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SURGICAL OBSERVATIONS

THE TREATMENT

CHRONIC INFLAMMATION

VARIOUS STRUCTURES;

PARTICULARLY AS EXEMPLIFIED IN THE : , . »v"

DISEASES OF THE JOINTS.

BY JOHN SCOTJ,

SURGEON TO THE LONDON OPHTHALMIC INFIRMARY; AND
ASSISTANT SURGEON TO THE LONDON HOSPITAL.

LONDON:

PRINTED FOR

LONGMAN, REES, ORME, BROWN, AND GREEN,

PATERNOSTER-ROW.
1828.

s-zs^

London:
Printed by A. & R. Spottiswoode,
New-StreeuSquare.

JOHN RICHARD FARRE, M.D.

AS A TOKEN OF ESTEEM FOR

THE DEPTH OF HIS MEDICAL KNOWLEDGE,

THE PHILOSOPHICAL STRUCTURE OF HIS MIND,

AND THE RELIGIOUS BENEVOLENCE

OF HIS HEART,

THIS WORK IS DEDICATED

BY
HIS RESPECTFUL FRIEND,

JOHN SCOTT,

PREFACE.

Of the diseases of the joints, the patho-
logy has been so fully and accurately in-
vestigated by various writers, especially in
Mr. Brodie's invaluable work, that little
remains to be done on this part of the
subject, but the treatment still admits of
very great improvement ; for in most dis-
eases the latter is seldom a logical conse-
quence of the former, but itself requires
a separate Investigation. Hence we find
that the most profound pathologists are
not always the most successful practi-

L ■

r
I

tioners. Dr. Baillie is said to Iiave re-
■ marked, that " although he knew better
than other men how to distinguish a dis-
ease, he did not know better how to cure
it;" and there is a whole nation (the
French) remarkable for the minuteness
of their pathology, and the inefficiency
of their practice.

The object of this work is to com-
municate that mode of treatment which
my father, Mr. Scott of Bromley, has
for many years employed in diseases of
the joints with complete success in a
vast number of cases, in which the
methods ordinarily employed had proved
ineffectual. It is now many years since
I first learned it from him. I have seen
its efficacy verified in numerous cases,
first under the care of my father, and

since under my own, and I feel it to be
too important to be confined to an indi-
vidual.

To this Essay is prefixed a short en-
quiry into the nature and treatment of
chronic inflammation, and ulceration in
general. This I have been compelled to
do in order to explain the operation of
the remedies proposed ; I have however
endeavoured to treat the subject as con-
cisely as possible, and to confine my ob-
servations to a statement of those facts
which are necessary to illustrate the prin-
ciples I wish to establish.

The influence of disorder of the health
and the digestive organs in keeping up
local diseases has of late years been fully
explained; but little notice has been taken

of the reverse truth, the influence of local
disease in keeping up disorder in the con-
stitution, and the digestive organs ; yet
the latter is as true and important as the
former. Pain or any irritation in a part will
assuredly spread disturbance throughout
the system, and thereby impair the func-
tions of the stomacii, and its connected
organs ; and if we can relieve this pain,
or soothe this irritation,by local remedies,
we shall go as far towards imparting
tranquillity to the system and the sto-
mach as by the employment of altera-
tives, aperients, and a regulated diet,
which it is often vain to adopt without
attention to the former. There never
was a greater delusion than that of sup-
posing, with some modern surgeons, that
medicine and diet are all that is necessary
tor the treatment of local diseases, and

that local remedies are needless. It is a
scrupulous attention to, and a dexterous
application of, the latter in addition to the
former, which has enabled my father to
succeed in curing so many local diseases,
which had baffled all previous efforts.

10. Nem Broad Street^
January y 1828.

CONCERNING

CHRONIC INFLAMMATION,

AND

ITS TREATMENT.

When inflammation is either originally
slight, or has been rendered so by treats
ment, it will sometimes, instead of sub-
siding altogether, continue its progress
in a chronic form. I proceed to enquire
what are the causes of its continuance,
and the means by which it may be re-
moved.

Inflammation in a chronic form differs
in degree, but not in kind, from that
which is acute : it may equally induce

the four general terminations of inflam-
mation, viz. effusion of lymph, suppur-
ation, ulceration, and (though more
rarely) sloughing.

Inflammation in the lower extremities
may be excited, maintained, and aggra-
vated, by a varicose state of the veins.
Under these circumstances, the vein
being greatly dilated, its valves become
unequal to their office, and no longer
sustain the column of blood wliich it
contains ; the consequent gravitation of
this fluid impedes the circulation in
the minute venous ramifications : thus
arises venous congestion, which ne-
ceBsarily excites increased arterial ac-
tion, and this being exerted not only on
the venous branches which are the seat
of congestion, but also on the secerning
extremities which terminate in the cellu-
lar tissue, there occurs in the latter an
effusion of serum. If the limb be con-
tinued in the depending position, the

inflammation is augmented, coagulabk
lymph is at length effused, and if the
process goes on, the vascular structure
of the part becomes weakened, and ul-
ceration is the consequence. Thus the
two essential conditions of this disease
are venous congestion, and increased ar-
terial action.

If inflammation be excited by an ac-
cidental cause in a lower extremity
where there are no varicose veins, it will
be augmented and the pain increased by
the depending position of the limb.
From this cause ulceration is of much
more frequent occurrence in this situation
than elsewhere. If ulceration occur un-
der these circumstances, and the limb is
continued long in a depending position,
the sore will become purple, gorged with
venous blood, which frequently oozes
out of it in considerable quantity. It is
certain, therefore, that in this case the
powers by which the blood is transmitted
through the limb are diminished, and

B 2

no longer equal to overcome the gravi-
tation of this fluid.

In a healthy leg (though in a depend-
ing position so many hours in the day)
no swelling occurs, and no congestion
in its blood-vessels. It is plain that in
health the heart and arteries are capable
of propelling the blood through the
veins, although the influence of gravita-
tion is continually favourable to the de-
scent of blood into the limb, and con-
tinually unfavourable to its ascent out
of it

Now the difference between these two
states of the limb consists in inflamma-
tion, which proves that in this state the
propelling powers of the vessels are
diminished, they become distended with
blood, which keeps up and aggravates
the inflammation as long as the limb is
kept in a depending position.

The true pathology of chronic ulcer-
ation in the lower extremities appears
to be this. The ulcer is only the ter-

mination and effect of the chronic in-
flammation by which it is surrounded, and
the former cannot be healed until the
latter is removed. In the treatment, the
direct object is not to heal the ulcer, but
to cure the chronic inflammation ; for if
this can be effected, the ulcer heals
spontaneously. The essential remedy
for this state of things is mechanical
support, which restores to the vessels the
power of propelling their fluid along
their canals.

This mode of treatment was first intro-
duced into practice by the late Mr. Bayn-
ton of Bristol, a gentleniiin who must be
remembered with gratitude as long as
improvements in surgery are estimated
by their practical value. The remedy he
has recommended is productive, when
properly employedjof incalculable benefit,
not only in ulcers of the legs, but in a
vast number of local diseases; the prin-
ciple therefore on which it acts, and the
B 3

mode in which it ought to be employed,
are questions of no trifling importance.
Mr. Baynton's notion of the mode in
which mechanical support operates, he
expresses in the following way : " In
consequence of a greater deposition of
lymph between the interstices of the
muscles, and the cells of the cellular
membrane, than is necessary for their lu-
brication, or than the absorbents can
carry away, which, gradually increasing,
will remove the absorbents from their
vicinity to the arteries, and consequently
occasion a loss to them of the effect of
arterial impulse, which, while the vascular
system of the limb continues in a perfect
state, may be supposed to have consider-
able effect in propelling the returning
lymph, as the lymphatic vessels are plen-
tifully suppHed with valves, therefoi'e,"
he concludes " that the principal diffi-
culty which occurred in the curing of
ulcers has been occasioned by deficiency
of i)ower in the absorbent vessels, and

that it appears certain that such defi-
ciency of power is a consequence of that
diseased state of the common integuments
of the limb, which failed to preserve the
parts in a natural situation, and render
them subservient to each other's natural
actions."

Thus, if I understand Mr. Baynton
rightly, an excessive effusion of lymph
separates the absorbents from the arteries,
and thus deprives the former of an im-
portant aid to their propelling powers ;
and this effusion depends on a want of
the natural support of the common in-
teguments: but there are strong objec-
tions to this theory. The oedematous
state of the limb is invariably preceded
by pain and tenderness, and consequently
looks more like the effect of inflam-
mation than of deficient absorption.
Besides, ulceration is a positive proof
that the activity of the absorbent vessels
is increased, and that the disease consists
essentially in Inflammation.
B 4

If a patient with an ulcer on his leg
be confined to bed, the pain, redness,
and tenderness will rapidly subside, and
the ulcer will heal, in many cases speedily;
but as soon as he begins to use the limb,
the inflammation will return, and again
terminate in ulceration. If however the
limb be subjected to mechanical support,
the inflammation will subside, and the ulcer
will heal as quickly as, and often quicker
than if he were confined to bed. All ul-
cers, not of aspecific nature, which occur
in the upper extremity or the trunk of a
healthy person are healed with facility j
yet the only diflerence between the parts
there situated and those of the lower
extremity is in the course of the venous
circulation. It is clear therefore that the
obstinacy of ulcers in the lower extremi-
ties depends on the obstruction to the
venous circulation, and this is corrobor-
ated by the fact that the means by which
this obstruction is obviated immediately
get rid of the obstinacy of the disease.

}

The above considerations lead me to
the conclusion that the effusion of lymph
and of serum into the cellular membrane,
and the distention of the integuments,
are the effect, not the cause, of inflam-
mation, as Mr. Baynton supposed. Now
mechanical support is a remedy equally
well adapted to ulcers on the lower ex-
tremity, whether they arise from a vari-
cose state of the veins or not. It is
capable also of affording great relief in
many cases of chronic inflammation not
so violent as to produce ulceration. In
the former cases, It is not the ulceration
that is the object of our solicitude, but
the inflammatory action, which induces
ulceration. The ulceration ceases as soon
as the inflammation is arrested; and
as this has been shown to depend on
distention of the veins, which are no
longer able to resist tlie gravitation of the
blood, we have only to afford such an uni-
form support to the limb, as shall prevent
the veins from yielding to the pressure of

their contents. If we adopt the adhesive
bandage with this view, it must be applied
in a manner very different from that in
which it is recommended by Mr. Bayn-
ton. He directs the * " middle of the
piece of plaster to be applied to the
sound part of the limb, opposite to the
inferior part of the ulcer, so that the
lower edge of the plaster may be placed
about an inch below the lower edge of
the sore, and the ends drawn over the
lUcer with as much gradual extension as
the patient can well bear. Other slips
are to be secured in the same way, each
above and in contact with the other,
until the whole surface of the sore and
the limb are completely covered, at least
one inch below, and two or three above,
the diseased part." — " The force with
which the ends are drawn over the limb
must be gradually increased, and when
the parts are restored to their natural

ease and sensibility, which will soon
happen, as much may be applied as the
calico will bear, or the surgeon can
exert."

I could relate many instances in which
this mode of applying the plaster band-
age has been' attended by great mischief.
The pressure round tbe part of the leg
encircled by the plastei* and bandage is
so much greater than at the lower part,
where a roller only is applied, that tlie
venous circulation is so ranch impeded
as to cause considerable tumefaction of
the foot and ankle. This produces ex-
tensive inflammation, which is propa-
gated to the original seat of disease.
Besides, in many instances, the inflam-
mation of an ulcerated leg extends much
more than an inch below the ulcer ; so
that, according to Mr. Baynton's direc-
tions, we are to apply to a portion only
of the disease a remedy which, when so

applied, aggravates the remainder; for I

repeat that inflammation is the disease,
and ulceration only its consequence.

Instead therefore of commencing the
application of plasters an inch below the
ulcer, it is necessary to afford equal sup-
port to the whole limb, in order effectu-
ally to bring about a uniform state of the
circulation. The difference between using
the adhesive bandage with this view, and
with that of squeezing the parts that are
swollen into their natural dimensions, will
be obvious to every one. By applying
the plasters to the whole limb In the
manner 1 am about to describe, we at
once relieve congestion, and the attendant
inflammation. The pain subsides, the
lymph and serum are secreted In a less
abundant quantity, and absorption going
on, the limb is less swelled on the follow-
ing day. In this manner it is gradually
reduced to its original size and figure.
When the limb is reduced to its na-
tural state, Mr. Baynton directs that the
plasters should be applied " with as

much force as the calico will bear, or
the surgeon can exert," I must confess
that, according to my experience, when
a limb is reduced to this state, all pres-
sure applied in a circular manner, with a
view to compress the parts into a smaller
space, is uniformly injurious, and pro-
ductive of inflammation, which, if this
principle be persisted in, will terminate
either in ulceration or sloughing.

With regard to the method of fulfilling
the foregoing indication, the eraplastrum
plumbi, P. L,, spread on calico, is the best
application, as it does not irritate the
skin. It is most conveniently made use
of when cut into slips of fifteen inches in
length by two in breadth. The foot
being placed at a right angle to the leg,
one of the slips should be applied from
the first bone of the great toe, along the
inner edge of the foot, around the pos-
terior part of the os calcis to the first
bone of the little toe ; the middle of
another slip should then be placed under

the bottom of the os calcia, and its ends
extended perpendicularly up on each
side of the leg ; the third is to be applied
along the foot, parallel to the first, and
overlapping the half of it ; the fourth
should be placed parallel to the second,
overlapping thehalf of it, and extending
perpendicularly up the sides of the leg.
In this manner they should be applied
alternately along the foot, and up the
leg, the one holding and as it vi^ere anta-
gonizing the other in the motions of the
foot until the whole limb is covered
from the toes to the knee. Subsequently
to this, a calico bandage is applied in the
usual manner, first alternately around the
foot and ankle, and then up the leg as
high as the knee. It is necessary to be
particularly careful that the plasters and
bandage be applied in such a manner
that their superior and Inferior edges are
accurately placed in apposition to the
akin, otherwise they will exert an unequal

pressure, which is highly injurious. The
whole should be applied with only that
degree of tightness which is perfectly
agreeable to the feelings of the patient,
and not with a view of compressing the
parts into a smaller space. In this man-
ner every vessel in the limb will be uni-
formly and effectually supported.

