by means of 
pads, with a bandage or strapping jdnii^ter. 

Subacute, or chronic aud uon-suppurative inflammation, may 
attack either a siiperticial or a deep bursa, and though the 
disease will no't. lead to such violent symptoms as the pus-pro- 
dueing malady, it causes frequently cousideruble itoin and in- 
conveaience. When the burvu thus affected is superficial the 
nature of the disease is easily discovered, and its treatment, if 
the attack be recent, by blisters, or iodine, or other form of 




846 



INFLAMMATION OF BUItSiE. 



Ciup. 



:oaed. 



oountei^irritant, is as obvious lus it is in goDeral efficacious. 
i<MWMM» kuown 08 lioasemaid'fl kueo is tlio most commoa example 
of this oomiJaint It consists in an inflammatioii, with enlarge 
meut, at first through meru effusion of synovia, then also throii 
thinkoning of the bursa between the skiu and the patella. Tl 
disease is brought ou by the necessity, which women thus 
ployed labour under, of kneeUug a great deal and of tuoring 
about on the knee, and when the bursa becomes thus affecte^ 
the pain of surh occupation is very considerable. Kec«nP 
cases, in which thi; wuUs of the sac are not yet ranch thickoaed,_ 
may bo advautageously treated by blisters, or otlier eountei 
irriJani. I have frequently cured such tumours by passing 
loug-bladtd tenotomy kiiife for some tlistance through the 
and divithug the bursa as widely as possible Bubcutaneously. 
Injection.^ with au aliim solution, or with iinUne, may also bo 
employed. If the walls of the bursa have become mnch 
thickened, however, excision is the only remedy. Two yeaiH 
ago I cut out what had been a bursii m that situation, but vma 
then a tliick bard lump of a fibro-cartilaginuiis material, with a 
* small s]>ace in its centre containing a yellowish tranHjiareut jelly. 
The bursa over the olecranon process of the ulna occasionally 
takes on au intlanunatory action, similar in nature and cause 
the housemaid's knee. 

Of more surgical importance are affections of the deep bar 
because they are aometiiues apt to perjilcx tbo practitioner wfc 
is not much in the habit of examining joint diseases. A large 
bursa situated under the deltoid muscle is not unfrequeutly 
the seat of a painful affectiou. It usually is produced by aomo 
slight accideut^ — a strain of tbo arm, or fall on the shoulder. 
and I have soen it combined with fracture of the clavicle^ Tbfl 
inflammation may be sub-acute or very slow and chronic, and in 
eitbt:r case may somewhat assimilate a synovitis of tlie shoulde^ 
joint The distinction ia to be found iu the greater |iiiiliilii iiiiiiJ 
of the deltoid muscle, ami the perfect nuiintcnance of the groove 
or division between tho deltoid and pectoral muscle — that 
between shoulder and chest. Passive movements of the limb, i 
the active movements as long as the arm Imngs dowu, are till hi 
painless, but as soon as the patient endeavours actively to abdu 
the arm ttio pain is excruciating. I'ossivc abduction, on 



Chap. XV. DIAGNOSIS OF DEEP BURSAL SWELLING. 



347 



coutmry, relieves the pain. The bursa thus inflamod nearly 
alwnvfi crepitates njwn pit* ssure. It is to be oljserved that this 
sac is said to commuuieatu somctimus with the shoulder joiut. 
Tho occiirrenec must be extremely rare, but etill the surgeon 
should remember tliat it may lake jdace. 

Neither the burnA at the olecranon nor that benoath tho 
biceps tendon is likely to lead to any complication ; its in- 
flammatiou can hardly simulate synovitis. Between the triceps 
and the humerus there lies a sac which sometimes is an inde- 
pendent bursu, but more often a prolongation of the synovial 
membrane of the elbow joiut This may become intiamed, and 
as the exact relation of the part is in every case doubtful, it be- 
hoves the surgeon to know with what he has to deal. If this 
sac be an independent bumta iuiluni^nl for and by itst-lf. the joiut 
remitimiig normal^ there will bo no swelling or pullSness between 
the inner condyle aiui olecranon process when the arm is bent at 
right angles; but tlie infuiliblo lest is that the line of junction 
between the head of the radius and the humerus is as clear and 
well defined as ever. H, on the other liand, the inflamed structure 
communicate with the joint, then these parts will participate 
in the general pufiluess and swelling. There ani several small 
bursce about tho wrist, but we will postpone their consideration. 

About the thigh are situated bursce whose inflammation may 
distantly simulate joint disease. That ono, which is placed be- 
neath the psoas and iliacus tendon, occasionally becomes thus 
inflamed, and produces very considerable pain at tlie top and 
inside of Uio tliigh in front of the origin of tho grai'ilis nuwclo ; 
it may even become sufHciently enlarged to cause in a thin yer- 
9on visible swellinj^ in tho groin. This sac sometimes commu- 
uicutes with the Kyiio\'ial membrane of the hip joint, and then 
that entiro structure will join in an inflammation which may 
have bc^n only in the prolongation ; tho symptoms of hip- 
joint 8)*novitis will then of course be found. Usually, however, 
the bursa is separate, and then the pain and tenderness will bo 
limited to tho upjK^r and inner ptul of the thigh and the groin ; 
there will be no pain, no tenderness, anil no swelling behind tho 
trochanter. This sac generally owes its inHaramation to some 
accident — a fall or a slip throwing the leg outward, — and if this 
occurred in an aged i)er80u it may at first lead to the snpposi- 



348 



BUIISX ABOUT UIP AND KNEE. 



Chap. Xi 



tion tliat tlko neck of the thigh bono has been broken ; it is w« 
known liow difficult it is to detect an imixictcfl fracture of tl 
bouc ; it JH thertforc wise nut to attribute thi-* pain at the ori« 
of the adfltictora (which is bIso present in tliat furm of fractur 
to tlie slightur mahidy, nntil the absence of a graver injury ' 
entirely Jiscertuined. The g^eat pain prfiducfd by an inUn 
mat()ry anuctiou of Uio p.soiiS bursa may be set at n^jitby llexii 
the thigh on the body, and rotating it sumowhnt inxviird^; tl 
patient should be kept in this posture for some days, andj 
counter-irritiutt l>o used. Blisters are iu this spot hardly appliij 
able, and iu delicate-skinned persons I have known even 
tincture of iodine produce a too violent effect and intense 
I have used with advantage the uiU-ute of silver lotion (sc 
p, 137), which does not blister and crack tlio skin like itxline. 
If the patient be seen immediately after the injun', a hot hiyt- 
bath will ofibnl great relief. m 

The hirge sac. situated beneath the tendon of the triceps auA 
cmreus muscle abuve the patella, is most commonly a prolonga- 
tion from tlie synoviiil mend)rano of the knee-joint ; tliis slnicv 
ture, as is well known, rises up on the femur in some persoE 
much higher than in others, and when the cavity becomes 
tended with fluid, as iu hydrarthrosis, itreochcs further than imde 
ordinary circumstances. Occasionally, even when there soon 
a sc]>arate bursa above this prolongation, the partition betwe 
them nil] be found incomplete; iu a few instances the bursa 
really separate. 'Jho diagnosis between in Hum mat ion of the 
synovial membrane and of the sac when ilij^inct is easy; par- 
ticularly while the patient is in the erect posture : swelling i 
lluctiialion on both sides of the ligameiitum patelhe moik tJ 
former disease ; limitation of these 8ym])t<ims to a space alxrtf 
the i>atella. and perfect contact of that bono with the femur, 
latter. Of the two bursa* situated the one over, the otlier unde^ 
the lij^amentum pitellte, mt^ntiou bus been made, and iuilammor 
tion of the former has been described ; the same disease occasiudH 
ally attacks the dft'jver sac, and 1 Iiave in two instances kuouiirt 
to be nii^t^ken for commencing osteitis of the head of the tibi 
It produces a dull |jaiu, aggravated by exercise, and a cer 
swelling of tlio part which Uwks as though the tuberosity of 
tibiu were abnormally developed. Limitation of the pain 



Chap. XV. 



TENDINOUS SHEATHES. 



S49 



iondcmces to a small spot just above tlio grontest protuliemnoe 
of tho bony process beneath tho tendon, msi^cient t<» mark tlic 
nature of the disease; and its ready yielding to slight coanter- 
irritants will confirm the diagnosis. 

( 'hildren between the ages of six and fifteen frequently suffer 
from A dull aching pain nt the back of tho heel, increased by 
exercise; grown people may also experience the same incon* 
venience, — chietly after liaviiig worn a boot which presses on the 
port. It arises from iu6ammation of a bursa situated between 
the tendo Achilles and the upper part of the tulx'p*isity of the 
OS calcis. The malady is only of importance as a disease to be 
distinguished from osteitis. 

Temiinous sheathes, — ^lany of tho tendons, chiefly those of tho 
hand and foot, are surrounded by so called sheathes, coosutting 
internally of a fine synovial bag folded round the structure, and 
generally protected by a dense fibrous raerabranc, — certain ten- 
dons arc isolated each in a separate sheathe, others are grouj»ed 
together, one she^itlie snfiieing for tlie whole numl)er. The syno- 
rial investment usually projects beyond the fibrous protection, 
cliieily at tlie distal end. The structure of the synovial tissue 
is similar to that of the joints, — it is very fine, and the fringes 
on its iimer surfoce are loss developed than in articulations. 

These synovial sacs arc liable to intlammation, wliich is not 
uufn-qucnlly suppurative; the disease gives rise to verj* acute 
pnin and to swelling in the part^ and If it bo alhvwed to continue 
without relief it causes in tJie surrounding structures an luHam- 
matiott, generally phlegmonous, with groat tendency to run 
along the alisorbents; such a malady frequently occurs in tho 
fingers, and requires, as is well kuo\vn, free incision, poulticing, 
and support to tho general system, • A similar condition some- 
times arises in the palm of the hand, and those extremely pain- 
ful suppurations beneath the plantar fascia generally originate, 
I believe, in a tendinous sheathe, \\lieu the large synovial 
structure in tho palm suppurates there is usually a great deal of 
constitutional disturbance with considerable pain, and the inflam- 
mation is very apt to spread up the arm. If tliis condition con- 
tinue sufficiently long unreduced, tho tendons may slough ; as in 
any othersheatJie, suppuration is apt to cause death of its contents ; 
it is therefore necessary, iu acute cases, to incise the swelling 



350 



AFFECTIONS OF STNOVIAL SHEATHES. C0AP4 



along the whole length of the |ialm ; eTcn this is not aJi 
enough, for, alihuugh Uio bog Is only oDe, it forms, by its 
I>li(!atioiw, thn^e 8iic» — one botwoen tho superficial temlorut 
annular ligament, anotlier between the suporneiol and deop U 
dons, a third betvrceu this latter set and the anterior carpal 
mcnt. The sac stretches from the palm, extending lowest ale 
the tendon of the little finger, to above the annular ligament ;J 
tliat when it is Hlled with tluid the swelling is in both tlie p 
of the hand and the wrist, there being between its two portic 
a division or constriction fonned by the above-named ligamc 
■ When the mijipumtion is very acut« it is necessary to open 
sheathe from end to end. cutting fearlessly and deeply 
fascia sheathe, annular h'^aiinent, and even letting the knife pa 
among the flexor tendons ; by such mt?ans oidy can wo save 
port. Sometimes, however, the suppuration is not so Txolc 
but that it will admit of a less heroic treatment 

Mrs. Godwin had sprained her hand Tory severely by over-oxertion. 1 
threo weeks aftorwftnia, having continunlly got wome, she came to me 
the Charing-Citwi Hospital. The palnj oFttie baud was much swoUeu 1 
red, aUo at the wrist vraa a rod putfy fluctuating tumour ; aho was HuflTdj 
iug conBidfniblo jiaiii ; the Bngcn) were semiflexeil ; movement, particn- 
larly of the three inner fingora, von oxoeedingly painful, that of the inde 
less so ; the thumb could be moved with but little incoDTenionce. 
appearance of the hand was peculiar, swollen at the palm aad*i 
while bctiroen these parts the tniaour was dueply hiHcuted ; it at once at] 
gested fluid iu the flexor sheathe ; the fingers of one hand placed on ih 
carjxU swolliug, those of the other ou the palmar, detected fluctua- 
tion between the two; and when the latter alone was pr 
fomier visibly enlarged The constitutional disturbance was 
but was sufficient, combined with the redness at the wrist, to lead j 
eoncluaiou that the fluid in the sheathe was pus. I incised the i 
swelling from the edge of the annular ligament upwards ; made a large ha 
pftd of tow, and bound it with great force in the hand ; placed the arm 
a splint, with the wrist bent backward, so as to obtain as much pressure 
M possible from the flexor tendons on the deep reflexions of the sheatli^ 
Throe days aftcrwardn T naw her again : the discharge had been at fird| 
profuse, but was now diminished ; she complained a little of the ponition 
Olid priwsure. The palmar swelling had nearly disappeared In a week 
1 was able to use a smaller pad ; and in a fortnight the discharge i^M 
ceased, and the wound was beginning to heal. I continued tlic pad ait| 
splint for three weeks, ufti^r which a haiulng^, with simply a few folds of 
tint in the i>aUn, wns substituted, and in a month the hand was roetor 
Btiflbess from couflnement only remaining. During the first part of 
^vatnientshe took quinine and stimulants ; aftcrwanls the latter romu 
were discontinued. 



Chap. XV, 



DIFFERENT FORMS OF SPRAIN. 



351 



Now, oithongh it would be a grievons error to negU-ct to mako 
(Jopp and long iiicLsions through the palmar fascia and liganaent, 
when euch treatment was necessary, yet would it also be mis- 
taken sur^ry to cut into the palm if the disease could be other- 
wiHo treated ; for when tlie palninr fascia has been wounded it 
conlracts on healing, thereby dragging on one or more of its 
attaebm(ints to the jthaluuges, and tending to bend perraanrntly 
some of thn fingers. Tlio jmlgment of iho surgeon must be 
foimded on the amount of ewelhng and of tension, the rapi<Iity 
with which the pus has fonued, the tendency of the iii(1iiinTna> 
tion to run up the ann, and tlie amount nf constitutional 
disturlianoG. In rapid cases, and those in which the system 
sympathises materially, the [wlm must certainly be opened, 
particularly if there be the Iea.st sign of absorbent inflammation ; 
in slower cases an incision above the annular ligament, with 
conBirlfi-able prosflnrt- in the palm, will suffice. 