In respect to the time at which it will
be necessary to renew the applications,
that must be regulated by the quantity
of the discharge, for when applied in the
manner that has been described, they will
remain for weeks, or even for months,
without altering their position in the
least.

By adopting this mode of treatment,
an ulcer on the lower extremity is placed
precisely under the same circumstances
in respect to the circulation, as one that
has its seat on the trunk, or on the upper
extremity ; and will heal with equal
facility.

A gentleman residing near Chelmsford
consulted me on account of deep and
extensive ulceration in his leg. He
stated that some time ago he had knock-
ed the skin off his leg, and had taken no
notice of it. As the disease extended,
he applied to his medical attendant, who
treated it as Mr. Baynton has recom-
mended. The leg was therefore com-
pressed more forcibly in the middle by
the plasters than either above or below
the wound, where a roller only was ap-
plied. The inflammation consequently
extended both above and below them,
even to the bottom of the foot, attended
with great pain, ulceration, and vesica-
tion of the cuticle. I explained to a
very intelligent medical man, who was
attending the case, that a more exten-
sive and uniform application of the
plasters with less force would immedi-
ately remedy the bad effects that had
thus arisen ; and by adopting this sugges-

■

tion the inflammation was arrested, and
the ulcer healed with great rapidity.

A gentleman, seventy-four years of age,
grazed the skin off the calf of his leg
against the step of a hackney-coach. The
adhesive bandage was apphed for a short
distance above and below the wound ; it
occasioned pain and violent inflammation,
which, occurring in an unfavourable sub-
ject, and continuing for many weeks,
ended in very extensive sloughing. When
I was consulted on this case, the patient
was unable to bear the least weight on the
limb, or to rest at night, notwithstand-
ing the use of opiates. The leg was
swelled to an enormous size, the sloughing
had been arrested, but the sore was eight
inches in length, very nearly encircling
the limb, and was extending by ulcer-
ation. I treated this case in the manner
already described : after the third dress-
ing he became quite free from pain,
and was very soon able to walk round his

apartment ; the leg rapidly diminished in
size, the ulcer healed, and still remains
perfectly well.

Mary Blackmore, forty years of age,
applied to me on the 1st of December,
1825, with a scrofulous ulcer on the calf
of her leg j it was nearly as large as
the palm of her hand, and contained
several deep depressions occupied by
sloughs. The sore was very painful during
and after exercise, was increasing in size,
with ragged edges, and surrounded by a
thickened inflamed circumference of
considerable extent, and of a livid
hue ; there were no varicose veins. She
stated that the disease had been of eight
months' standing, that her mother died
of consumption, and that she herself
had been subject to scrofulous enlarge-
ment of the cervical glands. /\ bout twelve
months since, two tumours arose on the
anterior part of the leg, and broke in
about a fortnight after their first appear-

ance : she was confined to the recumbent
posture, and they healed in the course
of two montha. She had not resumed
exercise more than six weeks when she
felt pain in the calf of the same leg, which
increased, and a small swelling appeared
and broke. She had made use of poultices
and various applications during the last
six months; but the pain was unremitting,
and the ulceration continued to extend.

I supported the whole limb with the
emplastrum plumbi. My patient could
immediately walk on it firmly, and with
little pain ; the feeling of weakness and
inability to bear weight on the limb
being instantly removed, as well as a
distressing sensation of the ulcer being
opened by every muscular effort. The
surrounding redness and induration di-
minished ; and together with the pain
had entirely disappeared in about ten days.
Tlie ulcer assumed a healthy granulating
appearance, and the discharge, instead of
being offensive, sanious, and bloody, sooa
c 2

became inoiFensive and purulent In six
weeks from the time I first saw her, she
was- well enough to return to her occu-
pation, and this was accomplished without
her resting a single hour, or taking medi-
cine of any kind. She has since con-
tinued in active employment, the scar
remaining perfectly well, and the leg in
all respects as strong and serviceable as-
the other.

A lady residing at Rochester applied
to me some time ago, on account of two
scrofulous swellings in the calf of her leg ;
they had been of some montlis' standing,
and occurred at the same time with other
indurations in different parts of the body.
_ The latter were removed by the means

■ employed, but the former resisted every

■ method of treatment : the veins in the

■ leg were not varicose. I supported the
I whole limb in the manner already de-

■ tailed, and under this treatment the
B swelling rapidly subsided. Some months

afterwards I saw this patient, when she
continued quite well.

That deranged state of the circulation
which constitutes chronic inflammation
is attended with so great a diminution
of the power by which the blood is pro-
pelled through the capillaries, as to pro-
duce congestion. This truth, although
more obviously demonstrated in the
lower extremity, must necessarily prevail,
more or less, throughout the whole vas-
cular system. Although the congestion
thus induced so frequently keeps up
increased arterial action in the lower ex-
tremities, it is not adequate to produce
this effect in other situations (where its
operation is not favoured by gravitation),
unless the heart and arteries are in a state
of debility, either natural or acquired.

If, however, the power of the heart and
arteries is barely equal to maintain the
venous circulation in a natural state, it is
obvious that this power being reduced,
c 3

congestion will be the result. This will of
course commence in that system of vessels
in which the circulation is the least rapid,
and the propelling power the least con-
siderable — the veins — distention of
the arteries will be a necessary conse-
quence, and their increased action will be
thereby maintained.

Accordingly we find that in robust in-
dividuals chronic inflammation rarely if
ever occurs, except in the lower extremi-
ties, and that if inflammation be excited
iu those who are of a delicate habit, it
will almost always assume the chronic
form. As the cause, viz. congestion, by
which the inflammation is kept up,
operates less forcibly in the upper ex-
tremity, it is for a longer time confined
to the adhesive stage, in this situation.
By its continuance, however, the blood-
vessels become more debilitated, the in-
flammation is increased, and ulceration
ultimately produced.

In these cases, local bleedingcan only be
of service in relieving extreme distention,
but cannot enable the vessels to resume
a healthy action ; and if carried beyond
a very limited extent, it acts prejudicially
by debilitating the system. On the con-
trary, those remedies which have a bracing
and stimulating effect on the fibrous
structure are of great service.

From these considerations it would
appear that mechanical support may be
employed with advantage in the treat-
ment of chronic inflammation in the
upper as well as the lower extremity ;
and I can assert from ample experience,
that it is not less beneficial in one situation
than in the othei'.

In some instances the power of the
arteries is so greatly reduced by long-
continued disease, that mechanical sup-
port is not capable of enabling them to
resume their healthy action ; or they
may have become so habituated to the
performance of morbid action, that they
c 4

r 1

have no disposition to return to a healthy
state, even when their turgescence has
been mechanically removed. Sometimes,
from the situation of the disease, you
cannot afford it that depjree of uniform
support that would be effectual could it be
applied, — as in the testicle. In other
cases, the texture of the part itself pre-
cludes the operation of this mode of treat-
ment; as in disease of bone.

It is now universally acknowledtjed
that mercury has the power of subduing
inflammation ; that when the whole vas-
cular system is placed under the influence
of this remedy, inflammatory action sub-
sides. This fact is so fully established in
inflammation of the iris and of the cornea,
in which the zone of red vessels surround-
ing the latter disappear, and the deposit
of lymph, or the secretion of pus, are
arrested as soon as mercurial action is set
Up, that it is unnecessary to dwell on
the subject I have met with many
cftses of chronic inflammation in the tibia

and periosteum, in which mercury had
been given to sahvation with the effect
of relieving the intense pain, which re-
turned with increased violence as soon as
this remedy was withdrawn, and before
its effect upon the constitution had sub-
sided. In many of the cases this mode
of treatment had been frequently em-
ployed, and continued as long as the con-
stitution could sustain its in6uence, with
similar reUef, and succeeded by similar
recurrence of disease immediately on its
being discontinued. These cases occur
in those who are of a scrofulous consti-
tution, or in those whose powers have
been greatly reduced by debauched lives,
by repeated courses of mercury, or by
other causes. Here, the vessels of the
part are so debilitated that they are
unable to maintain a natural state of the
circulation, when the stimulus of mercury
is withdrawn. Every successive course
still further impairs the powers of the
system, and it is unable to recruit in the

intervals, because of the immediate recur-
rence of pain, which is so intense as to
deprive the patient of rest. If, however,
the disease can be arrested by any means
that do not debilitate the system, the pain
ceases, and the patient being relieved
from constant agony, is able both to sleep
and eat, and his constitution becomes
recruited with a rapidity scarcely credible.
By continuing the same means, the vas-
cular action in the part may be controlled
until the heart and arteries have acquired
sufficient power to maintain a natural state
of the circulation. It appears, that in
these diseases, although the internal ex-
hibition of mercury is productive of
temporary relief, it so greatly impairs
the already debilitated powers of the
constitution, as to be succeeded by an
aggravation of the disease. It is plain,
that in this way the disease cannot be
effectually removed. Mercury, however,
when locally applied, has the same power
of subduing chronic inflammation as when

internally administered, and this without
producing its constitutional effect ; hence
we may get all the beneBt without any
injurious effect. Whether mercury em-
ployed in this way really possesses the
power I attribute to it is a question of
fact which can be determined only by ex-
perience ; but it appears to me that there
is ample proof of the correctness of this
opinion, and I will relate a few of the
cases which have seemed to me decisive
of the question.

Mr. Alexander Gullen, residing at
Poplar, applied to me on the 10th of
March, 1826, on account of disease in
his left tibia, which was so much
swelled, that its anterior surface was
nearly on a level with the patella when
the knee was straightened. The tume-
faction extended for about two-thirds of
the length of the bone, and was as hard
and incompressible as the remainder of
it ; the tenderness was so excessive, that

he could not bear it to be touched, nor
could he walk without great pain.

His general health was much impaired,
his appetite lost, and he was much
emaciated. His bowels were regular, and
his tongue clean. He stated that, about
ten years before, the left tibia first became
painful and tender to the touch, after he
had suffered from rheumatic pains attack-
ing other parts of his body. He then
took mercury, whicli affected his mouth,
and gave him relief during the continu-
ance of salivation ; but the pain returned
as soon as this remedy was discontinued.
He had previously taken mercury in
considerable quantity for the relief of
former rheumatic attacks. At various
intervals during the last ten years he had
made use of mercurial friction, and its
internal exhibition, on account of the
disease in his left tibia. It had always
produced a partial and temporary allevi-
ation of the pain, which, however, never
once subsided entirely, but had invariably

returned with increased violence after
each course of mercury, as soon as it had
been discontinued, even before salivation
Iiad ceased. Leeches, fomentations, and
blisters, temporary and perpetual, had
been employed. His agony was at this
time so excruciating, thathenever thought
of going to bed at night, but was obliged
to sit up in a chair ; and he declared
that he did not get an hour's sleep in
a whole month. The moment he be-
gan to doze, he was awakened by pain.

I directed him to take sarsaparilla, and
supported the whole Hmb with adhesive
plaster, having previously covered the
diseased bone with a cerate composed
of uqual parts of the ceratum saponis,
P. L., and unguentum hydrargyri fortius
c camphora.

March the 22d, he states that the pain
continued, witli very little abatement, for
the first week afler his last visit, but that
he has slept about four hours each night
during the two last nights. Exhausted

r 1

30 ■

as he was, he would of course sleep very
soundly the moment the pani was allevi-
ated. By rest, as well as in consequence
of the diminution of pain, he feels much
stronger ; his appetite is also improved.
During the last two days the leg has
itched, and there is considerable redness
and irritation on the skin.

March 29. — He has been improving
in all respects during the last week ; his
appetite, strength, and spirits are re-
cruited ; his rest has been more sound)
and of longer continuance every night, and
he slept soundly the whole of last night.
The tibia is much reduced in size, and the
tenderness gone. From this date the
swelling on the tibia continued to sub-
side, he rapidly improved in health, and
has since had no return of the disease.

A case similar to the last was referred
to me by Mr. Holgate of Hendon, and
it affords me much gratification to adduce
his testimony in favour of the practice I

am anxious to recommend. Tliis was a
case of disease on the tibia, to the extent
of a crown piece, attended with swelling,
extreme tenderness, and so much pain as
altogether to deprive the patient of rest
during the night, and to incapacitate him
for using exercise during the day. It
was of three years' duration, and had re-
sisted every remedy that had been em-
ployed. Leeches, repeated blisters, tartar
emetic and mercurial ointments, were
used at different times with a partial
alleviation of the symptoms ; but the dis-
ease acquired increased severity at each
attack of more active inflammation to
which he was repeatedly subject. Al-
terative courses of mercury were pre-
scribed, both separately and conjointly
with sarsaparilla. It had also been pro-
posed to cut down upon the bone, and to
evacuate the fluid which was evidently
confined beneath the periosteum ; but
the patient would not consent to the
[ operation.

By pursuing the mode of treatment I
adopted in the last case, the symptoms
were as speedily relieved ; the fluid be-
neath the periosteum was absorbed, and
the disease completely eradicated. Wlien
I last heard from Mr. Holgate, the
patient had not had any return of his
complaint.

I could produce numerous instances of
the same kind to prove that these are
not isolated cases, but that equal success
will uniformly attend this mode of
treatment under similar circumstances.

In the beginning of May I was con-
sulted about a gentleman in this neigh-
bouihood, whose left testicle was some-
what swelled, excessively hard, and so
painful, that he could not sleep for five
minutes during the whole night. His
constitution was greatly exhausted by
pain, want of rest, and the quantity of
mercury and opium he had taken. He
informed me, that in the preceding
August, a few days after having returned

from Ireland, he was seized with pain in
the testicle, without any assignable cause,
and it became so violent as to confine
him to bed for three months. Leeches
were frequently applied, and he was
kept in a state of salivation nearly the
whole time ; he also took decoction of
sarsaparilla. At length the symptoms
so far subsided that he was able to
leave his bed, the testicle and spermatic
cord still continuing somewhat tender
and painful. He had not been out
of his house more than four times be-
fore he was seized with a similar attack,
more formidable than the former : he was
again salivated ; leeches, poultices, and
fomentations were again had recourse
to, and also sarsaparilla. Blisters and
tartar emetic ointment were applied to
the part ; but they aggravated his suffer-
ing. The salivation was kept up till
January, and attended with some allevi-
ation of the symptoms. Sarsaparilla and
alterative doses of mercury were then

given for a fortnight During this time
the pain, tension, and tenderness became
so much more severe, that he was again
compelled to undergo salivation, and was
at this time so exhausted that he could
not turn in bis bed without assistance.
About the middle of April the disease
was so far relieved that he got about two
hours' rest during the night, and the mer-
cury was now reduced to two-thirds of
the quantity he had previously taken.
In the beginning of May he was so far
recovered as to be able to take an airing
in a coach ; this exertion was followed by
a relapse of the disease, as he describes,
more severe than ever. On this occasion
I first saw him ; he was then suffering
agony, find his constitution was in a de-
plorable condition. Sarsaparilla was pre-
scribed, opium was discontinued, and the
scrotum was enveloped in flannel covered
with camphorated mercurial ointment.
The immediate eifect of this application
Was a glowing sensation of heat on the
surface of the scrotum, which was not

■ unpleasant. No relief of any consequence
was obtained until the fourth night, when,
to his great surprise, he had six hours'
sleep. This abatement of the disease
was succeeded by a sudden improvement
of his appetite, strength, and spirits: in a
week he left his bed ; and in a fortnight
the pain had wholly subsided. The
tension and tenderness gradually dimi-
nished, and after the employment of these
means for six weeks, the part was restored
to its natural state, and his health was
proportionally recovered,

Mr. S., forty-five years of age, residing
at Stratford in Essex, consulted me on
the 14th of August, 1826, on account of
a disease in the right testicle. On the
previous day he had applied to Mr. Self,
of Mile-end, who, fearing that disorgani-
sation of the part had proceeded so far
ythat extirpation of the gland would be
necessary, requested my opinion on the
case, and I also entertained great appre-
D 2

hension that the patient could not be
relieved from the disease by any other
means. The testicle was as big as a
cricket-ball, and extremely painful ; it had
suppurated, ulceration having taken place
to a considerable extent, and the surface
had assumed a fungoid character, the
protrusion of which resembled in size
and figure the longitudinal section of a
hen's egg. The sore was foul and un-
healthy, with several superficial sloughs
adhering to the surface ; the discharge was
watery and offensive, and excoriated the
whole of the scrotum. He had latterly
become much emaciated, his health and
strength being greatly impaired by the
disease and by want of rest. In June,
1825, he first felt pain and uneasiness in
the testicle, but it was somewhat relieved
by the application of a cold lotion. In
the following October he was affected in
a similar manner, and was again relieved
by the application of leeches and a cold
lotion, and some medicine. In February,

1826, he had a much more severe attack
than either of the preceding. He suffered
intense pain in the testicle, which was
much swelled and exceedingly tender,
with considerable redness and heat of the
part. He again had recourse to the
means that had been previously employed,
and tlie violence of the symptoms was
at first abated ; but subsequently the
complaint became rather worse. In the
following June he received a blow on the
part, which caused great pain, swelling,
and a violent aggravation of the symp-
toms : leeches, together with other reme-
dies, were again employed, and one of
the leech-bites idcerated. The sore thus
occasioned spread, and a fungus rose from
the surface, which from that time had been
gradually increasing in size. I prescribed
sarsaparilla, the surface of the fungus
was covered with lint wetted with black
wash, and the scrotum was enveloped in
a piece of flannel covered with mercurial
, ointment, and was supported by a bandage.
D 3

August 28th. His general health is
much improved, the fungus is diminish-
ed, its suiface has become clean and
healthy, and the discharge is thick
and purulent. The testicle is reduced
in size, and the scrotum no longer ex-
coriated. The mercury has not prO"
duced the least constitutional effect.
The same means were continued under
the superintendence of Mr. Self, and pro-
duced a gradual subsidence of the en-
largement of the testicle and of the
fungus, the sore being contracted in the
same proportion. By the latter end of
October the sore was perfectly healed,
the testicle reduced to its natural size,
^L and the patient's health completely

H teatored. The constitution was not at

H any time sensibly under the influence of

William Skingley, thirteen years of
age, of a scrofulous habit, came to me
from Brentwood, on the 23rd of May,

1827, with a complaint in his left eye.
The conjunctiva was inflamed, swelled,
and elevated by the deposit of lymph
in its testni'e, overlapping the margin
of the cornea; at the angle of its reflec-
tion from tlie globe it was much swelled,
lying in large folds, which distended the
palpebrte. There were two large ulcers
in this part of the conjunctiva, one at the
upper and one at the lower margin of
the orbit, three-fourths of its breadth,
leading down to the bone. The cornea
was rendered so opaque by the deposit
of lymph, organized with red vessels, on
its conjunctival surface, that he could
scarcely discern my fingers when held
between him and the window. In the
beginning of June, 1826, he had an
inflammation of the lachrymal sac, which
continued for three weeks before suppur-
ation took place ; it then broke, and after
having remained open for nine months,
the tears escaping at the orifice, it
healed. Immediately after the wound

Was closed, the conjunctiva inflamed and
became gradually swelled and thickened,
lying in large folds between the globe
and palpebrje which it protruded. After
a time a thick matter was discharged
from the eye, and vision was obscured.

In this case, as the constitution of the
patient was too weak and irritable to
allow of the internal use of mercury, I
made trial of various modes of treatment
for seven weeks, which afforded him
scarcely any relief I then directed him
to keep some mercurial ointment on a
piece of flannel constantly applied to the
closed palpebrse, and to continue the car-
bonate of iron wliich he was taking.
After he had used this application for a
week, the conjunctiva was rather paler
and less tumid, and he thought that his
vision was improved. In the course of
another week there was a decided amend-
ment. After pursuing this mode of treat-
ment for two months, the ulcers were
healed, the lymph deposited beneath

and in the substance of the conjunctiva
was absorbed, the cornea had become
quite transparent, and be could see to
read as perfectly as with the other eye.
The only difference that remained be-
tween the two eyes was a slight drooping
of the upper lid, an increased redness of
the conjunctiva, and an adhesion of the
lower lid to the margin of the orbit at
its nasal angle.

Mary Ann Waldon came under my

care at the London Hospital, on the 10th

of October, 1827. The gums and the

inside of the cheeks and lips were covered

I with small unhealthy idcers, about the

I size of a sixpence, extending by ulcer-

I ation, with ragged edges and inflamed

I circumference. The uvula and sofl palate

m had been destroyed by the same disease,

I which was extending by ulceration. There

■ were small ulcers in the same state on

B the upper and under surfaces of the

brane beneath it. The ulcers were so
sore and painful, that she was obliged to
take the fluids she swallowed luke-warm.
Her appetite was good, and her bowels
regularly opened. She informed me,
that above a year before, she was first
affected with a sore throat, and about a
fortnight afterwards the disease extended
to her mouth and tongue. From that
time the complaint had continued, occa-
sionally better and worse, but with little
variation ; for as soon as one ulcer healed,
another broke out in its vicinity, so that
she had been unable to swallow solid
food for a twelvemonth. During this
time she had taken various medicines,
and mercury to salivation twice.

I directed her to take sarsaparilla, to
gargle her throat with the black wash
(taking care not to swallow it), and to
keep the sores covered with lint wetted
in the same lotion as constantly as pos-
sible. After using this application for a
week tlie sores were less inflamed, the

pain and tenderness were diminiabed.
In a fortnight they had thrown off their
central sloughs, and had become healthy
and free from pain ; and after pursuing
this treatment for two months, the throat
and the sores in the mouth were entirely
healed.

Abraham Chipp, a carpenter, thirty-
six years of age, applied to me at the
London Hospital, on the 28th of No-
vember, 1827. He was at that time af-
fected with several small ulcers on the
chin, upper lip, and nose, extending
within the al^ nasi, more particularly on
the right side, on the surface of the nose,
as far as the termination of the ossa nasi,
and on each cheek nearly to the lower
edge of the orbit. These sores were
I bounded on one side by an elevated in-

I durated margin, very tender, and ia

I great pain, which was increased by ex-

I posure to cold ; on the other side they

were circumscribed by a seam or a de-
pressed cicatrix.

He stated, that about sixteen months
ago, a pimple arose on the left ala
nasi, which he scratched ; it suppurated
and extended by ulceration across the
nose, and within the ala; nasi. As the
structure of the skin became destroyed
by ulceration, the sore healed on one
side, but extended in the opposite direc-
tion, and it had continued to pursue
this course from the time of its com-
mencement. Subsequently, the chin and
upper lip became affected with a similar
disease, which produced the scars and
seams now visible on them. His digestive
organs showed no sign of disorder. This
disease presented so much the appearance
of an inveterate form of lupus, that I
did not expect it could be arrested by
tlie mild remedies I am about to mention.
Having so repeatedly witnessed the good
eifect of the treatment pursued in the
last case, I directed this patient to keep

I Dial

the part constantly covered witli lint
wetted in the black wash ; and to take
sarsaparilla, Finding immediate relief
from using the lotion, he kept it con-
stantly applied day and night. It was
attended with a gradnal subsidence of the
pain, induration, tenderness, and ulcer-
ation. In three weeks from the time I
first saw him, the sores were healed, and
now {December 26th) there is not the
slightest appearance of diseased action.

From experience in many cases analo-
gous to those I have related, I am led to
conclude that mechanical support alone is
capable of arresting chronic inflam-
mation in many instances ; that in others
it may favour and expedite the subsi-
dence of disease which it has not the
power to remove. In these latter in-
stances, mercury locally applied is ca-
pable of controlling the diseased action
as effectually as it arrests acute inflam-
mation when internally administered.

Mechanical support, too, by i-elieving vas-
cular distention, favours the operation of
the above remedy as effectually as un-
loading the vessels by bleeding.

In all cases of chronic inflammation
when the situation of the part renders it
practicable, I am in the habit of combining
these two agents ; they are both adapt-
ed to the same state of disease, and it
subsides most rapidly when subject to
their conjoined influence. At the same
time it is necessary to obviate constitu-
tional disorder, and to invigorate the
heart and arteries by the means detailed
in the subsequent part of this work.

These observations equally apply
whether the- inflammation has proceeded
to ulceration or not. In the former, the
exposed surface is of course more suscep-
tible than wlien defended by a cuticle.
The rapidity with which a foul unhealthy
sore, with a sanious discharge, may be
rendered healthy, and thematterthick and
purulent, by this practice, is astonishing.

I must, however, confine myself to the
following examples of its eificacy. Were
Ito recite the caseslcould adduce, I should
far exceed the limits assigned to this part
of the work, which is intended merely to
elucidate the treatment described in the
following essay.

To enter fully into the subject of ul-
cerative inflammation, is also foreign to
my present purpose. I would, however,
observe, that the foregoing treatment
will be found applicable to the majo-
rity of scrofulous ulcers. The black
wash is the application most generally
adapted to them ; sometimes it is advan-
tageous to wash the sore with a solution
of the oxymuriate of mercury, or of ■
lunar caustic, at each time of dressing.

With regard to common ulcers (whe-
ther varicose or not), when of very long
standing, the vessels are sometimes so
weakened by the continuance of disease,
that the moderate support I have re-
commended does not enable them to

contract upon their contents. In these
cases, stimuli are necessary. This effect
may be produced by more forcibly com-
pressing the part, in a degree productive
of pain on the first application of the
plaster, but after a short time rendering it
easier than before. Were the limb to be
encircledwith this degree of tightness, the
circulation through the large venous
trunks would be impeded, and the in-
flammation thus aggravated. In order,
therefore, safely to compress the vessels
of the part inflamed with that degree of
force which shall produce upon them the
effect of a powerful stimulus, the plasters
used with this view must only extend to
half the circumference of the leg, and a
short distance both above and below the
seat of the inflammation. Externally to
these, the whole limb must be supported
in the manner already explained. This
modification, however, is rarely neces-
sary, and should only be applied to ulcers
of small extent, which the more mode-

rate and uniform support has failed to
relieve. With the same view, the lunar
caustic applied in substance to the part
is very serviceable, and will be found a
very useful adjuvant to this mode of ap-
plying the plasters. These means I find
so successful, that I rarely have recourse
to any others for the cure of ulcerative
in6ammation.

I transcribe the following letter from
my friend Dr. Farre :

" Pentonville, Nov. 10. 1827.

*' Dear sir,
" Mrs. P. consulted me on the Ist of
June, 1 827, for an irregular swelling
situated obliquely above, and a little
over the internal condyle of the hu-
merus, resulting from chronic inflamma-
tion, and rendering the elbow joint
nearly immoveable. Its size might be
equal to the one-half of the longitudinal
section of a hen's egg. Her husband, a

surgeon, informed me, that its formation
gradually commenced after the sudden
disappearance of a moveable tumour,
about the size of a pigeon's egg, seated
over the left gluteus maximus, which had
been stationary for twenty years. I pre-
scribed a draught of the compound de-
coction of aloes every morning, a grain
of the subnmriate of mercury, with a few
grains of the aloes and myrrh pill every
third night; the opiate plaster for the
swelling, and an issue in the arm. This
prescription, with the exception of the
issue, was carried into effect, and on the
18th of the same month, I had the plea-
sure of observing, that her general health,
which had declined, already manifested
an improvement, and that the swelling
was sensibly diminished.