A sjjraiu includes all iujtiries produced by forced displacement 
of an articulation sliort of dii^locaLiun ; anil, indeerl, a partial dislo- 
cation may have actually been present while the force a6tod, r6- 
placoment occurring as soon as it ceased. Such an extreme case 
of sprain is luiiually, if not always, accompanied by more or less 
rupture of ligaments, even of teurlons, ntid is Kuccecded by acnto 
sirTiovitis. A mihicr application of forco may rupture a few fibres 
of one or more ligaments, tear the areolar tissue, and some of its 
small ve-ssels, besides causing bruise of the tendinous sheathes; 
a still less ]x»werful injury may only produco the last eflect. 
A slieathe is nutst liable Ut Ih; bruised when the tendon which it 
contains is bent at a right angle, so that the muscle acting [ww- 
erfully forces the cune of that structure against the delicate 
synovial membrane. This is very much the case in the foot, 
where most tendons, lx>th anterior and posterior, are thus bent; 
also at the hand, when the wrist being forced Itanc^vnrdt* the ex- 
tensor muscles would drag the tendons into a atruight line, were 
they not confined by the sheathes ; the force necessary to resist 
this ttMidency produces the bruising. This is, of course, fidlowed 
by inflammation. A good knowledge of anatomy, and of the ac- 
tions of muscles, will had to an accurate diagnosis, if the surgeon 
will take tlie pains to observe that thost; positions, which put 
the injured tendon on the stretch, are painful; those which 



352 



AFFECTIONS OF 8YN0V1AT, SIIEATUES. Chap. 1 



relax it painlef». In all cas^ the painful active movemente ' 
bo the opposite to tho painful passive ones. To diagnose 
condition of the lignmeut it is necessary to produce a paaairi 
movement that Khali render tlmt structure tenwe without ii 
eating the neighbouring tendon. An example will show at i 
what ifi meant, liOt us suppose a sprain, with pain and Btvel 
behind iU)d I>eueath the intt^mal malleolus. If the tendous o 
the tibialis posticus nnd flexor digitonim muscles bo sprained 
passive flexion of the foot is very painful, while passive extei 
is comparatively painless. Active movements are contrary : 

patient can scarcely point the foot and toes downward from 

treme pain, but can raise it upwards with relative ease. If tSi 
surgeon, keeping the foot at right angles to tho tibia, endeavoiu 
to turn the sole outward, he put^s the intemallateral lij^mentoi 
the stretch witliout influencing tho tcmlons, and the preseifl 
or absence of jwiin during such operation will enable him H 
judge the cou<lition of that atnicture. The same mode o 
diagnosis, adapting tho movements and ^Kisitions to the pa^ 
cular joint in question, will always reveal the nature of M 
accident. It must \ie remembered, however, that all bad spraix 
are compounded of tendinous, ligamentous, and ofleu jc 
injury. 

It is much easier, there can bo no doubt, to recover perfe 
from a simple fracture tlian from a bad spmin, which implicatee 
the ligaments ; but the teudiuous, or ratbi^r the sheathe injurjTj 
of which we are now speaking, is not gcuurully difficult of euro, 
We Iwve to do with a thin synovial membrane lying general]} 
near the surface. If the sprain be seen early enough, a loca] 
bath of liut water, kept for an hour at as Iiigh a temperature a£ 
can bo borne without actual pain, will greatly relieve, if not 
altogether cure, this form of comphiiut Subsequent rest, with 
connler-irritul'tft, or pressure, or both, will remove whatcvei 
inflammatory condition may still linger, if, at the sumo tim& 
rest of the part be strictly enjoined. The great cause vhjA 
sprain, of the ankle for instance, often lastd so long is, that tffl 
sufferer walks about before tlic inflammation has been sabdned. 
and 80 keop^np the morbid action, wlule a few days* more t^ 
would suihce fur the cure. Another cause of the long continuuuca 
of the iullamuiatiou is, I believe, a bad clioice of co uatM^ 



Chap. XV. PAINFUL CREPITATION OK TENDONS. 



363 



irritants. When it is desired to affect, by 8uch means, a part far 
from tho surface, a slow, deep-biting application is desirable ; 
when, however, the inflamed texture lies close to tho skin, such 
a couDtcr^irritant add.i to, iust^iad of drawing from, the original 
evil ; and T am sure, that I have seen iodine reproduce inflam- 
mation of, and effusion into, superficial tendinous sheathes. A 
much better application is a mild and ofl rej>oated sinapism, a 
flying blister, the nitrate of silver lotion, which affect little more 
than tho smface. When the inflammation has subsided, and idl 
tliat is wante<l to complete the cur;- is, tliat tlie shuathe should 
regain its natural size and form, prossure is a most valuable 
means ; whether this be effected by tho bandage or by strapping, 
it should be rec<jllected that the natural hollows of the part 
must be tilled out by pmls. If, for instance, tlie ankle be 
strapped and the hollows beneath and behind the malleoli bo 
not thus padded, the application yn\\ surely do more harm than 
, good, particularly if the ligaments, or tendons there situated, be 
implicated. 

The mildest fonn of a n-eent, and more or less acute, inflam. 
mation of the Rvuoviul shimthes is that which Velpoau first 
described as painful crepitation {ciMpitatum douleureuse) of tlie 
tendons. Uappearstoarisetrom the application of too mucli force, 
not violently, as sprains are caused, but from a slow tuid giadual 
exertion of only a slight supcmbnndance of power : thus, washer- 
women are very subject to this complaint after a Iiard day's 
•work wringing out linen ; young ladies, after practising several 
hours at the piano, also are apt to contract the offeetion. It is 
altogether more common among women than min. It appears 
to consist of an inflammatory condition of the sheathes of the 
tendons whereby their villi are exaggerated and their inner 
suriace n^uglioned. It hardly (vcnrs except in the extensor 
tendons of the tiugers, sometimes in those of the toes. 

The symptoms are — an indefinite pain, on any movement of 
the parts govenied by the affocfet:! tendons, and, in the worst cases, 
even when these are still ; it sometimes continues during sleep, so 
tliat the persim, being aware of nueasiness, dreams and enjoys 
no sound slumber. There is very seldom any rc4n^S8 over the 
part. If the surgeon hold the limb in his hand and make tlie 
patient bend and flex the Angers or toes, as the case may W, ho 

2 A 



354 



AFFECTIONS OF STNOTIAL SHEATRF.8. Cnxr. 



will foel a poonlwr creaking beuoath the sVm — hardly a crepi 

a sort of rustling in the line of tlie tendons. Tlie treatmi 

is rest and elijrht counter- irritation, as by cnmphor liniment, tl 
npplicutioQ for (ive or six minut<'» of a uiustand poiikifc, u: 
soon; hut, in truth, the crepitation and jiainwill coase, if rest 
allowwl, without further iuterfon*nef. aud I have BOinetim 
<£iiostioued the l>ei]etit of any stituulant a]>plicjitiun. 

Sprains^ if not perfectly cured, may result in permanent 
lurj^enient an<l <lrt)pfiy of the injured sheatlie, and such disease : 
aliio follow the painful crepitiitiou of tendons ; it also may i 
iiide|>endentty of any knovm injury, or of any acute or painfi 
inllaniniutiou. Itcousista simply in the gradual difiteusion of the 
sheathe, by lluid of a synoTial character, until it presfMits u fl 
tuating tumour uudcr the bklu. Of course, such ilbrtenRion 
only tiiko phitHi where the synovial membrane is not Ixiuud do 
by a fibrous sliejitlie, licnce thiwe siics which lure thus eonfin' 
protrude only at either, generally the distiU end of their ton 
investment. The must usual situations for these Auid turn 
are the back and palm of the hand^ and the back of the fi 
The s}Tiovial sacs in tlione situations invest, us already has Ik 
8aid» one or more t<:!udona ; uud hence the swelling' mnv eitlier 
fusiform, if the tendon be single ; bifureatod, if doable ; trifi 
cated, if triple, uud so on. Those which appear on the Ijock 
the hand at it« inner side are aingk* towards the wrist and bi> 
fim'ated or trifurcated towards the fingers; those wliich 
over the index tendon are single, i.e., fusiform, at either 
they are usually lobulated, being in some places bound down 
stronger bands of the fawia than in others. The same appear^ 
ancesare fouud when the tendons of the extensor brevis digitoruii 
pedis are affected. In both these situations, as the tumour is v 
superficial, so is it diaphanous. Wlien dropsy afiects the larj 
sheathe, enveloping the liexor tendons of the fingers, the SW' 
ing has tlie same bisueulated form as wait described w! 
speaking of suppuration in that siu* : it presents a hirge tumour, 
port of which is in the palm, port in the WTist ; it is bisec 
by the annular ligament at the base of and between the then 
and h)'pothen&r eminences. The tumour may be diaptiano 
in the wrist, but is not so in the [lalm. 

Very often these slieatlie-dropsiee are multilocular, bei: 



Chap. XV. PT^OPST OF TENDINOUS SHKATHKS. 



955 



rlivided into a nnmbor of cavities by membrauous partitions ; 
moreover they frequently contain a variable number of little 
translucent bocUes, onlinarily about the size of mustnni ecod, or 
applo pips, floating loosely in the Huid. It is reniarkaiilo that 
these peculiarities of division into many cavities and of corpus- 
cular contents uro much more common in sheathes of flexor 
than of extensor tendons. No a<le<)uatc reason con be given for 
this predilection, we must therefore bo conteiit witli simply 
noting the fact, Dupuj-tren ronsidcred the loose botlies to give 
in some way a lobulaled form to the soo, whicli is in reality, 
however, due, as already siid, to the disposition of the fasciae 
which cover them ; he also considered them to bo hydatids ; 
hence, tumours containing such melon seeds were named 
tumeurs hydatiformes and tmneura en hisac. The account which 
Sir E. Home gave of Hunter's view concerning the formation of 
these bodies* may be in some rare instances correct, but there is 
now very little room to doubt tliat they nearly always originate 
in a hypertrophied condition of the synovial fringes in the 
same way as the false bt)die3 are produced in joints. (See p. 207.) 

' The growths in a recent state are oval in form, and in tendinous 
sheathes rarely larger, generally smaller, than apple pips; 
dtnplintiuus and colourless, or of an opal grey ; put into spirits they 
become D[>a(|ue uud wliite. Kxamined by the uueroscope they are 

[seen to consist of simple fibres ramifying id a jtdly, among which 
an occasional cell, or nucleus, maybe ob<i**rvefl. ITieir presence, 
unless in very small quantities, may be judged from a particular 

LBeusation, which they communicate to the liand of a surgeon 
oxamining the fluctuation of the tumour, namely, a sensation of 
minute parclmient-Uke crepitation, different to any other crepi* 
tatiou, to that of bone or to that of ituid crackling often present 

dn enliirgud bursto. It is important to become acquainted with 
feeling, because the absence or presence of these bodies 
ailuences both the treatment and prognosis of the case. 
A dn>{isical sheathe of the extensor tendons does not usually 
contain any melon-seed bodies, and therefore is more easily 



• 'TransacUoM of a Socip^ for tbv 

cal Kuowktlgf^^,' ToL i. .lolin Uimtor 
bconcvivt-d Uifjn to origiiintc in cloU of 
Iblood cffiuHl on Um mufMie of Uw 



' mraibnucp, vhioh adhered and becuae 
orgHoiwHl, Bu<] thuiPwuro gtudaall;' ■&• 
{HLrulud by frlctioti, Ituxing Dohiiid tfacm 
m fiUiDQutuiuattiwbmotit to the buranl 

Vttlls. 

2 ▲ 2 



356 



AFFECTIONS OF SYNOVIAL SHEATHES. Chap. XV. 



nuuugped, than a like state of tlie flexors, in which such forma- 
tii»ns are generally present ; often mere coimler-irritation, 
bincfl with pressure, will in time disperse tlie former swellings; 
but such treatment ia not invariably successful ; it always occu- 
pies considerable time, and it is occasionally important to get 
rid of so ngly and inconvenient a tumonr, trifle though it may 
be, as soon as possible. A subcutaneous section will evactiati? 
the fluid; it should })0 matle by passing a lung tenotomy knife 
through the skin, at a distance from the ehcathe, pieniing tho 
Bj'novial membrane, anddiridin;^ it to a considerable extent, car- 
rying the cutting edge of the t«notomt! under the skin and parallel 
to its surfar-e, m as not to wound, either it or Uie deeper parts. It 
often liappens, that even when tlie sac has been thus freely divided 
it will reform and till again, but counter-irritation hardly ever 
faile to remove the newly effused fluid pretty qnickly, however 
intractable may have been that 6rst effused. Injection with 
iodine may be reafjrted U) if desirable, and it never happens, 
that a dropsy void of melon-seed bodies refuses to yield to such 
a measure, combined witli couiit**r-irrl(ation and pressure. 

Tho distt-nded sacs cnufaiiiing mclon-sctid boclies cannot get 
well under more counter-irritant treatment.* Incision of the 
sac, as above described, is therefore necessary; but it is not 
always |HJiwibIe to cause evacuation of all these little coucrctioiw, 
and those left behind keep up suflficiont irritation to det«miino 
tlie returu of tlie dropsy. AATieu the disease occurs in the large 
Bheathe of tho flexors of the fingers, it is verj- diflicultof cure. Pro- 
fessor Syme has pul)lished the account of such a case, f in which 
he laid open the palm and wrist fi-om end to end, cutting 
througli the palmar fascia and the annular ligament^ and took out 
all tho melou-^eeds he could find ; but the anatomy of the part 
shows that, even ao, he could not get at the whole cavity of the 8ac% 
except by turning the siiperticial and then tlie deep tendons out 
of tho CArpal grcwve. I have treated snch cases less horoic-ally 
with success ; and, although I shotild not venture to Bay that 
ench an incisiou was never necessary, yet it certainly need rarely 
be resorted to.J 



• OltwrruthL'likt'uenofUjisJiflMiHolo 
hyHrfutlmwia with ctianga of fitmetnro. 

t *ContributionB to the PBtlinlogy 
uhI Pnicfk-e of Surppry,' p, 212. 



♦ See my Paper ' On Synoriid Tu- 
mours in the Neifftiboorhood of Jointi.' 
Luncct. « h-t. 9lli. 18S*>. 



Chap. XV. 



THE ORIGIN OV GANGLI? 



85t 



Ganglia huv« been much more the subject of miuute enquiry 
ill France thuu in England, where, if we are to judge from the 
de«tTiptions given in nmst surgical workf?, the utmost discrepancy 
as to their anatomy and pathology prevails. 

Thus CUeliua (Soutirii translation, p. B29) describes them aa 
" round, of alow growth, rarely exceeding the size of a pigeon's 
egg, and in general conjiisting of tliick-walled ca\itie8 developed 
in the ueighbunrhood of juiuttt and aheathej*." Miller, p. 54(1, says, 
" the cyst ia thin and transparent" Cooper (' Dictionar)'/ art. 
CIjinglion)'8iieaka (if "an eueystvd, circumat^ribcd gwclliug;" 
wliiie Syme, ' Medico-( 'hinii^cjil Transactions,' dfscribcB under 
that name, one of thotie uou-^ucysted tumours, which occasion- 
ally occur in the palm of the hand and wrist Again, Cbelins 
esjKxiiaUy mentions "little, white, cartilaginous bodies," ns a 
constant part of their contents, wliile most do not mention such 
Itodies at all. 

Whei*e such wide discrepancies in the description of the broad 
general characteristics of a disease exist, it is certain that the 
writers are tn^ating of different maladies under one name. The 
term "ganglion" has acquinxl a popular sense, and has Irecn 
applied so broadly, that it has lost the precision of meaning, 
whith alone stamia value on a scientific term. 

Tt is necessary, at the very <*ommencement» to deny what 
many have stated — that such tumours are usually new forma- 
tions, produced by the establishment, tlirough friction, of a bursa, 
which gnidually increases uutil it becomes a tumour. It ia well 
known that friction n|K>n the skin will often prodiire a bur^i, 
but not without thickening of the skin itself, and it is just at the 

[back of tho wrist, where these tumours are most frcqueut, that 
tile skin is thinner than in any other jxirt of the hand. More- 
over, there exist normally fix>iu fifteen to twenty small bursm 

I BUiut the hand, but not one of th^se is at the back of the wrist ; 
they are placed chietly over the prominent heads of bones, in 

[Bituatious where I do not remember ever to liAve observed 
a tnie gungUon or to have soeu one described. The fact is, 
that the membrane, which forms tlie wall of these tumourSt 

lis borrowed froui some normal synovial sac in the neigh- 
bourhood, and it is on account of the great abundance of such 
tissue about the carpus and tarsus — viz., in sheathes of tendons 



808 



IE orktIN of ganglia. 