" Persuaded that an attention to the
localities of the case, by removing the
constitutional irritation, would materially
contribute to her cure, I sent her to
you, and on the 5th of November in-

staiit, when Mrs. P. consulted me again,
I had the pleasure to find, that under your
local applications the swelling had dis-
appeared, and that she has a little mo-
tion of the joint, which may probably be
considerably increased. But there is yet
some pain occasionally felt about the
joint, brought on by motion or change
of weather. The easiest posture of the
limb is when the fore-arm is laid on the
table, so as to relax all the muscles.
" I remain, dear sir,

" Your faithful servant,

« J. R. FARRE."

A young woman from Camberwell
consulted me about a strumous disease
in her left breast. It was considerably
enlarged, thickened, and indurated, with
a somewhat elastic feel : several deep
sinuses led into the substance of the
breast. The disease originated in milk
abscess three years before. She was weak,
and very thin. She was directed to take
E 2

some bark and sulphuric acid. The
breast was covered with mercurial oint-
ment thickly spread on lint, and exten-
sively supported by adhesive plaster, and
a calico bandage. By the use of these
means the disease was rapidly arrested,
the induration and enlargement disap-
peared, and the sinuses healed in about
two months from the first dressing.

A gentleman residing in Jewin Street
consulted me in December, 1823, for a
disease in the left fore-arm. There were
ten ulcers of a scrofulous character, in an
unhealthy condition, with small sloughs
on the surface of the sores, which were
surrounded by considerable induration of
the cellular substance. The absence of
pain showed the indolence of the dis-
ease. He was in feeble health. About
four years before this he was thrown out
of his gig, and fractured the olecranon of
this arm. Some time afterwards he first
perceived a small lump at the lower end

of the ulna on its palmar side. In two
or three weeks it broke and continued to
discharge, but without pain. This was
succeeded by similar swellings without
pain, which broke and discharged in the
same way ; they did not heal, but re-
mained foul, unhealthy, and indurated
round about them. Other tumours ap-
peared and broke, leaving unhealing
ulcers ; and this process had been going
on for four years when I first saw him.
He had already tried poultices, various
kinds of plasters, black wash, a sea-side
residence, sarsaparilla in large quantities,
and various other remedies. The effect
of the plaster bandage, the sores being at
the same time covered with lint dipped
in the black wash, was most striking. In
siK weeks from the first application of it
all the ulcers had healed, and remain so
to this day. The only medicine I gave
him was one he had taken before, — the
powder of sarsaparilla.

E 3

Henry Frost, twenty-seven years of
age, residing in Brunswick Street, Poplar,
applied to me on the 27th of Decemher,
1826 ; at this time there were five nleeia,
each as large as a shilling, on the anterior
part of the head of the tibia. They were
in a foul unhealthy condition, presenting
a scrofulous appearance, with a small
slough adhering to the surface. There
was a small tumour on the inner condyle
of the femur, and another on the outside
of the thigh. He suffered so much pain
from the ulcers, that he could scarcely
walk upon the limb, and had been obliged
to give up his employment ; but he de-
rived no benefit from resting the limb.

He stated, that about three years and a
half before, he first perceived in the
situation of the ulcers a tumour about the
size of a walnut, which continued for
three years without occasioning any pain.
It then increased in size and broke ; sub-
sequently the skin gave way in the
situation of the remaining ulcers. The

tumour on the condyle of the femur, and
that on the outside of the thigh, had
been of about two months' continuance;
they appeared at the same time, and had
been gradually increasing in size, but un-
attended with any pain. He was directed
to take a drachm of tlie powder of sarsa-
parilla twice a day. The limb was sup-
ported by means of the emplastrum
plumbi, and the sores were covered with
lint wetted in the black wash, and the
tumours with camphorated mercurial oint-
ment.

December 29. The first application
has afforded him great ease ; he is entirely
free from pain, even when walking on
the limb. The inflammation surround-
ing the ulcers is much diminished, and
the tumours are also reduced in size.

January 3. He has felt nothing of the
ulcers since his last visit, and can use the
limb without the least pain : the surround-
ing integuments are quite pale ; the dis-
charge, which was thin and watery, is now
E 4

thick and purulent; and the ulcers are
filled with healthy granulations.

January 8. The indurated tumours on
the inside of the knee and on tlie thigh
are absorbed, and the ulcers are much
diminished in size.

January 15. The ulcer on the outside
of the leg is healed, and those which re-
main are closing rapidly.

January 22. The sores are entirely
healed, and the limb is quite restored to
its natural state.

A young man, twenty-Seven years of
age, living near Waterloo Bridge, con-
sulted me on the ninth of November,
about a disease in his right leg, in which
there were eighteen ulcers ; the largest,
situated over the inner ankle, measured
three inches in width, andfive in length; the
smallest was about the size of a sixpence.
They were foul and unhealthy, with cen-
tral sloughs and ulcerating edges, and a.
sanious offensive discharge, sometimes

mixed with blood. The leg was much
swelled, in such constant pain that he had
not had a good night's rest for six months,
and the ulcers were surrounded by a
thickened margin, of a livid red colour.

The disease had been of two years'
duration, and originated in an abscess
which formed on the anterior part of the
tibia. This was succeeded by similar
formations of matter in various parts of
the leg, which broke and continued open.
The last abscess occurred about a year
ago, and they had all continued to dis-
charge from that time. He was much
reduced in strength, and had lost flesh con-
siderably.

I prescribed sarsaparilla, covered the
sores with lint dipped in the black wash,
and supported the whole limb with the
adhesive plaster and bandage. This
mode of treatment afforded him imme-
diate relief; after three days the pain had
entirely subsided, and he could rest as
well as ever. The sloughing and ulcer-

atioii were arrested, healthy granuiations
rapidly sprung up, and secreted a good
purulent discharge.

December 4. He has had no return
of pain ; the sores, which have been gra-
dually diminishing In size, are now all
liealed except the two largest, and these
are reduced in dimensions more than one
half.

December 28. The sores are now en-
tirely liealed ; he is much improved in
health, and has walked from his residence
at Lambeth to the city, and back, every
day since he has been under my care.

A gentleman of very delicate habit was
under my care with a gonorrhoea, which
produced sympathetic buboes, and shortly
after their subsidence he had a severe
attack of fever, which greatly reduced
his powers. Very soon after the fever
was subdued, the glands in the groin
became again enlarged, very painful, and

.59

exceedingly tender, so that I appre-
hended they were about to suppurate.

In this case the inguinal swellingwas re-
produced without any local cause, solely
by the want of sufficient arterial power
to maintain a free course of the circu-
lation through a weakened part. As the
inflamed vessels were gorged with blood,
at the expence of the rest of the vascular
system, which was barely supplied with
asufficientquantity to maintain its action
(for he fainted during my visit), I con-
cluded that the former would not be un-
loaded by withdrawing blood from their
vicinity, which would therefore still fur-
ther impair his exhausted strength.

I therefore directed him to take the
sulphate of quinine, and having covered
the tumour with the cerate, made with the
ceratum saponis and unguentum hydrar-
gyri cum camphora. in equal proportions,
I supported the part uniformly and ex-
tensively with the emplastrum plumbi,
and a bandage passed alternately around
the thigh and loins.

He became quite free from pain in a
few days after the applications were put
on, and continued to improve so much,
that I did not see him again for a fort-
night. The pain and tenderness were
then quite removed, the swelling much
reduced, and his health greatly recruited.
I renewed the dressings, and on their re-
moval, at the expiration of another fort-
night, the swelling was entirely absorbed,
and he could use the limb as perfectly
as ever.

A young man living in Fore Street
applied to me on the 27th of October
with the glands in the right axilla in a
state of chronic inflammation. They
were swelled, tender, and painful, and one
of them bad suppurated, but it bad not
burst.

He informed me that about two months
before, he had a punctured wound in his
finger, which produced inflammation in
the course of the absorbents, and a small

abscess occurred about the middle of the
arm. This burst, and after a time it
healed, the axillary glands having become
enlarged during the time it remained
open.

I directed him to take some bark and
soda, and pursued the same local treat-
ment as in the last case. The applica-
tions were renewed every fortnight for
six weeks, at the expiration of which
time, the matter in the softened gland
had become absorbed, and the swell-
ing of the remainder had entirely dis-

A little boy, six years old, was brought
to me from Kingsland on the 10th of
December, 1827, with an enlarged ab-
sorbent gland in the right groin. It was
swelled to the size of a hen's egg, ex-
tremely painful and tender, with exten-
sive superficial redness, threatening sup_
puration. His mother told me that her
attention was directed to the part, by his

complaining of great pain three or four
days before, wlien she found a lump as
large as the top of her thumb, and it had
since increased with great rapidity.

Some time before, he was under my
care with a disease In the left knee (see
case the sixth), which continues quite
well.

Not being able to discover any cause
for the inflammation of the gland, I be-
gan to apprehend that it miglit be sym-
patheticwith incipient disease in the right
hip (of which however I was unable to
discover the slightest evidence) ; it was
then mentioned, that he had had a little
sore on his great toe for some time,
which originated in a chilblain.

I made use of the same local applica-
tion as in the last case, and prescribed
an occasional dose of calomel and rhu-
barb.

December 18. He has not complained
of the slightest pain since the second day
after I last saw him, and has been able to
take his accustomed exercise.

The swelling is reduced more than one
half in size ; the pain and tenderness are
gone. The applications are renewed.

December 26. He has had no return
of pain, and there is now scarcely a ves-
tige of the swelling.

It appears to me that the foregoing
cases, which are only a small part of
those which I could produce, are amply
sufficient to prove, that, when chronic
inflammation is going on in any texture,
or in any part of the body to which local
remedies are applicable, the local treat-
ment, so far from being of the least, is
of the greatest importance, and that the
most effectual remedies of this kind are,
mechanical support, and the local appli-
cation of mercury.

I now proceed to consider the em-
ployment of these remedies in a more
formidable class of affections, — namely,
the diseases of the joints.

DISEASES OF THE JOINTS.

The term white-swelling was once in-
discriminately applied to most of the
chronic enlargements of the joints. It is
now well known, that, however similar
they become in their latter stages, the
disease originates in different structures.
But it is often impossible to distinguish,
from the appearance presented at an ad-
vanced stage of these diseases, which
structure was primarily affected ; and the
diagnosis chiefly depends on what in-
formation we can collect about the pre-

vious symptoms and progress of the com-
plaint. This want of distinction, however,
is of less practical moment than might
have been supposed; thedisease, although
modified by the structure in which it is
seated, essentially consists in chronic in-
flammation, and its consequences. Hence
the same principle must regulate our
treatment in each form of these diseases ;
the practical object is to proportion the
activity of the treatment to that of the
disease, and this will be indicated by the
urgency of the symptoms, in whichever
structure disease is going on.

Although disease may begin in any of
the component parts of an articulation, it
may ultimately involve the whole. Mr.
Brodie has shown that there are three
parts in which these diseases commence;
the synovial membrane, the articular
cartilages, and the cancellous structure
of the bones : but textures so intimately
connected soon participate in diseased
action, and the disease, although simple

in the beginning, becomes more or less
complicated in its progress. The knee
and hip joints are more frequently the
seats of disease than the other articula-
tions of the body. I have therefore se-
lected them as the subject of the follow-
ing description, only remarking, that what
is true about theise larger joints, is true
also of others on a smaller scale.

P 2

DISEASE ORIGINATING IN THE SYNOVIAL
MEMBRANE OF THE KNEE JOINT.

When disease begins in the synovial
membrane of the knee joint, the inflam-
mation in general is not very acute ; it
pursues its course slowly, but ultimately
extends to the contiguous parts. It sel-
dom attacks children or old persons, and
is most frequent about the adult period of
life. The symptoms which characterise
it, and the order in which they occur, are
as follows ; stiffness of the joint, which is
greatest in the morning, and diminishes
after exercise (because the synovia, which
issuppressed by inflammation, ispromoted
byalittle exercise; yet the exercise, though
it may appear to be useful, is actually in-
jurious, for the joint is better after a day
of rest than of exertion), pain on moving
the joint, — tenderness, — at length pain
even when the joint is at rest, — tumefac-
tion of the joint, at first only a general ful-

ness, but soon more considerable, chiefly
prominent on each side of the Hgamen-
tum patellae, subsequently causing an ele-
vation of the tendon of the rectus femoris,
— fluctuation in the joint ; about this time
a partial and temporary alleviation of the
inflammatory symptoms, — pain greatest
at night, and chiefly referred to a spot
between the inferior edge of the patella
and the head of the tibia. As the disease
advances, the fluctuation is less distinct.
Now, the motions of the joint are more
limited, and the leg cannot bear to be
extended ; hence, the patient keeps the
limb half bent : tlie skin surrounding the
joint is so pale as to have given it the
name of white-swelling, and shows to
what an extent the blood has retreated
from the surface to the interior of the
joint ; it is also so distended by the swell-
ing as to assume a shining appearance.
Hence also the natural depressions of the
surface of the joint are filled up, giving
it an oblong spheroidal shape : there is a

F 3

sense of internal heat within the joint, the
remainder of the limb being chilly and
wasted, making the enlarged joint look
larger than it really is. This depends
not only on a wasting of the muscles
from disuse, but on a non-deposition of
fat, the supply of which is cut off by the
great excitement going on in the neigh-
bouring joint; sometimes the inflamma-
tion having begun and advanced slowly,
will be suddenly rendered more acute by
a blow, or disorder of the health. As the
disease advances, the internal heat, the
external swelling, the limitation to the
motion of the joint, the pain on moving
it, or resting on it, all become greater.
The pain in many instances is so violent
as to deprive the patient of sleep ; great
constitutional irritation arises, and often
spasmodic contractions of the muscles
of the affected limb. These are exceed-
ingly distressing, and occur chiefly when
the patient has relapsed into a doze, and

thus has lost all voUintary control over
the muscles.

Such are the symptoms, and their pro-
gress, when inflammation begins in the.
synovial membrane of the joint.

Whilst the above symptoms, in the
above order, have been indicating the
progress of disease, the following are the
changes which have been going on in the
internal structure of the joint, as far as
they can be inferred from the symptoms,
or have been detected by dissection.