Chap. XV. 



and muUitudinotw joints, that auch swellings are peculiarly 
common in ihaio situutioua. Cruveilhior was perfootly aware of 
tins fact, for lie Btiys, in the tliird rotnrae of his ' ^Vtiatomie 
ratholtH^^que,* (p. 455), '* I shall divide synovial cysts into two 
categories — a, into periailicular ; 6, into peritendinoua cysts." 
K«'iriliarfl, n Oermon writer of high eminence and remarkable 
preciaiou, observes, in tie art. Ganglion, of tlie 'Medeziiiitiohe 
Chirurpstche Encyklopadie,' " It was soon made out that they 
must belou}^ to tlie bursa; and synovial sacs of joints and sheathes 
of tendons." Other writers hold the same opinion «1lU re^rd. 
at least, to the synovia] sheathes, but it is strange that no EngUidi 
author amongst the muny whom •! have consulted, mentions 
their connexion witli joints, altliougb it is perhaps as commou 08 
tlio tendinous ongiu. 

The point to be now more especially examinotl, is tho mode 
whereby such swellings can be farmed from a norma! ^novj«i 
membrane. In every such sac, there must exist a certain 
lion of part^ in which the least space is given for its contents, 
and in which, therefore, such contents press upon the free aud 
reflected p<jrtions of the membnmo. Thus, if the sac belong to 
a joint placed in such a position, the fluid wiU be forced from 
between the articular surfaces against the free portion of mem- 
brane wliich unites the bone-s pressing it with mure tliou usual 
force against the restraining ligament, until some port of it 
being weaker tlian the rest, or being oppf>site a little mosh or 
criLiiny between the librea of tho ligament-, Iwcomes stri'tched 
and pushed back, citlier into tho subs^'noviai tissue, or into 
such a lacuna of the ligament itself. The same tiling may, of 
course, be SJiid, mutato nomine, for tendinous sheatlies. Tbo^ 
joints in which such actions are most likely to take place, arei 
tliose having large articulating surfaces, and small reflected por- 
tions, which act as diverticuUf. When such a knuckle of mem- 
brane has, as above described, been pushed out, it withdraws 
itself more and more, until it forms a cup which constantly 
secretes and receives fluid from the general cavity, till it 
becomes distended into a globular excrescence or hernia from. 
tho synovial membrane. This protrusion is at first very minute, 
not so large, perhaps, by half, as the head of a pin, and it may 
remuiu always of tliis sixe, having still a email commuuicatiou 



Chap. XV. 



SYNOVTPATIOUS CHYPIS*. 



S59 



with the synoTiftl sac, nnd ap[)eiiTing simply as a little additiiHi 
tUereto. Such appeudages havu beeu found coiuic'cted with 
viiriotis joints, tha knee, the shoiddfr, &v., but rIkivo all with 
the cariiiis. I have aliK> found them at the astragalo-ecaphoid. 
They have been described as nonnal structures ; M. Gusselin, 
of the H6]jital Cochin iu Paris, draws particular att<!ntion to 
them, and givinj^r them the long name of synoviparous crypts, 
diiticribes them as destined to increase the amomit of secrtjting 
surface, and as occurring not only iu muu, but iu animals also- 
Ho went to the abattoirs of Paris, and there examined the 
carpal and taii^l joints of a good mauy horses, and fouud avuo- 
viparoud crypt* in thum. Yet, in spite of all this evidence, I do 
mit beliere that the normal condition is tlie existence of these 
fiai'd ; becAUBe the physiological reason given for their presence 
is inadequate. Let us consider, for instance, the synovial mem- 
bmne of thu oar[)al joints, which is so extensive, tlmt it luhricaU'S 
not only the joint betwoon the two oaqjal i*ow8, but the junction 
between each pair of bones, and the four inner carpo-metacarpal 
articulHtionB as well. I say, when we consider the size of this mem- 
brane, and the extent of its secretorj- surface, we shall not readily 
believe that it can be materially as-sistcd by five or six foltictes 
not so big as pins' heads. Then, a;j;ain, I have examined many 
cardial jfrluts, and must acknowledge that, if we take our subjects 
from the dissecting-room or hospital dead-house, we shall in all 
probttbihty find synoviparous crypts. Such persons arc usually 
i>omewhat beyond middle age, and have led hard-working hvcs, 
but if Wtf take our example from the hands of children, no such 
structures will be found. The bands of ladies, who have in their 
lives done nothing severer than worsted work, come seldom 
mulcr examination, but in one that I had the opportunity of dis- 
secting. 1 fuuud no synoviparous cry[)ts, although I studied the 
whole membrane with a glass. Again, there is a class of women 
whose mode of life and jjoverty combined, often bruig them to 
the h<:ispital, although their hands are free from the signs of 
labour : in these, syrioviparous follicles are absent. Lastly, they 
are more common on the right liand than on the left. Indeed, 
we may take the condition of the skin of the baud to represent 
the probability or improbability of there being any such ezcrea- 
ceuceii ; tlicreforc they are, 1 believe, abnormal, the result of 



THK ORIGIN or GANGUA. 



CMAf. XV. 



bftnl work and Htrainitig of the jciinUt and they occar in the 
phicf% where we should ex|ie<'t muiIi rcxnilta to appeftr, — namely, 
chk'ily at the carfitut, where the whole secrctiiig snrface ia very 
lar}{e, and where the portions reflected &om one bone to another 
(wliich act as diverticula) are Bnudt Moreover, vben, &om 
(utrtain iHwitionH of tlie joint, tito fluid l)ecome8 forced iuto that 
Kpace, and prettse^ ugaiiwt tiie eynovial membrane, it most take 
OKiat effect upon that portion of membrane, which is least j 
Miipported hy ligament ; and this ia just at the angle of refleo- 
tion, where the membrane leaves the bone. It is at that spot,^ 
tlicrefore, that we should expect to And most frequently the re- 
Bulla of ovcr-exnrtion, and it is here that wc reiUIy do most fre» , 
qiiently And syiioviparous crypts. As for the aniniab which M. 
(iowelin examined, it muift be remembered that they w«rB 
omnibus and fiacre horHes. wluo]i, after a life of Bcvere labour, hod 
Ihth condemned by the knii-'ker, and therefore creatures on 
whose joints we should expect to find the results of over-work, 
iu> M. Le^mest has olwerved. 

The little pnjccssee, then, wliich are found pr(»jtfcting froia 
synovial membranes are not physiolojjical, but patbolt^cul for- 
mutionri, produced by a pressure from within, as previously 
described. They are ot flret «Imo&t microscopic, and may be 
best seen by examining the inner surface of the meuibnuK*, on 
which (causing it to protrude) they create a slight pit, gene- 
rally with an orifice in its contre. One of these excrescenoe^g 
which shall liave passed into a mesh of thecajisule, may incr 
considorably until it protrudes thrtiuj^h tlie fihroufi structure, form- 
iiifr a tutiiour un itH outer surfuce, 'i'he chamiel of communication 
with the* original siif may still remain ojien, or it may have dosed, 
leaving only an imperforate cord jiasuing through the ligament, 
and ciinnecting the cyst with the synovial membrane ; or, lastly, 
even tiiia oord may have di8ap[)earod, so that all means of 
tracing the origin of the cyst are lost, and it appears like a new 
fonnuttou. In a hand which I disitected (hu'iiig the winter of 
1H57, I found on the first phalanx of the ring-finger on oval 
tumour, not so large as a horse-bean, the long axis of which 
corresponded to that of the finger. It wiu* of an umber colour, 
nnti adhoreut by a small jwint to the fibrous sheathe. I removed 
tlie sheathe with, of couwe, its lining of synovial membrane, and 



CnAP. XV. 



FROM JOIXIB AND SHEATJIE8. 



361 



found, on looking at its inner side, a small opening, tlirough 
which a bristle could be j^assed, whereby it w«« ftliown to cotn- 
jnonicate with the iuterior of the tumour. I r-ndeavoured to 
preserve these parts in spirit, but the semi-fluid contents of tlio 
eyst were 8tK>n dissolved ; in endeavouring to jiass a bristle 
through the narrow opening to act as a spring in the tumour 
and distend its walls, T nnfortunately nsed a little too much 
force, and broke it away. This baud hiid belonged to a couch- 
man, and bore many Bigns of rough work. The palmar fascia 
was in one part scarred and coutracttd into n thickened cord, 
wlticb prevented straightening of tiie middle finger; and tliere 
were three sj-noviiMirous follicles at the base of the os magnum. 
Iti hands of this sort, cysts as above described are not very rare, 
1 have seen one on the sheathe common to the extensor ossis 
mctacarpi and extensor seeundi intemodii pollicis. This was 
bilobular, and extremely tense ; the peduncle connecting it to tlie 
above-named sheathe was very thin and imperforate. 1 liavo 
also seen one at the back of the carpal bones, connected by a 
stalk to the joint between the scaphoid, semilmiar and os magnum. 
I have seen one lying unconnected at this spot. In fact any 
one, who carefully examines a number of hands, will be sure to 
find such tumours in different stages of progress, from the first 
tdmple bulging of the synovial membrane, to the cyst lying free 
amongst the b-ndoiis and ujkhi the ligamuiits, wliidi increast^s 
L'ko other cysts by virtue of its own secretion, whilst its walls 
become tliickened by a fibrous layer, either derived from the 
structures tlirough which the tumour has ]>assed, or acquired by 
the constant friction to which its prominence exposes it, until the 
Lcyst be<omes round, hard and elastic, rather than Jhu^tuating. 

Ganglia may occasionally be cfu-ed by counter-irritation, 
iodine, or other such application, but in by far the greater 
kuumber of instances, they will not yield to such treatment, and 
I somctltiug more decided must bo done. There is generally in 
these cases, an amount of vague fear as to the effects of any treat- 
ment, which arises, I believe, from the evil result produced in a few 
cases, in which the sac of the ganglion sl-ill commimicated with 
a joint, and as this' condition has not generally been understood, 
it is evident that certain cases would, energetically treated, end 
disastrously. It is highly important to ascertain the true condi- 



803 



TKKATMENT OF GANGLIA. 



CHAr. XV. 



lion of the cyst, because we may use, upon an independent 
one, treatment that we dare not apply to one still in connection 
with a joint cavity. The mode i>f makinjy tliis distiiictiMn is 
by pressiiin; ou Uie cyst, and ol^aerving whether it l>eeomes 
slowW reduced, and whether, when this pressure be removcdi it 
will as slowly reappear ; if so, the rL-duetion is of course clue to 
the passage of Huid into the nomwU synoviid ciivity ; if, us 
sometimes happens, the tumour Tanish suddenly, and return as 
quickly ou the application and suspeu.siou uf pressiuxN (Iiis 
reduction is en mawe ; the whole cyst has slippe^l under a liga- 
ment or some otlier fibrous structure in the neighbourbood ; the 
greater number of these swellings are not in any way altered by 
pressure. 

If by tliesc means the entire independence of the cyst have been 
established, some mode may be adopted to produce its evacua- 
tion, and the subsequent absorption of its wulls. The old 
plan of striking it forcibly witli the back of a book or other liard 
object, is btu-barous in the extreme, and I have known it produc- 
tive of evil conseqiienccB ; the* same may be said of rupturing the 
cyst by pressuri.' with tlic thumbs. I liavo frequently iimptieil the 
cysts by a 6ul>cutaneous section with a small tenotomy knife, 
dividing their vvalla freely from side to side (occasioually I bflirv© 
I have cut them quite in half), and then applying q spliut with con- 
siderable pressure over the part. The following is a good mtxle 
of using a pod or splint, so as to obtain the j^atcst ainouut of 
pressure. A strap is fastcne<) by bracki;t{« to the splint, allowing 
a certain amount of movement up and dovm ; the strap carries 
a metul plate with screw Iioles, and a screw presses upon a pad 
placed over the ganglion. Undue pressure upon the rest of the 
wrist is prevented by the breadth of the splint and thicJcneeal 
of the pad, wliifh does not ulluw the strap to touch the skin any 
where, being lifted away by the screw. 

Sometimes eveu this is not sufficient, and then such a cyst 
may I* injected without f^ar. Tincture of iodine and water, one 
part of the former to three of the latter, appears to me the 
very best possible injection : in using it, we should endeavour to 
empty again through the cauula tlie same quantity, as nearly as 
possible, us was injected, but much manipulation and pressure 
are to be avoided. 



Chap. XVI. HYSTERIA AND HYPOCUONDKIASIR. 



303 



CHAPTER XVr. 
On Hvstkuic Pseudo-Disease op the Joints. 



PATBOUMiY. 

i&JK>NG diseases whose patbology is most ditiicutt. hysteria takes 
a lugh place, tiot ouly because of its multii'iu'ious tuauifestatious* 
but ulso, because they occur iiuiler hticIi widely tlifi'erent (urrum- 
Blauees. There is unomttly in its very iitime ; for it oceosionally 
presents itseli' in the male sex. Aud ibis misuomer is not oue 
of words merftly, for ! bcliove it frequently occura iii women 
without owing its origin in any way to tlie uterus or other orgtins 
of sex. It is well to consider this latter proposition moat care- 
fully, for certainly much harm is constantly done by determin- 
edly referring all so-called hysterical symptoms to an irritability 
of the generative system, and iu ignoring other circumstances 
and conditions, which would be at once perceived and whose in- 
Hueuce would be immediately atdsnowledged if this fixed idea 
did not too much occupy oar thoughts. Now hystoria may 
appear under a great variety of forms ; and, as is well kaovsii, 
has a very strong tendency to imitiUe avast number of diseases; 
but for our present purjjoae, and indeed for its whulo pathology, 
it will suflico to divide it into two classes: iiratly. Hysteric 
Panixyam ; secondly, Mock Disease ; and to observe the circmn- 
stances umler which ihese u^ma]Iy occur. 

llic Hysteric Paroxysm or tit is apt to come on under any 
condition, whether there be present or not any traceable uterine 
disturbance, such as amenorrhcea, dysmenorrhcea, &c. An 
emotional woman may at any time bo liable to such paroxysm ; 
but it is certainly more common in those whoso uterine functions 
are badly performed, or iu whom any temporary irritation exists; 
for instance, many women who ordinarily are in no wise hyster- 
ical always suffer from tendency to such attacks when with child. 
Again, prostitutes are peculiarly liable to the hysteric fit in 



364 



UTSTEniC MOCK-DISEASE. 



Chap. XVf. 



Iliese instances a generative irritation is easily traceable ; bat 
such paroxysmi! occur to persons in whom no such cause can be 
foun<J ; this is hartlly a case in which the <Iognia ^'de nan 
apparente ct de nmi exiaiente eadern est ratio"' will bold, althnu^i, 
ftractioaliy, we must aasume it. Wo never can look ao closely 
into the life of muii or woman as to assert that no ontward cause 
of dLsapiwintmeut or excitement may not have its iniiueuce. 

The slower and more obstinate form of hysteria, which assnmce 
tlie shajK) of some other diaeaae, is, 1 believe as a rule, uncon- 
nected w itli any traceable disturbance of tlie uterine functions. 
A great number of such cases have come midt^r my notice, and 
comparatively few of the patients have had imy such disorder. 
It is rare that Iwth manifestations of hysteria, viz., the paroxyKm 
and peeudo-diHcasi^ are co-existent; patients who8U0er from the 
one do not as a rule suffer simultaneously from the other ; but 
it is not unfrequeut, that when the fits disajipear a mock malady 
comes on the scene, and this latter is sometimes diispelled by 
a violent paroxysm. 

AU ])ructitionerfl frequently meet with diseases which they 
know to be morti or less iniaginury ; if they occur in a man wr i-ull 
them h)i>ochondriacal, but if in a woman hysterical ; although 
h!I ihf Hvinptonis may be precisely similar. lIyi»x*lioudriasis is 
Jiardly observed iit men who lead active. Iinrd-wurking lives, nnd 
we ascribe the condition to a state of imagination brought on by 
too little occu|jatiou for the budily streiij^'th or for the thoughts. 
U'wo compare, in regard to aetivity, the lives of women with 
those of men, we should be led, putting all physical* differences 
of sex aside, to consider that these latter less active class would 
be more subject to the hypnrhoiidriueal <K)ndition; when wo 
add to this comparison the more emotional and imaginative eha- 
raeter of the woman, their proueut^s to the disease would be 
heightened ^ritllout the necessity of including mere sexual forma- 
tion. Hence, for the Mock-1 diseases of Hysteria, experieuix* as 
well as tlieory leads us to conclude that dii^turbance of the gcn^-l 
rative functions plays a lees active part than is nimally ascribed 
to them. 

Against these considerations may be brought the fact^ that 
women, subject to this malady, so frequently get well njion mar- 
riage ; but it is not right to lix upon the change in bodily con- 



CuAP. XVL 



CENTRIC ORIGIN. 



365 



dition, thereby produc«<l» as the cause aiid sole cause of this 
recovery. A girl on marrying acquires dutieSj cares, and inters 
ests which then fully occupy lier mind, more particularly while 
they huvc ihc churiu of uovelty. lu muuy iustmices u jKirson 
will be cured of tlita hysteric condition during the firsi; period of 
married life, but fall into it again when the novelty of being mis- 
tress of a household has worn off, and has ceased healthfully to 
amuse aud attract her thonf^hts. 

Thus when wo come across auy case of such hysterical joint^is- 
ease, it behoves us to consider the actual rharactcr of tho malady 
presented to us, by a woman perhaps in all other re8|)ect8 |>erfectly 
healthy. It is, I conceive, hanlly riglit tosuppi>8e that tliese patients 
wilfully deceive their nearest relations, their medical attendant^ 
and all with whom they come in contact ; but at the same time 
we cannot for a moment imagine that any local disease is present. 
It seems that the malady is centric, not eccentric ; that the men- 
tal condition, whicli first conjured up in her miud the idea of 
local pain, may liave originatecl in nn irritation reflected from the 
aexual oiT:fan8 to the uervous system, or, may have simply been 
caused by wont of occupation and hypocliondriacism. The patient, 
however, believes her suflerings real, although she feels that she 
can cjill them forth or repress them by her own feelings and 
imaginings, until at InM, pleaseil at exorcising this indirect 
power, and at exciting the pity or exacting the attention of 
relations tuid friends, slie cximes, in the latter stages of the disease, 
to delight in alarming an<i tyrannising over all her surroundings 
by moans of her false pain and invalidism. Every one has met 
wtli pitiable instances of wives establishing over hushands a 
reign of terror, or of daughters reducing over-fond mothers to 
slavery. In the worst of these CAses the patient's condition 
would be more easily shown to be insanity ilian sanity, and in 
some a degree of mixed cunning and cruelty exists which 
are ver>- like the symptoms in certain forms of mental 
aberration. 



Stmptoms. 

The joint affection, the mere local manifestation of the malady, 
is of no importance except so far as it is of moment to distinguish 



HYSTEKIC MOCK-DTSEASR. 



it from a real dii^uso : a mitvtnko eitlier wny rany lead to disos- 
tnuiH results. 

In tho first placp it is necessary to disabuse our mind entirely 
of the idea that a uterine uitation or functional disorder liea of 
necessity at tlie root of this evil, but it is our duty to dihiiuguiiili 
betn'een the cases thus connected and those having no such cause. 
In some iustanees tho menittrual fuuotiou is more or loss disordered ; 
in some the patient luis been in the habit of having hysterical 
paroxysms and globus hyatericu^s which ceased before the pseudo- 
dieease came on. In other instances there never has been any 
derangement of those functions nor any suflering that can be 
traced to uterine dtninj*emeut. In the first, we rccognieo a caae 
truly hy.sterical ; in the third, one entirely mtiutal or hypochon- 
driacal ; in the second, one wherein the uterine origin of the dis- 
ease may still be active, and may keep up the condition of nerves 
whereon the malady depends. 

In an affection coafesswlly so variable as tills, it would be futile 
to endeavour to give any accoimt of all tho symptoms to be ob- 
sen'ed in a lai^e number of cases : but two peculiaritieB may be 
fixed upon asespi?ciaUy characteristic of the hysteric joint: these 
are anomaly, and the absence of the ordinarj- signs of inflam- 
mation. In estimating the furmer it is essential that the surgeon 
bo itcrfcctly acquaintetl, not only thoorelically but practically, 
with all tho symptoms of the various sorts of joint-disease, others 
wis+i this characteristic will escape or only puzzle him. With 
regard to the latter wo will shortly examine which of Iho four 
signs of iutlammation, viz., pain, heat, redness, swelling, are, by 
their absence, most inlluential in establisliing the diagnosis. The 
first is to the patient a subjective symptom ; it is one which does 
not present itself in any way to the senses of the surgeon, and 
\m \ukti to take thH aflirmation of the sufferer in regard to it 
more or less upon trust, and it is in this very 8\Tnptora therefore 
tiiat he chiefiy finds tho statements of an hysterical patient 
varying with actual fact, it is in this peculiarity that anomaly is 
chiefiy botrayed. 

Heat is an important symptom when it occurs in real joint- 
disease, but it is not always present ; its absence, therefore, be- 
comes less important in the pseudo-malady. A sui^on when 
be firiit sees liis patient will frequently find the alTiJCtud jitint 



Chap. XVL 



ABSKNCE OF INFLAMMATION. 



367 



» 



wruppwl in flannel, irritated by stimulating liniments, perhaps 
blistered, or flveii the SRat of suppurating issues ; all these add 
vory much to the diPHcalty of llio diflKuotfis, and if the last con- 
ditions be present he had better defer giving a d('ci<bHl opinion 
un til the normal state of partu has been i*e8tored. In eases not tlitw 
complicntfMi a few minutes' pQiiso after uncovering the part while 
the jiatiout ia engaged in conversation will allow tlie limb to 
return to its natural temperature if merely heated by fluunel or 
other wraj>a. An hysteric joint is not hotti^r than tho opposite 
untdVccted one ; indeed it has often appeared that it gives a scnso- 
liou^f greater cooluess. I am unable to give any thermomctrical 
proofs of thus fact> nor do I beliove greatly in their value wlieu 
applied to mere surtace manifestations of heat and cold. For 
tbero certainly are many surface conditions of all bodies, which, 
without ailecttng a thermometer, give a vi'ry different idea of 
heat or culihiess to tho band ; some such condition is always 
present in iuHammatory joints-disease, and always absent (unleA 
it Iiavo been artiliciully produced) in hysterical mock-disease. 

Bedness is, us we know, frequeutly altogether absent in real 
joint-maladies, particularly if the inflammation bo in a deep joint 
and if it be of the strumous cbamcter ; its presence or absence 
therefore is of little avail in determining the true or false character 
of any pai'ticular case ; but it is right to mention, tliat in certain 
instances of the hysteric disease there is frequently a capricious 
and transient blush upou the surfaeo, piukcr in colour and evi- 
dently more superliciul thi^n the dull hue which, when redness 
accompamcs real joint-disease, appears to Ue doep beneath 
the skin. 

Tiie fourth inflammatory gymptom, giveUing, is one which may 
have been produced by mistaken irritutiou. iVn hysteric joint ' 
is not swollen, (unlesa artificially) ; there may lie a nlight puffi- 
neas or (edematous enljirgemeut on the surface (sulxiutjmeous), 
but tliis is a very different thing to the appearance of effusion into 
the joint or deep-seated tliickening ; it may more resemble in- 
flammation of parts external to joints ; but thon, many symptoms 
related in the fon>going chapter, namely, circumscribed swelling 
and tenderness in tlie known situation of a bursa or tendinous 
sheathe, aru absent. 

We wiU now examine the difibrent forms of anomaly, the 



3flS 



HYS1*EKIC MOCK-DISEASE. 



COAP. X 



mode of detecting it, and its value in different joints ; only 
mising tJiat we liftve already discovered an important 
namely, the presence of pain in or about a joint without any othl 
cloarsyniptomof iuflammution j there may be an attempt ae it were 
to imitate those latter, but on examination they are all found 
to fail : let us see if pain can bold iis place against a 
invest igatiou. 

The articulations most Uablo to be aflected by this malady i 
the hip and the knee; other joints are occasionally attacked, 
more rarely, and the reader may easily transfer the account cd 
the diagnosiH in one of the two instances to be described ^fl 
case of suspicioits disease in auollier jnint. Hijvjoiut disease 
produces, as we know, in iti* sec^tnd stage certain deformities 
dependent in part upon actual organic alteration ; in part upon 
a jKiciUiar contraction of the abductor muscles pro<iuced by the 
loc-al irritation. It ia partly i» the mode of placing the limb that 
\fe wliftU find variations from the usual methods in joint-disease 
which may first of all render tlio case suspicious. On examining 
the patient, who gencmlly will be found in bed. we shall first 
observe thut the puin complainol of is tolentbly diffuse ovei 
the whole buttock of that side ; it is probable that pain in 
groin will not bo mentioned, (commonly absent at the bcginnii 
of hijvjoint disease), but if it be so it will be also somewhat 
fused, and has considerable tendency to locate itself above rat 
thiiii below Pouimrt's ligament. Moreover, tenderness is, a« Sir 
}i. Brodie has observed, " ver)' sever*yipon the slightest prefl8Qi| 
or even contact ; ** indeed, the patient shrinks almost before sfl 
ta touched, and if the sni^on magnil'y his commiseration for thifl 
pain and his fear of increasing it — if he suggest pain as being 
present in different parts — he will cause the patient to confess it 
any where. Thus it is very important tliat an attendant, seeing 
for the first time a young woman with a 6ns|ncious joint-malady, 
(particularly hip or kue*;), should not put such leading ques- 
tions as shall enable her to shape her answers accordingly, and 
thus to make up a good history of real disease ; rather, he should 
endeavour to put the question so aa either to leave her entirely 
to her own resources for a reply, or so as to suggest to her an 
answer manifestly incongruous. Any one having to do with 
ctu&s whieb liave been already tlirough a guxl many hands find 



Chap. XVI. 



rOSTUKE IN UySTERIC HIP. 



agftiii unit again that thrt pri^^liiio imaginings Imru hct?n im- 

i proved upon under thi* lenj^lioKed tuition ; in an unsophisticated 

[case this pain and excessive toudoruoss \vi]l not be ooiiHurd to 

I a spot beliiud the trochanter, and it will be so aouto tliat the 

patient cries out aa much or more when tho ekin merely is 

^ touched, than when a firmer and deeper pressure h made. 

Moreover, if the patient's attention can be engaged while tho 

exuiaination is going on, by conversation or other means, the 

parts pre\'iou8ly tender can bo manipulated without producing 

signs of piin. The sort of i>aiu complained of is more like that 

of a ncunUgia than of joint iu6ammatioii. Imt it does not run 

in the course of the ncrvos ; it is frequently said to keep tho 

patient awake, but it does not wake hor ; it very rarely liappeiiH, 

il'ever, that jmiu siniultaneoutily affectA the kueo, and pre8.<iing 

or kuoeking upon the sole of the foot doea not produce any pain 

at the hip. 

It has been shown (Chapter XIV.) that the chongee in length 
of the limb are duo, in real bijMliiiease, to position. Tho usual 
conree is that at first an apparent lengthening occurs which 
is Boou followed by short^mng, and there is always a certain 
though an indefinable proportion between these alterations and 
the intensity of the inflammatory symjitoms. In the hysteric 
pseudo-disease shortening is nearly always tlie iirst change, and 
this is di8pro]MfrtiouaUy great in regard to any iufiammatory 
6ym])tom ; and what renders this condition still more valuable as 
a means of diagnosis is it« variability. To estimate these appear- 
ances fully it is necessary tliat tho patient be made totftand up; 
the surgeon seated behind her will observe tliat tho pelvitt on 
' tho side of the pain is tilted up and <lrawn backwards in the 
. same way as in true hip disease ; but tlie spine is much more 
twisted, the nates on that side are protuberant and the muscloa 
Let the patient remain standing some ctJUidderablo time, 
, bo engaged in answering qui?stions having no especial refei"- 
euoe to the place of the disease nor to the pain, and the forood 
position becomes less and less marked until it is nearly uaturaL 
iiut a remark directed to tho liip, or a iiand htid upon it, will in- 
stantly bring about a resumption of the mal-posture. Again, 
whether the patient have a^umed one or tlio other jmsition 
(leuglbening or shortening), thr swelling cannot be imitatetl. 

2 n 



370 



IlY8Tt:KIC MOCK-DISEASE 



Ciup. XI 



We have previously rolled attention to the obliteration of tl 
fossa behiud tho trochanter, ftn<l to the deep swelling in 
groin Ix'lnw Puupart's lip;am(^nt, (p. 300). One or both of these 
are always prust-ut in n'ul (Useiiso when deformity seta in. The 
are the only points * in form and ontline which cannot be ir 
tated by hysteria. If to these signs be added the al«ence of 1 
expression of suffering and anxiety, which is always more or Ic 
frequently strongly marked in coxitis, the sui^reou will have 
difficulty in detecting tlie true nature of tho ease. Patieal 
affectod with hysteric liip-disease have nearly always a healt 
ttppeamnce, suilieient ombonixjint, and good appetite. 

In an imitation of knee-joint disease tlie pain complained of w 
often be very severe— disproportionally so to the amount of Ic 
liistnrbanco whicJi at fir*t glance apjjtyins ; it may kttKp, or 
said to keep, the patient awake at night, but it never wakes h^ 
when she is once asleep. The limb will generally, wliile under 
obser\*atiou, be held perfectly still and Bcniiflexcd in tho same 
position as is taken in real disease, or tlie patient may still walk, 
but with limping, anri signs of sufiVring ; the pain is referred H 
a 8|>ot on each side the Ugamentum patellce, aud is increased elm 
the slightest touch, particularly if a piece of the fatty nnshion 
there situated be gently pinched between the finger and thumb. 
8ndi mode of mauipulution, indeed, appears to cause mure 
tlian a pressure cxertf^i by the broad surface of two or 
juitaposed fingers, and gradually increased so as to iniluejice Ha 
deep parts. There is seldom pain or tenderness above the 
tella, and^ this bone, grasped at its upper part, be moved back- 
wanl and forward between the femoral condyles no tendeniess 
complained of. In those ras<^s, in which tho joint is kept rigid 
semirioxcd, tho surgeon slioidd endeavour witli slight force 
straighten the limb, keeping his hand at the time a{)on the ham- 
string muscles. lie will then feel these aot stmiigly with activo 
contraction, whii^h will communicate to his hand a seusatio^ 
utterly different to the passive retraction of muscles which fofl 
lows a long standing disease of the joint In a case of doubt 
chlorofonn is a most useful aid to diagnosis, which fact I believe 
myself to have been the first to point out, in a paper read 
fore the Medical Society in 1858. Under its influence 

* Except in tlie lato evontM nf liip-ditettae. 