The disease begins in that part of the
synovial membrane which does not cover
the articular cartilages, and consists of
the following changes, in the following
order : an increase in the vascuhirity of
the membrane; diminution of its se-
creted fluid ; slight swelling of the mem-
brane ; after a little time, an effusion of
an unnatural quantity of fluid into the
joint; a deposition and organization of
coagulable lymph, limiting more or less
the motion of the joint. Sometimes large
'f 4

masses of lymph are deposited, of" an ob-
long form, which adhere to the inflamed
membrane only at one extremity ; but in
most instances the inflammation is more
equally diffused, and the lymph adheres
to the whole inflamed surface ; thicken-
ing of the synovial membrane, and of the
cellular substance exterior to the capsular
ligament, constituting a soft pulpy mass,
often agglutinated to the skin. This
sometimes renders it difficult to detect
fluid within the joint.

When the changes that have been de-
scribed have taken place within the joint,
the disease, sometimes, by palliative treat-
ment, has become stationary, and the pa-
tient,keeping his limb at perfect rest, com-
paratively easy. Slowly, however, the dis-
ease advances, and at length ends in ulcer-
ation, which generally extends to the arti-
cular cartilage of the tibia before that on
the femur is at all affected. Next, caries
extends to the extremities of the bones ;
the whole cavity of the joint is in a state

of suppuration, attended with so severe
an aggravation of all the symptoms, that
too frequently the patient falls a victim
to the disease. The commencement and
advance of ulceration are attended by ex-
cruciating pain J but when suppuration
has taken place, there is often some alle-
viation. Thus this period of the disease
may be marked by a slight diminution in
the pain, with an increase in the bulk of
the joint ; yet this is not always the case :
sometimes the progress of inflammation
and ulceration, together with an enor-
mous distention of the joint, prolong the
suffering, which does not abate until the
joint bursts and its contents are evacu-
ated.

The articular cartilages being destroyed,
and thus the extremities of the bone de-
nuded, as long as the morbid action con-
tinues, the process of reparation cannot
begin. If it was difficult to arrest the
disease before, it is still more so now,
with an increased local disease, and a di-

minution of constitutional power, with
hectic fever. If the diseased action can
be arrested, anchylosis may be accom-
plished. In most instances, however,
the extremities of the bone have becoine
soft, and not so well calculated to deposit
bone as in their natural state. Thus the
great obstacles to anchylosis in this ad-
vanced stage of the disease are, the con-
tinuance of morbid action, softness of the
hone, and a debilitated system. Occa-
sionally, the disease, having destroyed the
cartilages, stops, and does not extend to
the bones, leaving them hard, polished,
and grating during the motion of the
joint.

Not unfrequently disease of the syno-
vial membrane is much more gradual and
insensible than the process above de-
scribed, for a long time being indicated
by no other symptoms than a trifling
enlargement of the joint, with slight stiff-
ness and slight tenderness on pressure,
or on extending tlie leg, and it will go

on in this indolent state for a very long
time. At length there appears a gradual
increase of the swelling, with an undulat-
ing feel to the touch, not from effusion,
but from thickening of the synovial mem-
brane ; the motion of the joint becomes
limited, partly from deposit, and partly
from pain ; the limb becomes contracted,
the surface of the joint pale, with a slight
aching at night. In this state a diseased
joint will often remain stationary a long
time, sometimes ultimately advancing
very slowly, but in other cases suddenly,
assuming a more active form, and becom-
ing the formidable disease which I have
described above. The two forms of dis-
ease already described have a common
cause, and also a common termination,
that is, the destruction of the joint. This
takes place in both cases in the same
way, so that, from the appearances of the
latter stages, it is impossible to say whe-
ther it began in the more or the less acute
form.

The causes of this disease are various.
In many instances it is produced by me-
chanical violence ; slight, perhaps, in its
effect in the first instance ; but the daily
exertion of the limb keeps up the inflam-
mation in the synovial membrane, till it
continues even though the joint is rested.
Fever appears sometimes capable of pro-
ducing acute inflammation of the syno-
vial membrane ; at least, when the con-
stitution has been affected by long-
continued excitement, this form of dis-
ease sometimes occurs. Cold, also. Is one
of its exciting causes, but I think seldom,
unless the constitution has been previ-
ously disordered. A loose cartilage in
the joint sometimes occasions it ; likewise
when joints have been weakened by acute
rheumatism, this state sometimes termi-
nates in inflammationofthesynovial mem-
brane. When the constitution has been
debilitated by the long-continued use of

mercury, cold will not unfrequently oc-
casion inflaramation in a joint, and this
may begin in the synovial membrane.
It may occur also in that feeble state of
health left by small-pox, or other eruptive
fevers ; but in all these cases, the state
of the constitution seems only the pre-
disposing cause, for the commencement
of the disease is generally, and appar-
ently with reason, attributed to exposure
to cold, or some mechanical injury.
The state of constitution, however, in
which this disease, when once set up, is
most liable to run the course I have de-
scribed above, is that which is called the
strumous.

DISEASE BEGINNING IN THE SPONGY EX-
TREMITIES OF THE BONES.

Disease may begin in the cancellous
structure of the bones, and be propagated
gradually to the cartilages, and to the
synovial membrane, of the joint; it
occurs most frequently in children, and
is rare after the body has arrived at ma-
turity. Those are most liable to it who
have a strumous constitution ; but this
may prevail in various degrees: it
may be so slight as to show itself only
when the health has been impaired by
long illness, or it may prevail in so great a
degree as to manifest its influence even in
ordinary health ; thus in some children,
the cervical glands will swell, although
their looks, feelings, and appetite indicate *
no falling off of the health. This form of
disease is very generally either accom-
panied or preceded by other scrofulous
symptoms, and is so insidious in its com-

mencemcnt as frequently to escape ob-
servation, until it has made considerable
progress. When occurring in children, it
very often is not observed at all, until
they are unable to walk without limping,
and on examination the joint is found to
be enlarged. The first symptom usually
complained of is an occasional obtuse
pain, deeply seated in the articulation,
and unattended by any swelling at the
commencement. This symptom, how-
ever, is neither constant nor considerable,
from the circumstance of the diseased
action being carried on very slowly, and
in a structure but sparingly supplied
with nerves. A feeling of weakness in
the joint is also complained of, and a
degree of fatigue after exercise, greater
than that which is experienced in the
corresponding limb : the pain Is alto-
gether inconsiderable, and is not imme-
diately increased by moving the limb in
any direction ; but the stiiFness and in-
convenience are more perceptible in the

evening of a day in which the limb has
been much used, and the joint is at this
time somewhat fuller and larger than
natural. This fulness arises partly from
the secretion of an increased quantity of
synovia, and partly from slight swelling
of the soft parts, and subsides after a few
hours' rest. The joint will allow of com-
plete flexion and extension, is not tender
to the touch, nor is there in the first in-
stance any effusion into the adjacent
structures. When the disease has ex-
tended to the periosteum, the pain be-
comes somewhat, but not materially
increased ; the joint is enlarged, and the
patient limps in walking ; the swelling
presents the appearance of an enlarge-
ment of the bones themselves, retaining
to a great degree the natural shape and
figure of the articulation, and affording a
firm and somewhat elastic feel to the
touch. The skin assumes an unnaturally
white appearance, which it retains
throughout a considerable period of the

disease. Subsequently, the soft parts
become tender and more considerably
swelled. In the early stages the chief
tenderness is just on the condyles of the
thigh bone, while no uneasiness is felt on
pressing the other parts of the joint
The periosteum and superjacent cellular
membrane sympathise with the disease
in the bone almost invariably before the
cartilages and synovial membrane of the
joint. The swelling is confined to the
soft parts covering the extremities of
the bones, in the present stage of the
disease ; the joint appears to be wider
than natural when viewed anteriorly, and
presents a very different appearance
from that which arises from disease com-
mencing in the synovial membrane.
From the wasting of the limb, the swell-
ing of the joint appears to be greater
than it really is. Wlien the disease has
extended to the cavity of the joint,
the motions of the limb become limited
and attended with pain, particularly in

the extension of the leg, so that the
patient keeps it bent to a certain degree,
and walks on his toes. But the pain,
swelling, and tenderness are by no means
so considerable as when the synovial
membrane is the primary seat of disease.
When it has extended to the soft parts,
it proceeds rather more rapidly than be-
fore ; coagulating lymph and fluid be-
come effused into the cavity of the joint,
as well as into the substance of the
synovial and cellular membranes. These
effects take place in general without any
pain, except on motion, and are attended
with little constitutional excitement.
Before suppuration has taken place with-
in the cavity of the joint, abscesses ge-
nerally form in various parts of the
cellular membrane, communicating with
the surface of the bone. When the dis-
ease has arrived at this stage, it not un-
frequently assumes a more aggravated
form. Ulceration proceeds with com-
parative rapidity, attended with more

considerable pain, and suppuration is
established in the cavity of the articula-
tion. When ulceration and suppuration
are about to take place, the disorder of
the general health becomes more consi-
derable than it has been during the
former periods of the disease. Not that
there is now any violent constitutional
disturbance ; but a dry feverish heat is
felt on the surface of the body ; the
powers of the stomach are impaired ;
great disinclination is felt both to take
food and exercise ; the appetite is often
depraved, as well as defective ; the bowels
are generally costive ; and the patient be-
comes weak, languid, and emaciated.

If the position of the Hmb be not par-
ticularly attended to, it will frequently
become contracted, and in some cases
this will increase until it becomes fixed
at a right angle with the thigh. In
other instances, the leg will be even dis-
located upward and backward by its
Q 2

powerful flexors, so that the condyles of
the OS femoris form a considerable pro-
jection beyond it. When the disease
has arrived at the latter stages, the pa-
tient is very much distressed by spasmo-
dic contractions of the muscles on the
affected limb, when he loses control
over them in falling asleep ; the pain is
also more severe at night. When the
constitution is highly disposed to scro-
fula, or when, this disposition existing
in a minor degree, its powers have
been reduced by previous disease ; it fre-
quently occurs, that a sufficient propor-
tion of phosphate of lime is not depo-
sited in the bones to enable them to bear
the superincumbent weight, and to resist
the action of the muscles inserted into
them. This state is more frequently
manifested in the spongy extremities of
the bones than in their more compact
structure.

Although the soft parts of the body
may be imperfectly developed, and

nourished in an inadequate degree with-
out giving rise to disease in them from
the absence of exciting causes, a defi-
ciency of earthy matter in the bones
renders them liable to be inflamed by
mechanical causes, which could not pro-
duce any ill effect, were they of their
natural firmness. The disease in general
arises without any assignable cause, and
often occurs in several joints at the same
time ; which latter circumstance proves
that it must be attributable to a cause
influencing simultaneously all the joints
that are so affected. " Although the
vascularity of bone is perhaps as com-
plete as that of many other structures,
it is so sparingly endued with nerves, that
it is less readily roused into diseased action
either from exciting causes or from
sympathy." * Admitting that the struc-
ture of the bone were perfect, it certainly
would not be liable to be diseased so fre-

• Hunter on Inflammation, &c.
o 3

quently as tins affection occurs. Tlie
disease occurs at that period of life, and
in that part of the bone, in which there is
the largest proportion of animal, and the
smallest of earthy matter, and in which
also the vascularity is the greatest. When
it occurs in the shaft of the bone, the
internal cancellous structure is the part
primarily affected. The first stage of the
disease may be considered to consist in a
preternatural softness of the cancellous
structure of the bone, from a deficiency
of its earthy matter. This portion of the
bone becomes increased in vascularity, in
consequence of its being inflamed by the
pressure and contusion it experiences in
the motions of the limb. The inflam-
mation is of course modified by the con-
stitutional predisposition of the individual,
assuming the form and producing the
effects of scrofulous disease. As the
medulla becomes absorbed, the vessels
having assumed a morbid action, cannot
produce a healthy and natural secretion.

The cancelli are therefore filled with a
transparent straw-coloured fluid, and sub-
sequently a substance of a caseous con-
sistence will be deposited in them.
Sometimes the former will be absorbed,
and tlie cancelli will be found to be wholly
occupied by the latter. This substance,
like the diseased action which produced
it, may pervade the whole extremity of
the bone, or it may be confined to a por-
tion of it. As the disease advances,
the cancelli themselves are partially ob-
literated ; portions of the bone mortify
and exfohate, other parts become carious.
Some time ago, I witnessed the amputa-
tion of a wrist joint, affected with this
disease : the operation was performed at
the earnest desire of the patient, on ac-
count of the excruciating pain he endured,
which was infinitely greater than could
be accounted for by the appearance of
the disease, and arose from a large piece
of the bone having exfoliated into the
joint. Sometimes the inflammation in
G 4

the bone itself will be more severe,
attended with pain and the formation of
matter in its substance, which may com-
municate by a small opening with the
cavity of the joint. In other instances a
considerable portion of the extremity of
the bone will be destroyed by caries.
The disease extends to the cartilages and
the synovial membrane of thejoint, which
ulcerate, and matter becomes effused into
its cavity. The ulceration of the cartilage
commences in that side of it which is in
contact with the bone. In some instances
the sinuses which result from inflamma-
tion in the cellular membrane external
to the joint, subsequently communicate
with its cavity, and give exit to the
matter it contains ; in others, the joint
becomes distended to an enormous size
before it ulcerates, its parietes presenting
a purple hue. In this form of disease,
even should the morbid action be arrested
after it has destroyed the cartilages, the
structure of the bone is so greatly altered

and impaired, that ossific union of its
extremities rarely, if ever occurs ; they
are usually united by a ligamentous sub-
stance, and may be separated again by
maceration*

DISEASE COMMENCING IN THE CARTILAGES.