Chap. XV F. 



AT THE KNEE. 



371 



mobility, as of ou ontiroly lioaltliy joint, will be rostorod. The 
above siguSt with absence of atiy swelling or thickening of llic 
deep parts, and of the other inflammatory syniptomUr as already 
mentioned, will fully suiSce for diagnosis, partifularly if mea- 
Burcjucnt show no enlorgcmont of the joint. 

There is a point which I have known to mislead in diagnosis, 
viz., a certain oropitation in the joint complained of. Now, 
many boys, as well as girJs, arrived at puberty, or at the period 
of rapid growth, are suhjiict ta a pecnliar cracklingat the jinnts, 
chiefly the knee, hip, and maxillary articulation. This is quite 
[laiuless under healthy eircumstancea, and children fre<|ueutly 
amuse themselves with the odd acnsation it prodoeee. But if 
the individual Ije a girl, who, vei^ng into pnbertyj becomes 
weaker witli chlorotie tendency, this crackling is very apt to 
continue in one of the joLuls, and at last to become the s^rondary 
eaoao of a nouropnthy fixing itself in a certain {>art, and gradually 
aasimiing the character of an hysteric joint. Thus, then, we 
may find in such a malady a certain amount of crackling, com- 
parable Ui rubbing together two surfaces of parcliment, of coarse 
silk, or of crape, and which is not like any of the crepitations 
in joint disease, exci-pt an early atage of hydrarthrosis. 

Occasionally, though rarely, hysteric pBCudoKliseaac of a joint 
goes 80 far that a sort of imitation of "' starting of the limb " 
comes ou, of which in some eases the patient complains, as caus- 
ing great pain, and wJiieh in otbera is perfectly painless. No 
surgeon will for a moment mistake this phenomenon for the 
starting pain whereof so frequent mention has boon made in 
previous chapters ; but the diRi^rences are worth reoonlin^ if 
mendy for their curiou-s physiologiciil character when regarded 
in connection with the true symptom. In most cases the hysteric 
movements only come on when some one is present, though the 
patient nmy allirm them to be constant, which they rarely are. 
niey are rythmical, sometimes rociirriug with immense rapidity, 
sometimes eynchronons with the pulse. But the circnmstance 
moat worthy of note, is that they cease during sleep, oven before 
conscionsncss is altogether lost, and they do not return until 
the patient is fidly awake in the rooming. Now, tlie starting 
of the limh from articular inflammation is always worst just as 
the patient sinks to sleep, when the oontrolling power of tlie vrill 

2 » 2 



372 HVftTEBIC MOCK-DISEASE. Chap. XVI. 

\B withdmwi- Thifl diflforonco in tlio time of occurrence TnarkB 
their several origins — tUo one ia dependent uptm the cerebrum, 
the other, iudependejit, even requires the withdrawal of its 
power. 

* Treatmknt. 

This malady lias attained an evil notorictTi fts the A^/*' noirt; 
of medical pnwiiw*. and nothinj; can be more fatiguing Ihiiti th« 
constant iteration of incongniouB pains, tlir unvaried rinping of 
inouotoiious changes conceniing Uiis seus*ition and the otbor^ 
which certain patients insist on forcing upon ua. Th6 weariuesa 
which the milijtM^t creates may have led us too mtu'li to pass over 
hysteria as a malady connected with some ill-defined, often un- 
discoverable ntorino disorder, and to order at once soniie set 
prescriiition of tonics and emmena{;<:^es. But if. as we have 
seen, there be two conditiuns in which a mock^liseuse may occnr, 
we ought to distinguish one from the other in onr mode of 
treatment ; even the form winch appears to have begnn in a 
uterine affection, but in which no detectable <listiirbance of that 
oi^an remains, must not be treated as though such condition 
existini. The so-called hysterical joint dificase Trrquently pre- 
sents itself in the perswns of strong llorid girls, troubled with no 
menstrual disorder or leueorrheal condition, and I am sure that 
cases have presented tlicmRclves to me in which the administra- 
tion of iron, aloes, and other such mediciues hns been injurious. 
Wlien, on the contrarj', any such disturbflnce is present, it i» tij 
be subjected to the recogm'zed methods of treating the particular 
form of the complaint. In most cases the best physical manage- 
ment is a combimition of Ruch hygienic measures as exercise, 
cohl baths in the morning, a uon-stimukting diet, Ac. 

Tlie most important part of the management is, however, 
rather mental than bodily, and depends upon tlie amount of 
control which the siu^eon can exercise over his patients. Having 
aAcertainwl sccui"ely his diagnottis, he must enfuR-e obedience to 
his ordinances, whatever tiiey may be. (Ireat caution and power 
of judging character are necessary, that he may ensure faith ; 
and considerabh* firmness, to insist upon the j>erformimce of any- 
thing he may conuuand, for if the piitieut once overi.'ome hjm 




Chap. XVI. 



TKEATMENT. 



373 



he will scarcely ever regain control. In some cases, even wheii 
the ]>atient has been in bed for weeks, perhape mouths, one can 
uiuke her get up aud wiilk about ou the first time of seeing her ; 
in uthers, one may Iwive to he a little h-es perimptory, Uiough 
equally determined. If the person be possessed of good sense, 
and of a n;al desire to recover, it may be woU to explain the 
absence of nil organic disease, and the necessity of exerting her 
own will ill order to recover. At the same time, in all cases, 
relatives, or other surroundings, must be ('autioned against yield, 
ing to any signs of invalidism, or any attemjit at lying by, and 
being nursmi and petted. 

Sometimes we may endeavour to interest the patient's imagi- 
L nation, and draw it away from the s]»t whereon it has fixed. 
For this purpose I have, in some instances, made use of an ex- 
pedient which, I believe, \nU often be found useful in cases 
where the patient's confidence rests fully in tlie attendant, and 
some real <ie8ire to recover exists. The value of the plan lies 
in calling the person's mind away from the affected spot of the 
body, and ostaldii^hing a firm belief that when a certain event 
takes place the pain will cease. I have used a soton of a single 
silk thread, paK»&d through a small fold of skin, at some con- 
siderable distance from the seat of pain, and have endeavoured 
to make her finnly hcdieve timt when the silk comes away the 
pain will leave her. Such a method of practice is nearly sure 
to lie successful, since it is applying directly to tlie mental fiinc- 
tion really aftwted, and it is such as is often injunoiisly employed 
by rairacle-mongers, clairvuyists, iind others, who take a dis- 
honest hold of the credulous imagination of their Wctima, and 
make them tlie iustiiiment of jugglery and deceit. The diffi- 
culty, however, in our treatment is to create a sufliciently firm 
belief in onylliing so plain and simple as to look like truth, and 
as not to excite the love of the marvellous, nearly always a largo 
part of the hyiKX'hondriac cou<Utiou of mind. M'hon, therefore, 
that metliod fails, it does so, I believe, because we have not been 
able to proiluce Kufficiently strong credence in its efficacy. The 
rapphig of a spirit or the winking of a statue might have proved 
more efficacious. JJut lot it be understood that I advocato no 
deceit. The patient may, in general, bo told I hat the disease is 
not really in the joint, but in the nerves ; and there is no de- 



374 



HYSTERIC KOCK-BISEASE. 



Crap. 



ception iu fixing the patient's belief on a certain event 
cnre, becauao if she really can bolievo it she will be cured j 
the occiurencp of the event 

It ifi to be feared, howerer, that many cnaes of hysteriu 
obstinately ineurable by what are called medical means ; 
frequently happens tliat when tlio patient has left im well 
free from all such disorder, she will come bock after mont 
or even altor years, with other syraptoma of the same 
Such will occasionally hapjwn, alUiough all the circomstanc 
of life may have been changed in the intervaL The ptitit 
formerly a green-wck girl, will return an establishe<i matron, wi 
three or four chiltlnMi, but afl'eoteU with another mauifestat 
of the diiW'afie ; and I Imve great re&*?on8 for believin|L^, that ]n 
sons who in their youth have Iteen subject to liyslerit^ 
festations, may, tliouph in middle life free from them, 
BuQor about the 40th or TiOth year. MediriU treatment, in 
strict meaning of the term, appears of little av-ail, eicept toil 
porarily, when there is uterine disttirlianec. Physical and ment 
hygiene, strong reason, good sense, and a sotmd tlislike to 
validism, is the only cure. Cold baths on rising in the momii 
exercise, pure air, and cheerful amusements, are tlio true meti 
of ctmibflting tlie morbid state. 

It should be particularly obtien'ed that imy ujtplication to 
l»art itself is injurious, as tending still more to fix tho i>atie 
attention upou that locality. Leeches nud blisters have 
done almost irreparable injury. 



Cabfs of this Diskase. 

Cask LVI. — Jane Goldwiu, a^tid 19. a One weU-grown girl, came into i 
Charing-Cros« Hospital, Ai»ril 2'2ad, 18.'i6, under the care of Mr. Iloncoo 
for disease afiecbiiig the right knee, which had come od about three luont^ 
prericuRly. The joint wan held somiflexed. She complainod a good da 
when the kneo was touched, or when the snrgeon attempted to flex it. i 
to B(.raight«n it. She usually kept it wrapped in flannel, but when this ha 
been removed aome time it wae not hot. 

The joint wa» nut altered in form, except that the ligamentum ] 
waa perlw]Ht a lilt le obscurud from superficial awelling oti eiwh aide of it ; j 
was in this place that both jiain and tenderness were most aerero ; Ifa 
fonoer,«ho skid, kept her awake, but she confossod that it did not awoke her 
when onc« asleep. Meaauremeal of the knee showed it to be a little large 
both nbovo and below tho patella, than tho other. Thia diifereaco < 



Chap. XVI. 



CASES. 



876 



slightly during the progress of the oaBo, but was always Icfie than ooe- 
wghih or an inch bolow, and nevrr amounted to a qnarter of an inch abore 
the Vnet'-pan. 

The joint has been bli8t«re<l, &c. Tlie whole case is snapioious. Mon- 
Btraation is perfectly regular and natural, there is no leucorrhtioa, she norer 
bad an h>-eterio fit in ber life, nor oould any confession bo obtained of a 
feeling Ulso,<f^ofci« fij/fltrtcus : those circumstances, and the pcrftwit rigidity 
of the joint, rendered the diagnosis a littlo diSioult. Chluntfurin, there- 
fore, was administered, and when she wa.H under its influence the joint 
became perft-ctly tdoUJo, without crepitus, or any morbid condition 
whatever. 

It is useless to follow out the various medicines ulministcred, the several 
pUns tnci], and their fkiluiv. l*ho girl seemed to autTvr more, and was 
ooDBtantly begging that the k nee might Ite taken out, nn operation of which 
■bo had apparently lieard. Accordingly, on the I7th May. she was token 
linto the operating theatre, chlornfomi was iulmiiii-''terod, nnd Mr. Hancock 
^toade a long incision on either side of the knee-joint through the skin ; 
these were then dressed, a splint was applied, and she was taken to bed 
again. 

May Ifltli. — She says she has had no pain, eioept tingling in the wound, 
since the operation. .She yt&a informed that it had not been found nuoea- 
Bary to take out the knee-joint, end that when tho wounds healed she 
^ would bo quite well. 

June I71I1.— llicre has been nothing Airther to record tlian gradual 
bealiiig of tho wound without return of the old pain. She has been of late 
walking about the ward perfectly well, and to-day she walked away cured. 

CaSB LVU. — M. C, unmarried, aged 28, a pale and rather anxious-looking 
girl, c«me to me, 21st August, 18^8, on account of a alight bursal inflam* 
mation and awoQing over the right patella, which was treated and cured in 
about ten days ; but in a week after she presented herself again, complain- 
ing of pain in the other knee, just under the patella, and on each aide of 
its ligament. The knee wa*i quite cool. When the foot was pressed even 
forcibly upwards, nor when the patella was moved from side to aide, if only 
the place to which tho pain was referred wero not touched, no expression of 
pain could be elicited. The joint wasineverydimension tho sixo of tho other. 
The menstruation was regular but small in quantity ; she had considerable 
leucorrfacea in the tntervala ; had gluhua ht/tteriem. It was very perceptible 
that the tcndcmcHs was iucreased and spread ovur a larger surface, and 
that she flinclied more at the monthly periods ; she also confessed that 
she suffered more from the knee at those times. Quinine and iron, with 
some valerian, was given thrice in the day; iron and aloes evening and 
morning with the etfeot of diminishing the leucorrhcna and iucreasiiig tho 
mL'ristruatinn. 

October 10th. — The general health had now considerably improved ; but 
finding that tha knee did not get better, 1 determined to try a means of 
making the patient's faith in a more visible treatment than internal reme- 
dies operate a cure. She was, therefore, told that blJstvni or other appli- 
cation to the knee would only do harm, but what was wanted was to draw 



37fi 



liYHTEHiu mix;k-diskasl 



Cbat. 



ihm pain to aaoUier pari« bat that we mtut b* aan to choase • time ' 
bar health waa well enough to bear it. Thin letter plinaa was wUed «l| 

to eidte bcr cnriOMty about tbe retoeJy, uf whoae nature afae was nofl 
It was oootrifad tliAt for a tine aometliiiig aboaid prevent this ap 
until abe begged eameatly for H becaeir, aod then abo waa informed 
it was the paaaing a jnaoe of silk tbrough a part of tbe leg, and that 
gradoaliy worked out ahe would be freed of bcf pain. A sutun was 
prepared, and considerable ahov of great caro in the choice of the 
pbee vnm displaTod, and then the amaU aingle threv) aeion panpod i 
a fold of ikin at tho inner aide of the cal£ Minute direotiona ' 
about the way uf droaaing the little puuciures, arid the neoeesitT of ^ 
ing it, Bhe came back very often to t«ll me of the pro^reaa of the sataB 
and aaid the knee was certainly getting better; and at last, < 
bad ooma out, came to thank uio, nayiiig tho knee was quite ] 

Cabb LVIlL, Sept. I6A8.— Miaa Mary L- , aged 18, strong and 

was removed two moutlis ago from school, being auppoaed to bare 
joint disease. 

Hie girfa aspect is from the very first sasi>icious, being maoh too be 
fur such a malady. She wa^t lying on a couch quite dressed, and ] i 
her upstairs to bed, ttiat 1 might fairly examine her. While lying 
she keeps tbe left thigh a little bent, su as to raise that knee from the 
the s]iine, at tbe same time, is crooked. Severe pain is complained of oil 
over tho thigh, hip, buttock, and side, even to near the scapula. The tsfl 
demeas n-as uot at first so oxtensivo as after prolonged oxamiuatioi^ 
Uado her stand up, 1 seated behind her, fouuil tho left side of the i>elTia 
raised, the fossa behind the trochanter not at all obliterated, the knee 
front of tho other, and somewhat inverted. Tbe poHJUou simulated ! 
joint disease sufficiently clonety, but the absence of all swelling 
remarkable. f)n keeping her standing some time tlie position 
ieea sjid Iims marked. 

The mimHtnial functions are quite normal, nor does there seem any t 
of bodily disease. I iiiKtsted upon her walking half a rlozeii times up i 
down without a Htiok. At firxt I took liuld of her hand, and partly helped, 
piirtly fnrciH], her iii walk; afterwurdK iiia<Ie liur go by hentelf, wliich i 
did at IiiMt, with hardly any limp, but half crying tho wliile. 

She had boon put upon a etroug diet, aud was taking steel. 1 prescril 
a less stimutatiug food : no wiuc ; meat only once a day ; enid both in ' 
morning ; a little walking every day. Kxplained to the young lady 
mother tho nature of tho case and necessity of her using all her influe 
in proventing her daughter lying up, and recommended some interest 
pursuit 

A great many battles had to be fought with this pationt. Somctir 
shs would declare sha oouM not get off tho bed ; but on one of the 
OMaaloDB she was left unattended to till tihe found herself capable 
moving. At last, when she obstinately refused to put foot to the grou 
aud the point was insinted u]>ou by both her mother and myself, she 
a ivgular hysterio paruxyMUi, and fmin that moment the case wasj 
easy of management. Hbo got well about four munths after 
MW bor. 



CH4P. XVII. HES'IX)RAT10N OF CKIJ'PLED JOINTS. 



377 



CHAPTER XVII. 



Ok the Restoration of Mohimty and Conformity to 

rHIPfl.KU JoINTft. 

In the large majority of the iuflauuuutory disousos which wo huve 
examine*!, tht? luiturul tomlency is to <)bIit<*ruto tho joint by a 
gr<)>rtli of granulations, both inside and ouUlde iU cavity. When 
those in the former situation orgauizo further and foim fibrous 
tissue, false anchylosis is i>r(Khiced ; wlion the structure becomes 
ossiticd the anchylosis is called true. The tibrification of the gronu- 
latious on the outside of the synovial irn'mbrunf is als(j aeoom- 
imnied by the same moiie of eontractinu wliirli takes place in all 
cicatrices; hence, tlie parts in which those structures have been 
proJuced tend to become cmitraciund. it frequently luippuus 
that the disease will have bejpm to heal before tlie eiivity of the 
joint lias been much encroachinl upon, hence, anchylosis does 
not take place, but contracture may follow ; on the other band, 
oblitemtion of the joint cavity cau hai"dly occur unless accom- 
panied by much tis8ue-pro<luction arountl thes}'novial membrane ; 
thus, though a contracture need not be combinetl ^vith an anchy- 
losis, this hitter is nearly always accompanied by the former. 

Throughout our indications for the treatment of iuilammutory 
joint-diseases, we have strongly insisted upon the necessity of 
c(?rtaiu [>05itions to be preserved tliroughout the active condition ; 
it hapjwus that tJio posture which is most conducive to the cure 
of iutlammatiou is also that which is most convenient to the 
[mtieiit .should unforluuate circumstances produce true anchy- 
losis. But this is not all : we bare found in the chapter on stru- 
mous synovitis and iu that on strumous osteitis, tliat inllamma- 
tion having yiehlctl, the process of consolidation very gradually 
sets in. Thus, the state of anchylosis is bounded by no very 
distinct line, and we may take up the pi-esent subject at the 
[Kjint where, inflammatory action havuig ceased, the consolidating 
granulations are gradually causing contracture with or without 



378 RKSTORATION OF CBIPPLED JOINTS. Chap. XVII. 

ftctnnl oblit<»ration of the joint. At p. 145 we saw that oven when a 
great deal ofgmnulatioulmd been prcjdiiced we might, by the nse of 
sliampooiug, |HUMivf> iiiutiaii^and other juclu-ious meaus, Herure the 
re-absoqttion of a large part of tlu'se formations, tho more rapid 
and complete org>*nization of the rest Whether this fibrating 
part l>e much or little, whetlior it be situated jtartly inside or 
almost entirely ontside the joint, it is most deciiledly our daty 
to prevent its contracture into such form and shape as to produce 
distortion ; or to interfere more than to a certain unavoidable 
degree with the Diovements of the articulation. Unfortimately 
there has been engendered in the surgical mind a great dread 
of allowing any movement in a stnimous joint,* whetiier any in- 
Jhimmutiou remain or no, until the cavity is obliterated. The 
attendant, indeed, aa soon us a scrofulous joint-disease has been 
diagnosed, only lotjlcs fon^ard to that which is called (by noiirtesy) 
a euro by ancliyloais. The consequences of such treatment are 
by no meoiiH satisfactory, and it is fortiuiate that the same plan 
is net followed in other diseases. For instance, a surgeon, having 
treated and subdued an acute inflnminntion of a joint, insists 
upon the performance of movements ; if they be painful in the 
active form he institutes passive motion, and tlie roBult is that 
an acute, non-suppurative synovitis very rarely produces an 
inconvenient amount of anchylosis or contracture. But when 
in a chronic synovitis the intiflmmation has been overcome, 
the surgeon still keeps the limb immovable, and the result 
is tliiat sucli a malady, even when non-suppurative, rarely 
gets well but by producing an inconvenient amount of stiff- 
ness and deformity. If, after a fracture, implicating a jomt, 
had uiiit(Hl, the atteudant wc^rc to defer passive motion until 
the h'mb were fixed, just complaint miglit be made; if (to 
take an example from a subject not yet broached) a surgeon 
were to excise the elbow joint nod to neglect passive motion until 
the new tissue between the l>ones hail consolidated, the judicious- 
ness of the after treatment might well be doubted. Yet, in stru- 
mous synoml disease, all inllnmmation having ceased, my 
recommendation that passive motion might l>e used is often met 
by the question, " Hod we not better wait till the tissues are eon- 

* The stnimoiu influnmatioD 1b so I losi^ aud defonuitv tluin any olber. Ihul 
much mum freqncutly a oihu» of aiioliy- | ii U Itcrc eflpeoiiiljy mcntioDLHl 



uhap. xvn. 



PREVENTION OF ANCnYLOSIS. 



379 



„ Bolidated ? " WTiat a strange query that is ! Wait till the joint 
IB all but immovublo before we try to e«tabliah siobilityl 
Wait till the bouse is burnt down before we attempt to extin- 
guish the fire I 

I huve no hesitation in atHnningthat ineveiy caseof strumoas 
synoritiSt when all signs of intlamuiatton hare ceased, * au amount 
of mobility and a geuoral coufonoity of joint can be gained, whi<'h 
fits it for the ordinnry u.st« of the jwirt, though not for any violent 
exertion or very active exercise. This is not written for the 
sake of making a startHrig projMJsition careless of its truth ; but 
it is a fuel tuught nie by careful ubservatioH ami experience, 
extending over a number of years, and the more I see of such 
cases the more am I convinced of tiio soimiiness of thiit state- 
ment Tliere are very few examples indeed of strumous synovitis 
which pass immediately from the iutlammatory to tl»e degciiei*a- 
tive stage ; aud not many instances of stnimous osteitis occur 
(if the effects of pressmrc be prevented) in which such an instant 
transition takes place. If the joint be kept immovable during the 
passive period, a very long time must elapse before a cure with a 
considerable amount of deformity and stiftiie^ will follow, or 
before degeneration becomes so rapid that removal of the part 
will affiii'd the only chance of life. 

Tlie trealmt-nt wlxich prerente either of these contingencies, 
and establishes niuhility of the joint, is passive movement, with 
shampooing and pre&stirc ; aud when some amount of mobiUty and 
jKjwer is restored, active movement with proper support J have, 
during only the last eight mouths, treated one case of strumous 
synovitis of the elbow and tliree of the knee ; two of the latter fell 
under my efire while in the passive stage ; one when some dege- 
neration and suppuration had already begim in certain parts of 
the sluggish granulation. In all of them the above means 
rested, after a time (the last case being the most difficult and 
protracted), mobility to a certain extent. When tliis cliauge was 
pretty firmly established 1 employed a splint, as described below, 
and permitted the |Mitient8 to walk with first two crutches, then 
with one and a stick ; subsequently with two, and lastly with 
only one 8tick,t encouraging them to put the foot properly on 



* TtiflAionuiU'iii hoB ucam.'^ iu tliceo 
caoejt wbon thfre in riu tuiultruuMd at 
Ihe (.-hoicc fenl* of iMin, do hciil, tin 



alortJQgs, Ste. Sw y. 143. 

t Oue of tiftbi: putitmb «tUl iuf« two 
sticks. 



380 



HKS'rORATlOV OF CRlPPr.ED JOINTS. Chap. XVII. 



the ground, boginiiing with the heel and lifliug tlie toe at last 
RWHV. A^ in each of tliose cascH the knee was fiomewhat l>ent, I 
applied H iqiliut in front of the limh, consisting of a ihiyh-pieco 
itnd ft leg-jiioue of wire gauze, comiected together at mi inter\'al 
hy a Hat band of strong stt^el. The conneciing steel portions 
were tlms diiit])08od : they wers p!ar«l along the lower end of 
tho thigh and tlio upper end of the leg-piece, and projecting bo- 
yond their cdgua, weni riveted together so a^ to form a hixige 
at the outside and inside of the joint, iu the sitniition of the re- 
spective lateral ligameutis. Tho splint in itself gives no support 



SPUVT rOK YLKXbD KVKK. 



to the articulation ; but two doiiblo hooks of an S eha}>e are in- 
serted into meshes of the gauze on the upper and lower portions, 
at such distance apart that an india-rubber accumulator can be 
suH]jeudcd between them at a degree of tension, which may be 
increaacd or decreased as circumstances shidl require by moving 
ouo of the hooks iuto another mesh of tlie gauze. Tlie power 
of the india-rubber forces the joint into a stmighter pO|itiou. 
gives sutlicient supitort, and yet allows an amount of healthy 
movement, and therefore, gradual re-establishment of museulur 
strength. No Iwd effects have followed its wm' : it is only neces- 
sarj" that the bingo be made of steel sufliciently strong to prevent 
tho india-rubber tlrawing the two portions of the splint tr)gether, 
and so forcing tht^ hones to press abnormally uue against the other. 
When the apparatus luis been worn some time, I adapt to the It^ a 



Chap. XVIT, 



TRTTR A?n> FAT-SR ANCHYLOSIS. 



381 



pulley and rope, whereby the patient can flex the lirah piissn-ely 
against tho power of the india-rubber springs; by piillinp; upon 
the Hue and then relaxing it action of alternate cxtenaiou and 
flexion can be produeed. A further notice of sunh maehiiiery 
ifi given in the soqueL The same mechanism can bo adapted 
to other joints of the Ixxly. 

These principles, fairly carried out, are not remedies for in- 
flammatory joint disoatto, sinre the first ueeessity for tlicir ariop- 
tion is that inflammation shall have ceased ; they are rather a 
means of curnrinjr ont the gootl proverb ** Prevention is better llian 
cure," a means of combating anchyhwis while it is coming on, 
rather than waiting until it is established. The process of 
anchyloRis is thii same as tliat of cicatrization ; as we would 
prevent sucl» action pnxlucing contraction and deformity in 
one place, so ought wo to prevent its doing tho same thing in 
another. 

Many eases, however, come under treatment when more or 
lees deformity and immobility has existed for a considerablo 
time. These may be caused, aa we have seen, by anchyloais, 
with contracture of parta outside the joint, or by the latter con- 
dition alone. Tho anchylosis may bo cither tnie or false, and 
may fix the limb in almost any position.* It may also be simple 
or compound : the former term meana tliat the joint surfaces 
retain their normal relations, the latter that tlie lH>ne8 have Iwen 
dislocate<i entirely or partially Irefore they were united. These 
various conditions iK'ing in rliflerent degrees susceptible of benefit, 
aro to bo distinguished one from the other. 

The diagnostic signs of truo anchylosis are utter iitimobility, 
with which is combined a completely pawive oipdition and a more 
complete wuKting of the muscles, than is ever found in the 
other forms of stiff joint If the surgeon, grasping the limb, 
endeavours to d(?crease the deformity, tlie muscles at the opposite 
side do not got tcnso, or ofler any sense of resifdauce, neither 
does the patient feel any pain on the aide opposite the direction 
of attempted movement — that is, no pain on the flexor side, if 
the limb be drawn towards the jKjsition of extension* and vice 



• ScHim writers, i-hufly Dr. Little, 
ile^cribo au atignliir luirlijliMio, anil u 
atraiglit aouliytiMiM : lliu ilivisiuu in pntn- 



ttcully of little valne for tlic Bubji-ct 
[)ow utiilor coniidf'intioD. 



882 



RESTORATION OF CRIPPLRK JOINTS. Chap. XVII. 



venA. If tlie joint be superficial, the siirgeon'e sense of touch 
distingnislieH ari ovidont unity, which, although not of import 
enough to form a diagnostic sign, aids as a confirmation, llie 
ear may, I have found, ho usefully omploywl to detect this dif- 
ference, for by placing a stethoscope over either bone anchylc 
to the other, and striking \i& joint fellow, a peculiar riiifr 
heard, indescribably but utterly different to the 6ouud carried to 
the ear when the bones are separate. 

In false nncliylosis there remains some d<^;ree, howerer slight 
of mobility, perhaps a mere springiness, which is the mor 
readily felt if the bones foi-ming the joint be long. If the sur- 
geon endeavour to decrease the distortion, the n|i])nsing muscle 
will become more rigid under his fui^'cr, and if tlie attempt af 
movement be carried furtlier, pain will be felt upon the opposite 
side. 

It is in a great number of cases perfectly possible to distin- 
guish false anchylosis from mere contracture — that is to say, 
those cases in which the dofonnity arises from fibrous bonds in- 
side, from those in which it arises simply and entirely from bonds 
outside tlie capsule. In the latter case, the movement is easy 
within C4'rtain limits, and it very rarely happens that equal con- 
tracture takes place on both sides the joint. In the former, the 
movement is not free, even in the narrow spiice allowed. The 
one feeU like moving a hinge free witliin certain checks, the 
latter like bending a thick piece of gutta percha. It must be 
remembered tliat either form is seldom found unaccompanied 
by the other. 

All those points are most easily made out while the patient is 
wilder fhluroform. it is often unnecessary to give tlie ane^thassio 
simply for the sake of diagnosis, because tlie joint being falsel] 
anehyloeed, it is sufficiently flexible to prove tlie fact. In 
the contrary condition, however, when a joint is so stiff that no 
mobility can he ascertained, a true anchylosis should never be 
diagnosed until the effect of chloroform has been tried. It often 
happens that an articulation which appears utterly unyielding 
will, when muscular rigidity by means of cliloroform bo over- 
C(nne, allow some amount of motion. Certain joints — as the 
knees, elbows, and others— whiclu lying in the middle of a 
linib, have a long lever both above and beltiw them, offer con* 



coAP. xvn. 



VAmETT OF POSITION. 



383 



I 



siderable facilities for the detection of mobility; but if the 
articulation Ut bo cxaiiiined be either shoulder or hip, it becomes 
difficult to recogaise whether the motion produced be due to the 
joint in question or to another part. Tliis ambiguity is ckiefty 
mark<-<l at the Bhoutder ; it is all but imp>%>iblo to fix the 
ficiijmla, and even in health one can scarcely raise the arm fr*jm 
the side without moving the glenoid cavity. In fliildren the 
sacro-iliac: joint is very flexible, and ifi hip-joint dist-^iso bo- 
comes still more moveable, bo as to permit of a tolerable 
amount of apparent flexion and extension of the thigh without 
the slightest motion in the hip joint. Moreover, some of the 
muscles wltich are rendered most rigid on attempted movement, 
viz., the ca^isiiLir group of lK)th shoulder and liip, are out of 
reach of ilie finger. Our diagnosis may be assisted by the 
fact thiit trno ancliylosis of either joint is not common, in tlie 
shoulder indeed is excessively rare. 