Disease sometimes begins in the arti-
cular cartilages. Tliis is most frequently
met with at the adult period of life. The
first symptom is pain, which is inconstant
in its duration, inconsiderable in degree,
and referred to various parts of the affected
limb. At first, the joint is more particu-
larly painful after much exertion, and is
relieved in a corresponding degree by
rest; shortly, however, the pain becomes
both fixed and permanent, and is aggra-
vated by every movement of the joint.
The patient consequently limps in walk-
ing, more especially when he first begins
to move the limb ; he keeps the knee
bent, and the heel raised, the toes only
coming in contact with the ground. He
is compelled to keep the limb in this
position, in consequence of the great
pain experienced by the compression of
the ulcerated surfaces in any attempt to

extend the leg. For the same reason, he
can bear the hmb to be moved by his
hand, when he cannot raise it by means
of its own muscles. These symptoms
occur before there is any tumefaction
of the soft parts about the articulation.
The pain becomes more severe in pro-
portion to the progress of the disease,
and the patient is very much harassed
and distressed by spasmodic contractions
of the muscles on the affected limb. He
will usually point to the head of the
tibia as the chief seat of the pain, which,
in the generality of instances, will con-
tinue to harass and distress him for several
months before the soft parts are affected.
It will be particularly aggravated by any
position of the limb in which the articu-
lating surfaces are compressed against
each other. When, however, tumefaction
of the soft parts does occur, it is slight in
degree, and by no means proportionate to
the pain. It arises from inflammation
and thickening of the cellular membrane

external to the cavity of the joint, and is
unattended by fluctuation. In some cases,
where a portion only of the articulating
surface is diseased, the patient will ex-
perience relief by placing the limb in
such a position as shall take off the pres-
sure from the ulcerated surface, and throw
the weight on that which is not affected.
This accounts for his being in pain in
certain positions only of the limb.

After the disease has existed for a con-
siderable time, fluid is in some instances
effused into the cavity of the joint,
in consequence of the whole synovial
membrane becoming ultimately in-
flamed. At length, the ulceration in the
cartilages extends to the bones them-
selves, which become carious ; matter is
effused into the cavity of the joint,
attended with an aggravation of all the
symptoms, and ulceration of the syno-
vial membrane. This form of disease
is readily distinguished from that which

commences in the synovial membrane of
the joint, by the following circumstances.

At the commencement, the pain is
inconstant, inconsiderable, and referred
to various parts of the limb; it gradually
increases in severity, and becomes subse-
quently both fixed and permanent. It
is altogether unattended by swelling or
tenderness on pressure throughout a
considerable period of its duration ; there
is greater pain in the flexion and exten-
sion of the joint, and in every motion of
the limb, in which the ulcerated surfaces
are rubbed against each other ; the patient
is also very early in the disease distressed
by the starting of the limb at night.

V\lien disease commences in the syno-
vial membrane, the pain is always at-
tended by tumefaction of the soft parts,
and it is in general as severe in the com-
mencement of the disease, as it is in the
subsequent stages, until suppuration is
about to be established, and although the
motion of the joint is not attended with

such extreme pain as in the preceding
form of the disease, it is more limited in
extent.

Disease originating in the cancellous
structure of the bones, occurs generally
in young subjects, and much more rarely
after the period of puberty. Although
pain may precede the swelling of the
articulation, this symptom is much less
severe than in those cases in which the
cartilages are primarily affected, and is
not at all increased by moving the joint
in any direction, nor does the patient
limp in walking, until the swelling of the
soft parts occurs from the extension of
disease. The disease is very slow, at-
tended throughout all its stages with
less pain than either of the preceding
forms. The tumefaction is also firmer
to the touch, and extends more over
the extremities of the bones, present-
ing the appearance of their actual ex-
pansion, and retaining to a great degree
their natural figure. Successive abscesses

form, and leave sinuses communicating
with the diseased surface of the bone in
the vicinity of the joint, before suppura-
tion has taken place in its cavity. When
an abscess has formed in the cavity of
the joint, the size of the articulation is
not nearly so much diminished by its
evacuation as in the more acute form
of disease which commences in the
synovial membrane.

DISEASES OF THE HIP JOINT.

Disease commencing in the synovial
membrane of the hip joint is ushered in
with pain, which is usually confined to
the hip in the incipient stages, and is not
so frequently referred to the knee and to
the other parts of the limb, until the
disease has extended to the cartilages
and to the bones, as when it commences
in these structures. The pain is increased
by moving the joint, so that the patient
limps in walking: it is very soon succeeded
by tendei'ness on pressure, and slight
tumefaction of the nates and groin ; but
from the joint being so deeply seated,
the swelling is less evident than in the
more superficial articulations. The mus-
cles on the affected limb after a short
time become flabby and wasted, the nates
appear flattened and wider than on the
opposite side, and the line by which they
are defined at the inferior part is lower

than on the sound limb. The limb be-
comes elongated, and bent upon tlie
pelvis.

When the inflammation has extended
to the nmscles, their fibres become im-
patient of extension, so that the crest of
the ilium on the affected side now be-
comes drawn down towards the tro-
chanter major. When the thigh is bent
forward, the flexors of the leg are put
upon the stretch, and this cannot be
effected without compressing the dis-
eased structures. To take off this pres-
sure, the knee becomes permanently bent,
and any attempt to straighten it gives
considerable pain, which also is frequently
referred to the knee itself. This circum-
stance tends to mislead the patient, and
induce him to attribute to the knee the
disease which is actually seated in the
hip. The thigh and leg being thus elon-
gated, and in a state of flexion, the toes
only touch the ground, and any attempt
to straighten the limb gives pain.

Fluid becomes effused into the ca-
vity of the joint, varying in quantity
in different cases; this may be dis-
tinguished from a collection of pus, by
its occurring at an early period of the
disease, and not being preceded by so
great a degree of pain and constitutional
disturbance as would have attended the
occurrence of suppuration. Coagulable
lymph is effused into the cavity, as well
as into the substance of the synovial
membrane, which is agglutinated by a
similar deposit to the surrounding cellular
substance. The disease, continuing its
progress, extends to the cartilages and to
the bone ; producing ulceration, and in
this stage the patient is much distressed
by spasmodic muscular contraction. The
formation of matter is preceded by rigors
and an aggravation of all the symptoms,
both local and constitutional : these, how-
ever, vary in different instances, in pro-
portion to the violence of the disease.
In general, the soft parts surrounding the

joint become exquisitely painful and
tender to the touch, attended with a con-
siderable degree of inflammatory fever.
The spasmodic muscular contractions are
more frequent, and more painful, thethigh
more contracted, and even the slightest
movement of the limb intolerable.
Ulceration occurs in the substance of the
synovial membrane, and usually proceeds
more extensively in the acetabulum than
in the head of the os femoris.

This joint being deeply seated, the
collection of matter in it occasions more
extensive diseased action before it can
be brought to the surface, and is con-
sequently attended with greater consti-
tutional disturbance than in the more
superficial articulations. Sometimes the
abscess will break beneath the glutas'i
muscles ; in other cases, it will point in
the groin, or on the dorsum ilii. Not
unfrequently too, in consequence of the
strength of the fascia lata femoris, it will

>-■''•' ■ H 2

100

gravitate down the thigh, and break just
above the knee.

When the thigh is kept in a state of
permanent flexion, and the cartilaginous
brim of the acetabulum has been exten-
sively destroyed by ulceration, the dislo-
cation of the femur on the dorsum ilii
may occur. Thus an abscess being formed
in the joint, inflammation is propagated
to the superjacent muscular structure, in
order to bring the matter to the nearest
point of the surface. This structure then
becomes swelled, tender, and impatient
of the extended state of its fibres, which
no longer hang in a loose and flaccid state,
more especially if there be a large collec-
tion of matter. Under these circum-
stances, the patient is dreadfully distressed
by violent muscular contractions, which
ultimately dislocate tJie femur on the
dorsum ilii, the toes and knee being per-
manently turned inward, and the limb
considerably shortened. It has been stated
that the dislocation of the limb results

101

from the head of the bone being pushed
out of the socket by the pus and lymph
effused Into its cavity. The former would
certainly gravitate out of the acetabulum,
and, as the bone is retained in its situ-
ation chiefly by the muscles, it is difficult to
conceive how lymph can have the power
of overcoming their resistance, more
especially in the stage of the disease in
which their irritability is increased by
the extension of inflammation in them,
and in which stage alone this effect is
produced.

Sometimes we witness very large col-
lections of matter occurring in the hip
joint, unattended by the dislocation of
the limb. In these instances the inflam-
mation is less acute, and the matter, gra-
vitating down the thigh, does not distend
the gluteei muscles. When this is the case,
the limb is very rarely dislocated, unless
the head of the bone has been destroyed
by ulceration to a considerable extent.
When this latter effect has taken place,

H 3

102

although the limb is shortened, it is move-
able in all directions, and, when left to
itself, is generally turned outward instead
of in the contrary direction. At the com-
mencement of the disease, the pain is
more severe than at any subsequent pe-
riod until ulceration is about to take
place, and is greater when the patient
moves the joint than when he bears his
weight on the affected limb. The pain,
however, except when ulceration is about
to take place, is not nearly so excruciat-
ing as in that form of disease which com-
mences in the articular cartilages.

Many of the symptoms enumerated in
considering the disease of the hip joint,
commencing in the synovial membrane,
are common to those which originate in
the articular cartilage, and in the cancel-
lous structure of the bone. The latter
occurs commonly in young subjects, and
is much more rare after puberty. The
organic changes produced in the struc-

103

ture of the joint are similar to those de-
scribed in speaking of this affection of the
knee. There is Httle or no pain until
the disease extends to the soft parts,
which takes place very gradually, and it
is then much less acute than in primary
disease of the synovial membrane or arti-
cular cartilage. Very frequently, indeed,
the enlargement of the part is the first
symptom that arrests attention. I have
seen a large collection of matter take
place in a joint, the head of the bone par-
tially absorbed and dislocated, without
producing pain enough to disturb the
patient's rest. At first, he does not set
his foot fairly to the ground ; complains
that the limb is soon fatigued, and that it
is stiff and uneasy after exercise. The
motion of the limb is for a long time un-
attended with pain, which, when pro-
duced, is generally referred to the knee.
As the disease advances, the soft parts
become tender to the touch, both in the
groin and nates, and the latter, instead of
H 4

104

their previous flattened appearance, ex-
hibit some degree of roundness and ten-
sion. The swelling, too, is firmer and
more extensive on the dorsnm ilii than in
the other diseases of the joint, and arises
from the soft parts sympathising with the
disease in the bone ; sernm or coagulable
lymph, or both, being eifnsed into the
cellular membrane. The inguinal glands
are sometimes swelled and tender, and
occasionally proceed even to suppuration.
Abscesses form in various parts of the
cellular substance, not communicating
with the cavity of the joint, before the
latter becomes the seat of suppuration.
They are attended with little pain, and
terminate in sinuses, which not nnfre-
quently ulcerate into the joint, so that
the matter is found to escape by various
apertures. Ulceration has generally pro-
ceeded to a great extent in the head of
the bone before the cartilage of the ace-
tabulum has become affected. The bone,
therefore, is seldom dislocated until its

105

head has been so far destroyed as to
allow the toes and knee to be turned out-
wards instead of in the contrary direc-
tion.

When the cartilages are the primary
seat of disease, the pain, at its com-
mencement, is neither severe nor con-
stant, but gradually becomes so, and is
unattended with swelling or tenderness.
Pain is the only symptom that is mani-
fested for a long time ; it increases with
the duration of the disease, and is aggra-
vated when the ulcerated surfaces are
moved on each other ; it is usually re-
ferred to the knee, or to various parts of
the limb, and is more severe in these situ-
ations than in the hip itself, until the soft
parts participate in the disease. The
wasting of the limb, and flabbiness of
the nates, occur earlier than in the pre-
ceding forms of disease, and are more
apparent from the absence of swelling,
The patient walks lame, and, after a time,

106

is unable to bear weight on the limb, or
the slightest motion. Spasmodic muscu-
lar action occurs early in the disease, and
becomes gradually more distressing dur-
ing its progress. Ultimately, the soft
parts become involved in the disease,
swelled and tender, and at last are con-
verted into a confused organized mass, in
which it is impossible to trace any ap-
pearance of the original structures. Ul-
ceration most frequently occurs in the
cartilage of the acetabulum at the same
time tliat It takes place in that covering
the head of the thigh-bone. When the
cartilage is destroyed, the bones become
carious, the head of the thigh-bone is
diminished, and the acetabulum is ren-
dered more capacious, its brim being
often entirely removed. Sometimes ulcer-
ation proceeds completely through it, and
the matter escapes into the pelvis. At the
London Hospital, some years ago, there
occurred a dreadful case of this disease,
affecting both the hips, and the abscesses

107

communicated with the cavity of the pel-
vis on each side through the acetabulum.
When suppuration takes place, there is
usually only one collection of matter, not
several small abscesses occurring in suc-
cession, as when the disease commences
in the bone itself.

108

TREATMENT OF DISEASES OF THE JOINTS.

I NOW proceed to the practical part of
this Treatise, — that which relates to the
treatment of the diseases of the joints ;
and this divides itself into two parts —
first, the constitutional ; and, secondly, the
local. I shall first explain the constitu-
tional treatment. In this, little novelty
will occur to the well-informed surgeon ;
but as I design this treatise as a guide to
the young surgeon, in the treatment of
diseases of the joints, it is impossible for
me to omit an important part of this
treatment, merely because it wants the
recommendation of novelty. Besides
which, I shall have an opportunity of
explaining the result of my experience
on the degree of value to be attached to
the different constitutional remedies, and
the rules by which they are to be em-
ployed, so as to extract from them the

109

fullest advantages. The best remedies
may be employed so as to be entirely

CONSTITUTIONAL TREATMENT.