Now, whether the joint be fixed by a bony bond or by fibroua 
bonds, in or outfiidethecaj>sule, the limb maybe in any position. 
But, 08 wo liavo seen in former chapters, there comes on during 
the inilammatory stage of a Joint disease, contraction of certain 
muscles, wliich, if it be not resisted, acts on the limb, and in the 
vast majority of instances it is the flexors which are principally 
thus affixted. Therefore, a limb which Itecomes fixed after 
joint-dise^io is usiuiUy bent, because all the parts which were 
inliamed consolidate their new tissues and mould them to this 
form, and because also the muscles do not of themselves give up 
the contracture they have assimicd The very term <rftcvKcK, a 
bend, a flexure ; aj/cvkoca, to bend ; and ultimately, ar/miKa^, 
in a crooked manner, shows tliat the fundamental meaning of 
the word is, that the joint is permanently flexed. Hut we occa- 
sionally find limbs whose bones arc united in a straight position ; 
an effect sometimes due to surgical management, sometimes to 
accident. Such [>osition necessitates the use of the barbarism, a 
straight anchylosis. It is more fortunate for our terminology, 
tlian for the patient's |)ower of movement, that such cases are 
somewhat rare. 

It is in reality of little importance, as far as the principles of 
treatment are couecrned, whether the bones be united in a more 
or less straight or crooked manner, although the condition will 



384 



RESTORATION OF fmiPPLKD JOiyTS. C«*r. 



cause great riifferenc© in the details of procednre. The m€ 
at oar di«[)osal for overcoming the sttffiieas maybe in tliesiini 
tenna describcHl as, forcible movement Ui l>reak np the 
sioDS, the knife to divide, and maehinos for slow espat 
contraotun'.*^ The nnion of sadden, of gradual foree, aiid nf\ 
blade leaves wide room for difference, aceordiup aa fine or 
other be chietly resorted to, Ih-. 8tromeypr, of Hanover, 
inventor of rabcatanooos tenotomy, need only the slow met 
of reducing deformity by means of apparatus whirh shonld, 
division of tondons, exerciMo a comparatively flight but Id 
traction on the limb. Dieffonbaeh, to whom this method ap 
peare<l objectionably long, proposed and carried out suddfm tM 
forcible rupture, or stretching, frf parts, without divisitm by fli 
blade.* Langenbeck, of Iterlin, has carried on, and indeed ha 
become the cliicf advocate of this system. Other surpeons 
commend rather tlie tmion of force nnd tenotomy, ailcr 
methiKl to h*' dctHxihcd. 

The objectiona to each of the three means may be 
ahortly stated. Whon a joint is nnchylosed (falsely), 
the tissues are pretty solid and tinu. the method of Stromey«| 
by gradual extension, is not only long* and tedious, but otU 
fails to effect the object. It is only to be tnisrted in mceil 
cases, wherein the tissues are still weak and flexible. 
method of ].)ieffenl>acl) and Langenbeck exposes titt [i»rt«] 
unnecessary violence ; if the musirlcH and fasciie be much cent 
tared and strong, these stnictnres may be torn ; a ne 
or even an artery, may be lacerated ; owiu^ to such injn 
inflicted upon the parts, mobility cannot be so perfecth 
restored as when contractm-cs, being divided, less violencoj 
necessary. The muscles of children, which can be readily ov 
como by very stigtit force, retract again, and are apt to prodti 
secondary deformity, or to limit motion very considerably 
Any old «car.s of the skin arc extremely fJtposed to danger o 



• Txmrrier lind nroTimwly inTcntoil 
on Kppantas nheteby llie lunb, Wms 
Knu<i>tKl in sbttM aiui »i{vluits, vra«i mul- 
aonlv fstetwlM fiy some irresiHtilOo 
foncfiinery vf ecrvwa anil ni]lli>ys. TIid 
romilbi were freqnonl trftctiires and 
laofrutionn, fitlloweil lij- hucIi njmptoins 
as utict^tusitutud omuntulion or cansL'd 
tlwith. 



t Pr. Tjingeiitrock OMorU, Uiai| 

ctfltitnirtim-il mitficic dooft uol. wIhi 
Ihr iH'lioii of tlio will ii mii-iH.'iiili.^ b] 
clilorofonn, become latii:ntU«l tlurio{ 
rioliint cxUTiaioti i tb« ftwuitKin, boW' 
evpr, is not lomc ont hy facl*. •• Coin 
mviitatiu ilo oontmctiiHl (4 MikyhiM 
geao novp niuJo violeiii-ie extofiwotui 
oane Hinnndifl." IWnl. IHStt. 



Chap. XVII. 



OOMDIKATTON OF METHODS. 



885 



rupture, and when lliis happens, gnpparative inflammation is 
violent nnd dangerous. Fourthly, the bouos ra&y be broken, or 
the cpiphvaes sopuratod. 

A combiiiiition of the two methtMls certainly offers tho best 
advnntagc iu all eascB where coiitractiiro outsido the rapnule is 
couaiderabU', and the |)oeitioD requires mucli cliange. I^angenbeck 
ot^mI agui[i»t tEifl mcthcHU that the wounds made by the teno- 
tome will ga|>e duriu^ extonsiou. and air ha trucked in, bcddea 
wliioh they form points of departure whence cutant^ns niptnro 
may U^gin. This is of^rtainly inw- ; and it was oneo my laififor- 
time to be present at an ojjeration f<ir <'Xt4^ndiiig the knee: both 
hamstrings were divided at the time, and the skin in the popli- 
t*>al n»gion split from side to side. It wna, 1 bolieve, 3lr. Brod- 
hurst,* who iirst suj^j^ested the wise course of perlormiup all 
subeutaueous divisions of fasciro and tendons some days before 
extension is to bt? used, and not resorting to this \*art of tlio 
treatment until the wounds produced liavo become thoi*oughly 
and soundly healed. 

There is no doubt, however, that in every ease, iu which we 
would restore position to a diseased joint, it is not necessary to 
divide teudous.f This depends partly on the gize and complica- 
tion of tlie joint, the strength of the limb, and the age of the 
person. The stronger nnd Jargnr the joint, tlie younger the 
patient, t tho letis chango should be effected nilhont tenotomy. 
It follows from this, that the angle, at which the limb is de- 
funned^ should have mueh influence in our choice df means: the 
greater arc through which we must move the limb, in order to 
fieBtore it, tho more necessary it will bo to divide tendons, &c. 
Here also the size of the joint inflncncos the decision, bccanso 
we may effect a larger change in a smaller articulation, the elbow 
for instance, without tenotomy, than wo could justifiably attack 
by the same simple mcAiis at the knee. But all these [joints 
are again ijifluencod verj- considerably by the length of ]M>rind 
during wluch the mflammatory portion of the rlisease lasted, and 



• ' On RcuUtraiioii of Motion by forc- 
tblf Exti'iuiuii un<l Rapture,' &c. 

t LitriiuttT tt uLjcvtions U> liiiiotoiny 
tw »tiiU'«l ill Uie acijuvl {p. l-Wfi). 

X The uiUM-'Ieti lit cLiMren, Wing 
rcTj MumLL oru euUy atrtkhed, hut 



they bear tliia act extrcntoly ill. retmot- 
iii(f nftcrwartlfi Aftnin and ilrnwiiiE the 
liml' into abiionnal posluixit: liciicu ia 
(in n'lult we mny uvcrconiu mi amount 
of iH>iitnH'tutv, which tn a cHiMimomh 

nitatM tCDCltODlV. 

2 c 



SEvraftATnai or cbifpucd jon^n. cbat. 

the tine Umi fm$ ekafaed owe the jocat m 
■KiWi C B t Thew latter DonditJoDswiQ be more dooely I 
wbai««- rr^Tfj^jfCttUjrtothfrliipaiid Uk kaee;* but it : 
here viAted* tbst to cmat-* m which the prinMry 
MVte, or ■ahftmti', un] of but ihart dantian, the delbrmitj 
iIMmm depend opoo ao anaU an aluntkn, that a very d^^ 
naorenuBt ii able to oreroone them. On the ofiier ] 
the anchy loaia haa been eetaUnhed, after a serere chronic i 
of long ftanding. nnd the* deformity heelf has lasted 
iht) difficulty will be lound mncfa greater, aikd the ; 
hff ukf'ti are more imperatlTe^ The following modes < 
daro are only for «^ere caaes, the ^'ghttr ooes reqmriDgl 
other dcacription. T>t>fnnnity from faW aDchyloBis and oontnS 
ture may occur at any juiut in tlie body, and may be combia 
with partial dijtIoL'atioiL We will very shortly examine 
of thftu*, liiit will Tomrve the chiff and most minote study 
th» hip, and more espcoiully for the knee. 

At the Mhoulilcr tme anchylosis is very rare ; it is not 
easy of diaguoeis, as the mobility of the scapula renders it~ 
cult to dorido the amount of fixity that may be present in 
joint itself. Ilio best position for discovering this point is as 
follows: — The patiirnt is to ait on the ground, or on a low stool, 
and the mirgt'on, standing behind him, fixes the acromion and 
nhiiiiMrr by pluclng one hand, with the thumb on the acromion« 
tho Angers in the axilla ; then he lift3 the arm away from ^M 
side mthtmt force, and in u pliinc pnrtiltel with that of tlsi 
oh(«t : he will tlius be iihle t*) detect whi^ther or no any motioa 
ut the articuUtioQ tuke plaeo ; in all probability he will fid 
some mnvciu'iit. An intlammntion of this joint suflfioientl^ 
»(»vere to Inn-' rjiuscil false anchylosis, will ulso have produced 
ri>i)triirtiirf> of tlio scjipulur group of muscles, and in ull probfl 
hilily of ihe Ion;; hi'iul of the biceps. All these parts are beyond 
legitiiuAto n'ach of the tenotome, and ha must trust to foroa 
only in order to ro-cstjiblish the movements of the port IS 
patient, Ix'ing subjected to tho influence of chloroform, is placed 
ii}M)n Uio side opposed to that in which tlie disi-ase is situated, 
and the o]}rmtor begins the following manojuvTcs. lict me 
strongly cnutiun the surgeon against begiwiing at once to for 
tho arm away from the siile in the direction above described,! 

• Seo pp. 390 uiil niM. 



Chap. XVn. 



THE BHOULDER. 



887 



such procedure is pxtremely likely to produce dislocation into 
the axilla. Thy first inovomciit must be simple rotation : by 
bciuling the elbow at right angles with tho bumenis, and using 
the forearm as a lov(?r. sufficient power is gained, and by f^asp- 
ing the upper ann as high as jKit^ihle the surgfeon can direct tho 
force. J*t him not, however, rotate tho humerus further out- 
I vards than it normally ought to go. When this movement is 
pretty free, ho places the arm in front of tho body, and makes it 
oroBS the chest, till the elbow lies over the eoaiform caitilage; 
he rotates the humerus a little while in tliut uituatiou, then 
places the arm behind the trunk witil the elbow lies just 
aboTO the sacro-iliac synchondrosis,* in which situation tho 
humerus is not to be rotated. Having thus loosened tho 
adhcjdons to a certain degree, the operator holds the 
acromion and joint with one hand, in the manner previously 
descril)ed, and lifts the arm, as far as it will go^directly ia 
front, urithout the utte of force, and commences circumduction, 
eudi-avoiiring to make the arm describe as largo a circle as pos- 
sible : it must be brought to at least a right angle and a half 
with the body ; this amount of elevation is the very least that 
shoidd satisfy him ; and the more he can raise the arm in thia 
circumduptorj' method the better. Ho will i)robably require assist- 
ance in currying out these actions, but ho shnuM with his own 
disengaged hand hold the humerus, and govern its movement, 
and on no account should allow it to be forced apward directly 
from the side, or great peril of dislocation will be incurred. 
During all these manoeuvres cotisfderuble extension should be 
made to diminish that risk as much as po88ible.t The hand in 
the axilla will enable him to judge very accurately of the eOfecta 
that are being pnj<lucud. 

More or leas immobility of the elboW'joint is a frequent result 
of its inflammation. If the surgeon have convinced himself that 
there is no true anchylosis (see p. 381), he next must determine 
which are the eoutnu;tured parts. It is very rare that the pos- 
ture during an iunammatory ilisease of this articuhitiou has been 
such, that the arm if fixed in a straight position ; still, it is 



• In oVfw pfntoiw ai'itliLT tli'm nor 
tli« ]m>Tii>iix p<it<tivti atii \y) utttiiiifH) to 
tlie fnll fxtt>iit liure ik-Mcribetl. 

f The after tmtweiit being Uie same 



t»t »Il articalatiiHu, iU ooosidciation ia 
pcrilpuDMl till tLe meani of gaining 
mobility for all juinta Iiato berai coo- 
Hideret). 

2 c 2 



S88 



RESTORATION OF CUIPI'LED JOINTS. CnAr. XVn. 



frequently bo miirh ext<?ndod as serioosly to dim!ni»h the use of 
the hanrl. In such a cnse it l»ecorae8 a question whether or no 
it xrill be better to divide the triceps, and the auHwer mitst be 
Houfi^ht from three circiunalam'<f«: the age of (lie patient, the 
amount, and tlie duration of the m&lpostare. If the person ha 
under fourteen years of age, if a boy — twe-Ive, if a girl — the muscle 
Hhould liu dividinl, unlets the maljwsition be very slight. In 
afhiltR. if the ami be fixed at more than 120", myotomy should 
bo used in eases where the contractui'e is more than six months 
old, and the orij^ina! disease hiivo lieen gomethiiig Ix-yond a 
slight attack. Let us first suppOHo the muscle is not to be cut: 
the patient being subjected to the influenee of chloroform, the 
first movement is to be simply rotation carried, if possible, to 
the normal extent ;• the next is to be tbat which is the opjx^site 
of the particular niobihty wu wish to establish. For instance, if 
the enM)w be too straight, we, desiring to procure flexion, must first 
straighten it still more.f and then flex it. In the same way, if 
it be immovably too much bent, we first bend it still more and 
tBen straighten it. Some care is necessary in cflecting this last 
change. Wlien the arm is overflexed, the surgeon should grasp 
the ellmw-joiiit in .sueli a manner as to keep his thnmh over the 
head of the radius and biceiw tendon. During the action of 
extension, which is better performed in a nnmber of jerty 
nctioiut than by a constant fortie, the abovo tendon may 
become perfectly tense, while the head of the radius docs 
not follow the movement. The attempts at forcible exton^on 
must then be discontinued for a while. It may be that increa*>d 
narcotism \iill cause sufBcient relaxation* and a more careful and 
gradual mode of procedure will effect the object witliout injury ; 
whereas a coutinnauco of the same means would be verv- likely to 
produce dislocation of the radius.} It may be, however, that the 



• The order io which Uik movfrnontji 
eretulwoebil>lii))ic(l<loi>« iiutnioki! itntt- 
miitary Ui»t thi.- une inuiil, nt nil Iiiuunlis 
bo nccont]ilialKOil b^forp lUe uHiL-t l>t> 
niicn)|>Uwl. It u Mimctimiri impofutihle 
Io nitnl*! tlte rorourm. 

t Tliu reason of this ift tluil tliere are 
two n.-«)Hhuici-» to hv uVL'rf<iiiH<— that of 
fibrouamlliceiuiiM in- or outMide tlii^ jtilnt 
■ihI <-oiitnu-| iinii on liic u«fH<-t of tlio 



X 



limb). If, wlutu Uio joint h« over ox- 



t<-n<l«(l, TTp otU^mpt ill flexion immedW 
nti^ly, both Uiivu- ri'Hihtiiii(-(*ti An* tout at 
onof>, iukI r^nMitk-rnhV' torvi? will bo rt> 
(|ui^l^4] : if, nil thni-niitmry, wu»trmi};htou 
tlip litiili hH'uro fttxii]j; ii. thi- ruIltcKinrt^ 
will l>i> firtt brnkt'ii down, koJ Hum tl,o 
musciUnr L-ontmctrnvit ort^ironiL* : liiiu 
wti uiu; etft'c-t tliu ubjuvt uuro i;cuily 
ftn<t ratioually. 