Even in the most acute stages and
most inflammatory forms of the diseases
of the joints, there is usually little occa-
sion for general depletion ; the relief of
the part is nearly all that is required for
the removal of the febrile state of the
system it may have produced. The only
constitutional evacuants that are necessary
are purgatives, the choice and manage-
ment of which depend on the particular
disorder of the digestive organs. This
commonly consists in inactivity of the
alimentary canal, with deficient and un-
healthy secretions not only of this canal,
but of the liver. Hence the combination
of mercurial with other purgatives is
generally necessary. Our object is better

attained by the repetition of moderate
doses, than by any sudden and violent
operation. When this plan has been
pursued sufficiently long to unload the
bowels, and to procure sufficient and
healthy secretions, the digestive organs
remain weak and irritable, and liable to
relapse into their former disorder. This
is best prevented by an occasional mer-
curial aperient, and a daily dose of neutral
salt, sufficient only to keep the bowels
gently soluble. Whenever it is practicable,
however, it is more desirable to promote
the action of the bowels by exercise than
bymedicine,and this may often be effected
by the aid of crutches. In many instances,
however, where the digestive organs have
been long disordered, a continued employ-
ment of mercurial alteratives and saline
aperients is necessary for its permanent
removal ; but in these cases, the mercury
requires to be used in the mildest form,
and with the greatest caution. Occasional-
ly however, even with these precautions,

Ill

it increases instead of diminishing the
irritabihty of the digestive organs. This
may often be obviated by giving it in
conjunction with sarsaparilla. Sometimes,
where these have failed, the tongue has
become clean, the appetite improved, and
the secretions healthy, by laying aside
mercury, and giving in its stead the sul-
phate of magnesia or potass, and in other
cases, by the use of soda with some
vegetable bitter and aperient.

In some instances, the power of the
digestive organs has been so greatly re-
duced by the continuance of disorder,
that the quantity of food necessary for
the support of the individual cannot be
digested with sufficient rapidity to pre-
vent the occurrence of fermentation. In
these cases alkalies are of essential ser-
vice in neutralising the acid that is thus
generated, and obviating the deleterious
effects that would arise from its presence.
The operation of this class of remedies
has been estimated so highly as to induce

112

many persons to believe tliat they possess
the powers of a specific. Although such
a supposition is altogether nugatory, they
certainly exert a most beneficial influence
in many instances. Probably they may
in some measure — more especially when
combined with some aperient bitter, as
aloes, &c. — supply the place of" the bile,
the quantity of which is so evidently
deficient. Tlie carbonate of soda is the
form that I have generally found the
most serviceable, given in doses of half a
drachm three times in the day : smaller
doses I have not found so efficacious.

Next to medicine, the diet requires
attention. It must be such in quantity
and quality as the stomach can readily
digest. Early in life, when the constitu-
tion has to withstand the debilitating
effects of local disease, as much nourish-
ment should be given as can be well and
readily digested. When the system has
been much reduced by local disease, the
constitutional disturbance has been in

113

some degree relieved, and the patient
resides in a pure dry atmosphere, the
quantity of food that will be digested is
far more than could be expected. It is
impossible therefore to determine before-
hand the quantity of plain nourishment
that may be allowed; but if it consists of
plain animal food, and well-boiled vege-
tables, and all variety of dishes is for-
bidden, there is little danger that the
unpampered appetite will exceed the
powers of the stomach.

The disorder of the digestive organs
being removed by the above treatment,
they are still left irritable and feeble, and
prone to relapse into their former con-
dition ; the constitution, too, is enfeebled
by the excitement of the disease. In
this condition, experience shows that
what are called tonic medicines are of
essential use. If properly timed, they are
seldom given for a week before it ia
manifest from the amended appearance
of the patient, that a step has been gained

114

in the treatment of the case. Some
management is requisite in the use of
them, beginning with the lightest, as the
mineral acids, and then proceeding to the
more powerful, as Peruvian bark, at first
in infusion, but ultimately in powder, in
which form it is far more effectual than
in any other. The extract is a good form
for children, and the sulphate of quinine,
which seems to contain all the tonic as
well as the anti-intermittent power of
bark, when combined with sulphuric acid,
may be borne when the powder could not.
It is, however, of all forms of bark the
most stimulating, and sometimes parches
the tongue and quickens the pulse, in
which case it should be withdrawn. The
employment of steel is often attended
with decided advantage, more especially
when given conjointly with some of the
last-named preparations.

In many instances, especially in the
advanced stages of the disease, when the
constitution is so weak and irritable as

115

not to bear tonics, sarsaparilla is a
medicine capable of producing extra-
ordinary benefit ; it will often (when all
other medicines fail) succeed in tran-
quillising the irritability of the stomach
and of the nervous system. With regard
to fermented liquors, I have not seen so
much benefit arise from their use as to
induce me to recommend their general
adoption, even in the latter stages of the
disease, except under peculiar circum-
stances. During the early periods of its
progress, they are altogether inadmissible,
and even afterwards I think that their
acescent quality is so predominant, that it
is more injurious than their stimulating
property is beneficial. I have frequently
found that instead of increasing the
strength and powers of the patient, they
excite disorder of the stomach, diminish
the appetite, and thus debilitate him.

There is another agent of great im-
portance, but requiring great caution, and
that is exercise: if not carried to exhaus-
I 2

116

tion, if used with regularity and moder-
ation, it strengthens the muscular fibre,
invigorates the circulation throughout the
body, and thus is beneficial to the general
health. If this was its only effect, its
employment would be beneficial in all
chronic cases of these diseases ; but it often
does more harm to the local disease than
good to the general health. Whilst the
disease in the joint is in the slightest de-
gree acute, exercise will increase the
inflammation, which will he indicated by
pain ; but in the chronic stages, whenever
exercise can be taken on crutches with-
out pain, either during the exercise or a
few hours afterwards, it may be taken not
only with impunity, but with advantage :
thus pain is the guide. This exercise,
however, must never be continued long
enough to produce fatigue. In the inter-
vals, the patient should be confined to the
recumbent posture, by which means he
will be able to walk longer than if he
fatigued himself by sitting up. The exer-

117

cise, too, should betaken in the open air,
in which it is far more invigorating than
in apartments, however spacious : it ought
never to be taken immediately after meals,
the undivided energies of the system
being required for the process of diges-
tion. Exercise, by promoting all the
secretions as well as the peristaltic action
of the bowels, often supersedes the ne-
cessity of aperient medicines.

Another point which deserves attention
is the function of the skin : its due per-
formance has great influence over the
state of the digestive organs. Besides, if it
is checked by cold, as is often the case
in this variable climate, more particularly
in persons whose circulation is languid,
internal congestion is frequently the
result. Hence, to promote the action of
this important surface, woollen clothing
should be worn next the skin. With the
same view, the warm bath is very useful ;
its temperature should not exceed 98,
and it should not be used longer than
I 3

118

ten minutes at a time, in the middle of
the day. If used longer and at bed-time,
it is liable to debilitate by producing
excessive perspiration.

The warm bath, however, is inadmis-
sible in all cases attended with excessive
perspiration. Id such cases it is very
useful to sponge the surface of the body
with cold spirits and water, afterwards
rubbing it perfectly dry. In such cases,
too, cold bathing is sometimes eminently
useful, if it is speedily followed by a
general glow.

But of all the means of invigorating
the constitution, there is nothing com-
parable to a residence in a pure dry air :
that it will not alone arrest local disease,
as some suppose, must never be forgotten,
but of all constitutional remedies it is the
most valuable. I have often observed
that the removal of a patient from London
to the country, more particularly to the
sea side, has produced a sudden and great
amendment in the health and the local

119

disease. That the invigorating power of
sea air is far greater than that of country
air, I am quite satisfied by experience.
When we witness the deleterious in-
fluence of marsh air on the human con-
stitution, and the length of time it trill
last in the form of ague, even after re-
moval from it, it is easy to believe and
comprehend the opposite truth, the bene-
ficial influence of a healthy atmosphere.

I have thus far explained only the
constitutional treatment necessary for the
successful management of the diseases of
the joints. On the importance of this
treatment I need not enlarge; for an
attention to it, unless I am much mis-
taken, far too exclusive, is the peculiar
characteristic of modern surgery. I now
proceed to the especial object of this
work, that is, to explain the local treat-
ment, which, in the hands of my father
and myself, has been very successful in
these formidable diseases.

120

LOCAL TREATMENT.

The first condition is the absolute rest
of the affected joint, for the best remedies
will be counteracted by the friction of the
diseased surfaces. The degree of rest
will depend upon the violence of the
disease. In a very aggravated form, the
patient must be confined altogether to
the horizontal posture ; and this strict
confinement must be continued some time
afi;er exercise has ceased to be painful.
A fresh accession of inflammation is often
produced by an accidental slip. The best
rule is to keep children off their legs as
long as possible, as It requires consider-
able time after the subsidence of disease,
before the joint can bear their active
movements, and it is difficult to prevent
them from using their limbs, when they
find they have the power; at the same
time, it is desirable to let them walk out
on their crutches, when they can do so

121

without experiencing pain In the diseased
joint, either during the continuance of
exercise or subsequently. In some cases,
although pain is not felt while they are
walking, it will come on in the evening,
and when this occurs, exercise should not
be persevered In ; but if this be not the
case, they will derive great benefit from
it. The same rule will also be a criterion
as to the degree of exertion they may
safely employ, and the length of time it
may be continued.

If the joint is in a state of more or less
active inflammation, the first object we
have in view is to subdue it, and this is to
be done by the same remedies, whether
the inflammation is primary or that which
ushered in the disease, or a subsequent
relapse of a later period. In fulfilling
this indication, it is desirable accurately
to proportion the quantity of blood that
is taken to the degree in which the dis-
eased action is carried on, so as merely
to produce a local effect, and not influence

122

the constitution at large. In this manner
the disease being mitigated, the system
will be relieved and not debilitated.
With this view, from six to twelve, or
even twenty leeches, may be applied to
the part, proportioning the number to
the age and strength of the patient, and
encouraging the bleeding subsequently
by fomentations ; or from six to twelve
ounces of blood may be taken from the
part by cupping. This method will be
found very eligible in the hip-joint ; but I
have aometifnes thought that the pressure
of the glasses has aggravated the disease
when they have been applied to the knee.
On the whole, however, my experience
leads me to believe, that the probable
effect of blood-letting will be better indi-
cated by the state of the constitution
than by the activity of the local disease.
In patients much emaciated, local bleed-
ing has rather aggravated than reduced
the disease ; yet, subsequently, in these
very patients, when their constitutional

power had been improved by proper
treatment, local bleeding has been dis-
tinctly serviceable.

When a sufficient quantity of blood has
been removed, the best application that
can be immediately employed is the com-
mon bread and water poultice. I have
never found that benefit result from the
use of cold applications which others have
described, nor do they appear to me to
be calculated to produce a good effect in
these diseases. The inflammation is in*-
ternai and deeply seated, and the circula-
tion in the minute vessels of the skin
imperfect, as is evident from its remark-
ably pallid hue. It is desirable, therefore,
to promote the cutaneous circulation,
leather than diminish it by the use of cold
applications.

The abstraction of a sufficient quantity
of blood will be succeeded by a diminu-
tion of the inflammatory symptoms. It
is desirable to abstain from any further
bleeding as long as they continue to sub-

124

side, and then to employ another bleed-
ing, and, it" necessary, repeat it after a
similar interval, and so on as long as it is
followed by relief. By these means the
disease will be gradually jeduced to a
chronic state, which will not be benefited
by any further blood-letting, as long, at
least, as it remains in that state ; but it is
extremely disposed to accessions of in-
flammation from very trifling causes,
which will require the application of
leeches to be renewed.

Although, in the more acute stage of
the disease, a warm poultice, by soothing
irritation, and promoting cutaneous per-
spiration, was highly serviceable, yet here
It ceases to be of advantage : the utmost
effect it can now exert is, in some degree
to palliate a disease it cannot control.

In this stage of the disease, instead of
attempting to stimulate the absorbents,
to remove the fluid or solid substances
that iiave been deposited either in or
around the joint, the true object is to

125

put an end to that morbid action of the
vascular structure of the joint which is
still going on in the chronic stage of the
disease, and which, though it manifests
itself externally by less striking symptoms
than those which attend the acute form,
is within, gradually destroying the texture
of the joint. If this action can be ar-
rested, the absorbents will spontaneously
remove the deposited matter.

Since the diseased structure is supplied
with an inordinate quantity of blood, and
nervous influence to such an extent as to
deprive the remainder of the limb of its
due proportion, as is evidenced by the
pallid colour of the skin, and the wasting
of the muscles and the fat, we must infer
that this supply is necessary to the main-
tenance of the diseased action, which will
be diminished if we can divert the former
to its original destination. As the state
of congestion in which the internal ves-
sels are placed has been brought about
in a very gradual manner, it can only be

126

relieved by means that are equally gra-
dual in their operation. If, however, we
excite in the vessels of the skin which
covers the diseased structure a degree of
inflammation which does not irritate the
system, nor cause any increase in the
heart's action, the blood and nervous in-
fluence, which are now determined to the
maintenance of the new inflammation,
are necessarily diverted from the internal
disease. If this effect be produced in a
degree which shall excite irritation in the
constitution, it frustrates its own purpose,
by increasing the rapidity of the circula-
tion throughout the whole body, and
consequently through the diseased limb.
The new inflammation is therefore main-
tained, and the original disease is aggra-
vated in two ways. First, it will, of
course, proceied with greater rapidity
when the constitution is in a state of ex-
citement ; and, secondly, the superficial
inflammation being too violent, will ex-
tend more deeply, and will be actually

127

propagated to the disease itself, instead
of influencing it by derivation. We must
therefore be particularly cautious not to
produce too great a degree of inflamma-
tion in the skin ; and, to render it effec-
tual, we must increase the extent of sur--
face to which the stimulus is applied,
and continue its operation unremittingly.
This may be done with perfect safety
when a more violent excitement would
be inadmissible. If we trust to counter-
irritation alone, it is generally impossible
to excite it in a sufficient degree to arrest
the disease, without producing constitu-
tional disturbance.