; 8u(-li cuudition of ports u Tati%. 
I mot »-ith it in a caso yrhexo ib« ann 
wua hont at nu acute aiiglo. 



Co A p. XVII. 



THE ELBOW. 



389 



bioepfl tontlon must be divided, and it will be far better to per- 
form this little operation than to nm any risk of dislocMing the 
rwlius forwards. In floxiuj;: an over-stmifiibt ami the siirg^-oa 
secures a greater iM)wor by placin;,' his knee in Uic bend of the 
elbow, but he must take care not to use sufficient pressure to 
endanger veaseU and uervca ; uaually, indeed, sulTicient force is 
obtuiti^d by the use of the hands only ; Hoxiou should be carried 
60 far that the band can be laid U[K>n the pectoral muscle. 

It has been said, that under tlio age of twelve or fourteen the 
triceps id to be divided, unlesa the amount of coutracture be very 
Hmall ; hni somctUing must 1m? addwl lo this Ktatement If tlio 
triceps resist much in a ]X!i-8on imder eighteen, or even more, if 
developiuejit be retaixled, it is better to cut the muscle than to 
run thu risk of brejiking tlmjugh tile epiphyniH of tlie ulna — a 
mLst^lianco of serious imjiort. The little o|>ei-ation is thus per- 
formed : — The inte^iment is to be drawn inwards as mueh oa 
possible, and a puncture made witli a sharp-pointed tenotome 
thnmgh the skin and su])erl]eial fascia, about an inch above the 
outer condyle, behind t)ie strong piece of fascia, which here 
forms an inter-muscular septum. The operator substituting a 
bhuit^poiuted knife keeps the fore finger of his left hand a little 
outside the cour»^ of tho ulua nerve, and jmsses the instnmient 
between the mxwclc anti the skin, with one ilat side toward-s each 
structure, until he feels its end with tho fiugor of the left hand. 
Withdrawing the knife a little, he turns it, with its edge to tho 
muscle, and cuts it through to tlie bone while withdrawing the 
luiifc, taking care, however, not to continue the section up to 
the extemid pimctnre. This being completed, the patient is to 
bo left mitil tho wound in tho skin has qnitc heaUnl, and then 
tlie movements, above descril>ed, are to be put in force. 

Tho various jointg about the hand are subject to disease, from 
which contraetnre may follow ; the wriflt is j[x?culiarly exempt 
from snch defonuities, but the thumb and the fingers are more 
fi>?queutly attacked. These are, as far as 1 know, the only 
apparent cx<xt]ition to the general rule of the predominance of 
flexors. In these membere, tho extensors verj- frequently 
prevail over one phalanx, while tlie flexor predominates in another. 
Thus the first phalanx of the thumb will be over-extended, 
until it forms nearly a right angle witli the met4icarpal bono, 
while the second phalanx is bent very considerably on the first; 



KESTORATION OF CRIPPLED JOINTS. Cuak XVnJ 

and the metacar|M>iiliaIangeal joint of tlie fingers will tx>me- 
tiraes be over-extended, while the others are flexed. The 
exception is, however, appftrent only, for the defonnity is in 
everj', or in nearly every lustanee, produced by coutractxire of the 
flexors. Tlie iiiKertiou of the flexor tendons into the base of the 
tjeeond and tliird phalnnx enables their coutractwre t-o prorJuce 
great flexion of (hose joints, but lias no effect upon the first phalanx. 
Such action produces a strain njxjn the extensor tendon, drawiug^ 
the first phalanx, in whi<'h there is no resistance from flejcors, back- 
wards. Such deformity, when it arises from joint disease, is more 
often due to chronic rheumatic arthritis than to any other ; from 
this malady, iudeed, 8ome of the strangest distortions of the 
hand arise. The condition, however, is very frocjuuntly derived 
&om some neurotic affection ; may follow a wound over the course 
of a nerve, or on the finger : it is sometimes impossible to trace 
its origin. Division of a flexor tendon is rarely necessary, an 
extensor need never bo cat; the beut joint can usually be 
Btnii^'httiDed under ehhiroform with the greatest ease, when the 
straightened ones will rcsimie their nuliiral pcwture, quite 
without externa] aid. A case occurred to me, in which, having 
straightened a finger, I put it on a sjilint in a flexed condition,* 
and the operation had to be repeated two days afterwards, 
since which I have always put up a straightened finger or 
thumb extended, and have never heard complaint, or found evil 
effects. 

In hipjuint dma«e, the deformity arises, as wo have seen, 
from ccrt^iin remarkable alterations in the position of the thigh, 
whii'h is first ali>fhicted, ainl thou adducted,f (according as tho 
contraction of certain muscles predominates over that of otliers,) 
and tends, throughout, to become flexed. At p, 385 it was 
observed, that the duration of a joint disease, whereby distortion 
was produced, must be gravely considered before any operation 
for its reduction be undertaken, because we can conclude, from 
the greater or less continuance of the original malady, on the 
amount of change which the articular surfaces bad undergone. 
An acute or subacute attack, of inflammatory hip-joint disease^ 
may have been subdued U>foro abscesses had formed; starting 

* TLiH, with oUicr joints, is the rule. I f Fur moro rtiiiiuU.' dcBcriptlons uf 
tiee p. 4U4. | tliue dialurtJuiu rvtvi to Gliap. SSV. 



I 



Chap. XVII. 



THE HIP. 



301 



paina, hariug been severe, may hare hod but slight duration ; and 
though the muscular contraction ooiitinoee as passivi? couinic- 
ture, tlie actual iiiflnnioiation will have lasted but a sliort time. 
Such cases are chiefly to be met witli auioug wlults, who have 
been expose*! to vicissitudes of climate, great fatigue or other 
hardships, but occasionally occur also to inipubic persons. They 
coiumeuce suddenly by an attack of pain, with rapidly succeeding 
spaKiu and distortion, and >ire thus siidieiently strongly separated 
I from the slow form of strumous disease, beginning almost xm|)er- 
ceptibly, and most commonly in ohihlren. We may form a very 
probable conclusion, as to the condition of joint surfaces, from this 
more or less rapid history of the case and from tlie absence or the 
amount of suppuration ; whereby we may jnd<re on the advisability 
of any opertttlve procedure for amelioration of the couditiou 
left behind. The deformity which most detracts from the jwwer 
of progression, is considfrnble flexion of the thigh upon the 
pelvis. We eannot fonn any cont-Iiision, upon the. amount of 
articular injury infllicted by the disease, from the amount of 
distortion left behind, for it depends upon many collateral clr- 
cuin.stauces; an attack from long exposure, combined with great 
fatigtie, may, as 1 have seen, produce mora deformity in a few 
days, thrtn will bo caused by montlis of the strumous malady of 
childhood, although the articulation itself will be changed ia 
much smaller degree. Yet considerable distortion lias this 
effect, that while it renders change in posture more imperative, 
our prc^uosis of its effect must be in a degree less favourable, 
because even in the abisence of articulorinjurj-, greater stretching 
of contracturcd muscle is not so favourable as less of that action. 
It is, however, wise to give no decided prognosis until, chloixiform 
having beeu ml ministered, it can bo discovertMl, whether or no 
the distortion be not almost entirely muscular; it generally 
happens, in the case we have been cousiduriiig, wherein no 
abbesses have formed, tliat, the joint which previously was 
fixed and rigid, becomes sufficiently flaccid to warrant our pro- 
^piising very c*jusiderable amelioration. 

The cliloroform should have beeu uduiiuistered with sucb an 
understanding, as shall leave the surgeon free to do much or 
nothing, as he linds the result of narcotism may teach : and if it 
turn out favourable, the iuljiitdment of the Umb may take place 



3!)2 



RESTORATION OF CmPFLED JOINTS. Cbap. XVU. 



at once in the foUowiug manner. The patient lying on the 
sound aide, tlie surjreon Ifis an assfstant jrrasp the pelvis firmir, 
while ho, by one or two jerk?, flexes the thigh on tlie pelvis.* The 
adhesions yield with a pociiliur short rending sound, and tbo 
moveiueuU of the limb hecorao free. It is wise, however, alao to 
extend the joint, a process which requires no fore*, unless a 
fibrous band remain unbroken by tho flexioa, and then it is 
neccssttry that this bo niptiired, sinct^ otherwise the operation 
will have failed in ita great desidoratnm ; viz.. procuring a 
straight liuib. 

On the other luiud, wo may bo consulted, conreming a patit*nt 
who had slowly run tlirongh all tiie stages of morbus cox«e, 
sutTering much from starting [lains, exhausted greatly by 
absoesfics, and at last recoTering jDaiufully, with a tlislorted and 
sbrivellwl limb. The coutnd orations in such a cfw:; regarding 
oi>erative iiitorfereuce, become more pnive and diiliciilt, becanso 
it involves an amount of inteiference, with parts which may be 
too much altered (« submit patiently to disturbance. Tho 
question of operative mca^ureB or no, resolves itself into a com- 
parison between tho state of the patient at the time, the stnto 
in wliicli ho may reasonably hofw to be jjlaeeil, and the amount 
of risk incurred in the process. The distortion, viz., adduction of 
the thigh, which pi-oduces tilting of the pelvis, and apparent 
shorteuing of the liml>, is not in itttelf sufficient to annul tho 
power <if walkiug ; but when thiw ia combinitil with a cetioin 
amount of ilexiou, the patient is in a vei-y pitiable condition, and 
when til© bend is considerable, locomotion becomes bai-ely {jossible. 
Under such cinmmslances, we are cun-fully to conMider tho 
probable be-nefitto be gained, and the risk nin by any 0{»eratJon. 

K the head of tho femur, having been dislocated during tho 
disease, now lies on the dorsum ilii, it will have contracted cer- 
tain adhesions, and tho miuHdes will have adapted themselves 
to their new length and posture. Tlie position of the thigh 
being usually, in such cases, one of considemble flexion, Uio 
limb is almant worse tliau uauIeSH, and very consi^lerahle efibrtfl^ 
may justifiably be made to change tliis posture, to straighten 
and even to bring down tho thigh. Such treatment may bo 



* Iji lUiiUiii; Willi B cliiM. even w-I(li . 
m girl ur liul uf uliglit bulM, (ho sngeoii i 



vrill ttavt> power mifGciontly to fix tho 
ptlvii with uilo Land bitnaoir 



Chap. XVU. 



MYOTOMY AT THE HTP. 



393 



undertaken with the more confidence, Waiiso we hftve not in 
buch ooiies to do mth a joint, nor with a bone impacted in an 
nnyieUing^ stHrket, but simi»ly with one lying amonf; fibroiia ad- 
hesions. A very probabli' concinaion nmy bo arrive<l at regard- 
ing the iirinDess and toughness of tliose bonds, a» well as the 
unyielding nature of the muaeolar contracture, by considering 
the length of time during wliicli the disease lasted, and the porind 
ehi|»sed sineo tho dcfonnity wa« established. No decision as to 
mode of procedin* should, however, be determined n|>on until, 
chlorofurin haviiv*^ Ix'en athuiniKtered, tlie amount of easy and of 
forced mobility can be aiK'ertaiued, and the condition ol muscles 
examined. It will usually bo necessary to perform myotomy npon 
the sartorius and tensor vagin.-e femoris on the one side of tho 
limb, and occasionally upon the adductor mass on ^e other, also 
upon the rectus femoris. Such wholesale division of muscles ap- 
pears a formidable undertaking, but it is not so in nyility ; and aa 
ILr. Canton atlvisos, we may, by keeping the tenotome close to the 
pubic bones, avoid divitling tho obturator vessels and nerves 
with the adduetore.' The limb Hitould not he Btraightoned at 
once, but should be left until the wounds have healed. In from 
three to tivo days, the patient is again to be subjected to the 
influence of chloroform ; tho limb is to bo first flexed, and then 
exteniled, then dragged downwards, until its length bo as nearly 
equal to the other iw can 1)0 managed without the applicatiou of 
An injuciicioua amount of power. Cold is to be applied to the 
part ; but the limb may be put up straight, as we liave not now 
a joint to deal witlu I should reo4>mm(md a iJesault'a splint, 
provided with pulleys, as described at p. 250, so that in from 
three days to a week extension may be employwh 

Hut if the head of tho bone bo not dislocated, and if the 
tliscaae have been of the slow wearing nature just described, 
we have no right to ex|)eft otherwise than that mut-h change 
has taken phice in the shape, both of the head of the Ixtne, and 
the acetabninni, and that the new material wliich luw formed is 
tough and hard. Let the nmder rnfr^r Ut the woodcut at p. 363, 
and observe the oval or almost trilateral form which the head 
of the thigh-bone has assumed, and the perfect accuracy with 



• I m»y refiT to a cuse of Sir. Can- I 
turn's, ia whicli he divided tho mtuclca | 



nbavo rnuim^mtod. 
29tl], 1656. 



Lancet, Nuvvmber 



394 



RESTORATION OP CRIPPLED JOINTS. Chap. XVU. 



which it fits the now portion of cavity it has liollowod out for 
itielf. Now, it is evident, tliat Lf this patient, having recovered 
from all inflamniiitory disease, and siiflering merely from tho 
deformity left heliind, had been subjected to powerful flcuon, 
rotation, and other such movements, the bones mnst have been 
severely injururl, und a new, very pndmbly a fatal iuihiifimatioa 
would have been lighted up. We have no possible means during' 
life of forming a conclusion on the abnormal 8ha]>e of the new 
articular surfaces, after many abscesses have b<wn produced by a 
chronic joint intlamintition, but we may very generally ctmclode 
that they have losttheircircularityan<l perfect adaptation. Hence, 
in all such cases, any violent efforts at movement are uuscioutific 
and unsnrgical, leading never to good, and often to evil results. It 
will not be always wise, even in a deformity with the above hietoryr 
to exi)re88 a decided prognosis before giving chloroform. A\Tien 
the auefithiBHic has had full effect, attempts at movement may Iw 
made of snch strength as would, in the cases first mentioned, be 
successful, and if no mobility be produced greater violence is not 
to be applied. 

A hip-joint disease which lias been treated by any method. 
wliother M. lionnet's, Dr. Bauer's, or Heine's, which keeps 
the limb in a direction parallel to the mesial line of the 
body, will prevent (liat eztreme distortion (by flexion of the 
thigh on the abdomen) wliich ftirbids the foot coming to the 
ground. The deformity left after such treatment is addac- 
tion, with some rotation inwards, and apparent shorti^uing of 
the thigh, the latter being produced by ptjlvic maliHjsition.* 
Now, this condition produces an amount of lameness which, 
although distressing, is supportable, and does not prevent loco- 
motion to an extent which wuuhl justify any interference so 
dangerous and so Little satisfactory as tliat above described. 

On the other hand, if the limb be |iennane