The degree of counter-irritation which
is safe, yet effectual, will vary in different
cases, according to the susceptibility of
the patient. The means most com-
monly employed are blisters, tartar eme-
tic ointment, setons, and issues. With
regard to blisters, I have not found
them well adapted to these diseases.
They succeed very well in mild or incipient

128

cases, with fluid only in the joint; but they
are far less serviceable in those of long
standing, in which lymph has been depo-
sited. Even the former cases may be
relieved with greater ease by milder local
treatment. If they are applied sufficiently
near the seat of the disease to exert any
influence over it, the inflammation they
excite is frequently propagated to the
morbid structure. In the cases which I
shall relate in a subsequent part of this
volume, there is one in which the joint
became contracted and stiffened during
the time that a blister was kept open.

The chronic stages of diseases of the
joints are usually attended with little
pain, except on moving the limb. For
the remedy, therefore, to be proportioned
in activity to the disease, it must produce
little effect on the sensations of the
patient. If the inflammation it excites
is attended by any great degree of pain,
it will produce constitutional irritation,
and thus become injurious. These ob^

129

servations are applicable not only to
blisters, but to the ointment of tartarized
antimony, which often excites as much
irritation as blisters. With regard to
caustics, I have met with many cases in
which they have been altogether ineffec-
tual, and many others in which they have
been decidedly injurious. In those cases,
however, in which the disease has com-
menced in, and is confined to, the arti-
cular cartilages, we have the high and
valuable authority of Mr. Brodie in favour
of issues ; yet in these cases he remarks
that their long-continued use is some-
times injurious. " I have seen many
cases," says Mr. Brodie, " in which the
caustic issue has in the first instance re-
moved all the symptoms of the disease ;
and yet, after some time, notwithstanding
the patient has remained in a state of
perfect quietude, and there has been no
evident cause of aggravation, they have
returned nearly in the same form as be-
fore, and with their original severity. In

130

some of these cases their recurrence is to
be attributed to the issue itself, which,
from some cause that the present state of
our knowledge does not enable us to
explain, produces an effect apparently the
opposite to that which it produced when
it was first made. The issue being allow-
ed to heal, the symptoms again subside,
and perhaps the patient may find himself
entirely and permanently relieved before
the sore is completely cicatrized. The
same thing may be observed, perhaps,
more frequently where a blister has been
long kept open by means of the savine
cerate ; and here, If the blister be of large
size, the recurrence of the pain is usually
attended with a quick pulse, a furred
tongue, and much constitutional irrita-
tion ; of all which the patient is relieved,
when the blistered surface is allowed to
skin over." *

' Brodie, on the Diseases of the Joints, p. 194.

131

I cannot refrain from relating the fol-
lowing instance of the injnrious effects of
issues. A young gentleman had a disease
in the hip-joint, originating in the can-
cellous structure of the bone. After the
acute symptoms had been subdued by
local bleedings, so that he was free from
pain, except on moving the limb, an issue
was made behind the trochanter major.
This was immediately followed by exten-
sive inflammation in the cavity of the
joint, attended by the most excruciating
pain, and violent constitutional disturb-
ance. A large abscess formed, and the
joint became dislocated.

Of the use of moxa in these diseases,
I cannot speak from my own experience ;
holding it liable to the objections, just
stated, to the use of caustics; and having
seen many cases of its failure in the
bands of others, I have not felt disposed
to make trial of so severe a measure. I
have now under my care a case of dis-
eased synovial membrane of the knee-
K 2

132

joint, which is rapidly yielding to the
treatment I shall have to describe, in
which moxa was applied four times, and
produced as many eschars, each of the
size of a half-crown, without influencing
the disease in the slightest degree.

The inflammation of an issue Js not
readily controlled. It often becomes more
violent than is desirable, and in some in-
stances is propagated to the diseased
structures. In the instance of the com-
mon boil, that degree of inflammation
which terminates in sloughing of the cel-
lular membrane, produces merely ulcer-
ation of the skin ; and the degree of coun-
ter-irritation necessary to relieve a local
disease, may be excited in the skin far
more safely than in the cellular substance,
both with regard to the part and the con-
stitution. The mischief produced by
issues and perpetual blisters, can never be
produced by the local treatment I am
about to recommend ; and I can confi-
dently affirm, that it will produce all the

good results that the former severe reme-
dies can ever effect. The degree of cu-
taneous inflammation, which I have found
so safe and beneficial, produces merely
a slight smarting in the first instance, and
subsequently an itching in the skin, an
uniform redness of the surface, and a slight
eruption. When the skin is found in
this state on removing the applications,
blood will readily flow, by applying leeches
or cupping-glasses, provided the symp-
toms, especially pain, indicate the neces-
sity of so doing.

The above-mentioned irritating, and
sometimes very mischievous remedies
may be all superseded by the following
treatment In the first place, the surface
of the joint, suppose the knee, is to be
carefully cleansed by a sponge, soft brown
soap and warm water, and then thoroughly
dried ; next, this surface is to be rubbed
by a sponge soaked in camphorated spirit
of wine, and this is continued a minute
or two, until it begins to feel warm,
K 3

134

smarts somewhat, and looks red. It is
now covered with a soft cerate made with
equal parts of the ceratum saponis and
the unguentum hydrargyri fortius cum
camphora. Tliis is thickly spread on
large square pieces of lint, and applied
entirely around the joint, extending for
at least six inches, above and below the
point at which the condyles of the femur
are opposed to the head of the tibia ; over
this, to the same extent, the limb is to be
uniformly supported by strips of calico,
spread with the cmplastrum plumbiofthe
London Pharmacopoeia. Tliese strips are
about one inch and a half broad, and vary
in length j some are fifteen inches, others
a foot, others lialf these two lengths, and
the shorter or longer are selected accord-
ing to the size of the part round which
they are to be applied. This is the only
difficult part of the process. This adhe-
sive bandage ought to be so applied as to
preclude the motion of the joint, prevent
the feeble coats of the blood-vessels from

beinir distended by the gravitation oftheir
contents in the erect posture, and thereby
promote their contraction. Over thia
adhesive bandage, thus applied, comes an
additional covering of emplastrum sapo-
nis, spread on thick leather, and cut into
four broad pieces, one for the front, the
other for the back, the two others for the
sides of the joint. Lastly, the whole is
secured by means of a calico bandage,
which is put on very gently, and rather
for the purpose of securing the plaster,
and giving greater thickness and security
to the whole, than for the purpose of
compressing the joint. This is an im-
portant point, as otherwise an application
which almost invariably affords security
and ease, may occasion pain, with all its
attendant mischief

In some cases, in which the skin is
thick and indolent, sufficient irritation will
scarcely be excited by the above applica-
tions, and this may be promoted by rub-
bing on a small quantity of tartar emetic
K 4

136

ointment previously to the application of
the cerate. This, however, is rarely ne-
cessary.

In some cases, also, it is desirable more
effectually to prevent the motion of the
limb, particularly in children. This may
be done, by applying on each side of the
joint, externally to the plasters, a piece of
pasteboard, softened by soaking in water,
and cut into the length, breadth, and form
of splints. These being soft, will accom-
modate themselves to the figure of the
joint, and, when dry, effectually preclude
all motion.

I think that this form of splint is infi-
nitely preferable to those that are made
of wood. It affords a very firm support
to the limb, and at the same time coun-
teracts the contracting effort of the
muscles in as great a degree as can be
effected without exciting inflammation.
I have met with cases, in which the dis-
eased surfeces have been so forcibly com-
pressed, by means of wooden splints, as

137

to excite inflammation, and thereby cause
a more violent contracting effort of the
muscles, the resistance of which has ag-
gravated the disease.

It is manifest that the contraction of
the limb arises from the disease in the
joint, and the degree of the former will
be proportioned to that of the latter. It
is equally obvious, that any forcible com-
pression of the diseased surfaces by splints,
or other means tending to restore the
limb to a straight position, will aggravate
the disease, and therefore frustrate its own
object. It appears to me, that the con-
traction of a limb, under these circum-
stances, may best be prevented by those
remedies that will most speedily and ef-
fectually relieve the disease, at the same
time urging the patient to favour the re-
storation of the limb to its proper position
as much as possible, without occasioning
pain. It is surprising how completely
this maybe effected in a gradual manner,
during the subsidence of disease. I have

'ifl

138

at present under ray care a young gentle-
man, whose flip-joint is anchylosed in a
position perpendicular to his body, which
when I first saw him was forcibly con-
tracted at a right angle to the trunk.

The remedies thus applied will not re-
quire very frequent removal. The time
during which they may be left undisturb-
ed, will depend chiefly on the necessity
for a repetition of the bleeding, in which
we must be guided by the degree of pain;
or when there are open abscesses, by the
quantity of the discharge. Should neither
of these influence the question, the only
necessity for removing the dressings will
arise from their having ceased to keep up
any irritation in the skin. In some cases
it will be necessary to re-apply them
every week ; in the generality of instances
they may be allowed to remain a fort-
night, and in others for a longer time.
Even where there are open wounds, I
allow them to remain several days, or a
week, being firmly convinced by espe-

139

rience that the presence of the matter
does less harm than the frequent disturb-
ance of the part. A strumous ulcer can
scarcely be disturbed too seldom; nothing
does so much harm as officious dressing
and probing.

Consider the condition of a joint thus
done up. First, it is thickly encased
in emplastrum plumbj, leather, and
calico, by which perfect rest is ensured,
and it is so supported and secured from
external injury, as no longer to be a
source of perpetual anxiety to the pa-
tient. It is a striking sight to see a child,
who, before the application of these dress-
ings, was in constant fear of being touched
and moved, this fear keeping him in a
perpetual state of nervous irritation, im-
mediately after their application losing all
fear about his joint, and permitting him-
self to be touched and carried with per-
fect tranquillity of mind. This circum-
'stance alone cuts offa constant source of
irritation to the constitution.

140

Besides this, the moderate, uniform,
extended support which the plaster-
bandage affords is the best remedy for
the vessels, weakened by long disease, and
in that state which constitutes chronic
inflammation. Of this, the best proof
I can offer is the great efficacy of this
bandage in old ulcers of the lower extre-
mities, which are kept from healing by a
chronic inflammation of the integuments,
and which heal on curing this chronic
inflammation by mechanical support.
Let it never be forgotten, however, that
this remedy is inadmissible, as long as
active inflammation exists in the joint,
which it is sure to aggravate, and that,
in applying it, it is of tbe utmost import-
ance to distinguish between a moderate
and uniform support, which affords the
full benefit I have been describing, and
violent unequal compression, which, by
impeding the circulation, is sure to ag-
gravate the disease. There is only one
rule that can be a safe guide in this

141

respect — to apply the plaster-bandage in
such a way as shall afford ease and com-
fort to the patient. If it occasions pain,
either on its first application or subse-
quently, it is either applied badly, or the
part is not in a fit state for it. So much
for the mechanical mode in which this
method of treatment operates.

Next, it is a powerful means of excit-
ing the vessels on the surface, and by
that means of determining the blood
from within. The skin is rubbed with
camphorated spirit until it is red, and
smarts ; it is constantly under the influ-
ence of an ointment strongly impregnated
with camphor, and, by being enveloped
in an impervious covering, the perspir-
ation of the part is confined, so as to
keep it constantly in a steam bath. In
these ways the action of the vessels of
the skin is greatly promoted, as is evi-
dent by the surface being no longer pale,
and commonly becoming covered with a
crop of slight pustules or vesicles.

142

Lastly, this surface, thus kept in a
constant state of augmented action, is
exposed to the influence of a powerful
mercurial preparation. That mercury is
one of the most powerful means we pos-
sess for controMing the action of the ca-
pillary vessels, removing congestion, and
subduing inflammation, has heen so fully
proved of late years, more especially in
inflammation of the iris, that it would be
superfluous to attempt to prove it. In
these cases, the whole system must be
subjected to the influence of the remedy,
in order to control the disease of a
part. In diseased joints, however, the
debility and irritability of the constitution
are so considerable, that if mercury be
given so as to affect the system, it inva-
riably aggravates the disease. The only
question, therefore, is, whether it exerts
the same power when applied locally,
without affecting the constitution. I am
aware that the prevalent notions about
the way in which mercury operates are

unfavourable to a belief in its local oper-
ation. But if mercury did not possess a
power when locally applied, why is it
ever employed as a local remedy? What
shall we say to the many instances in
which enlarged glands and other tumours
waste and disappear under mercurial
plasters? When mercury is introduced
into the system by friction of the skin,
must it not pass through the vessels of
the part before it can reach the system ?
and how can it pass through, these ves-
sels without acting upon them ? To deny
it, would be to contend, that it did not
act upon the part until the whole consti-
tution became impregnated with the re-
medy, and, as it were, reflected its action
again on the part from which it was
received; a proposition which implies a
much more minute knowledge of the
way in which the remedy operates than
any man in the profession possesses. I
trust, however, that what I have already
stated is conclusive on this subject; but,

144

at all events, I am certain that the other
remedies are not nearly so efficacious if
the mercurial ointment be omitted.

The remedies I have just detailed
maybe employed for any length of time,
and over any extent of surface that may
be necessary, without irritating the con-
stitution, or producing salivation. They
also admit of being varied and modi-
fied in as great a degree as the disease
varies or is modified by them ; they are
consequently adapted to disease com-
mencing in any of the structures of which
a joint is composed, as well as to the
various stages in which it may be found.
Mechanical support is applicable to that
degree of diseased action by which lymph
is deposited, and it is capable of arrest-
ing the progress of ulceration and sup-
puration, and preventing their occurrence.
Whether merely the effusion of lymph
has been produced, or whether ulceration
and suppuration have taken place, the
disease we have to combat is essentially

I )

145

tlie same, differing in degree rather than
in kind.

Thus there ma_y be active inflamma-
tion excited in every form and in every
stage of the disease : this must be re-
duced by proportionate loss of blood,
and by soothing applications. The for-
mer must be regulated by the degree
of tenderness and pain when the limb is
in a quiet state, and repeated as long as
it continues to afford relief. If there be
no pain at all except on motion, this
remedy is not required, but we may
safely have recourse to the other means.

The more chronic form of disease in
the synovial membrane is so indolent, that
it is with difficulty acted upon at all, and
is very little relieved by the loss of
blood. In this description of case a
greater degree of counter-irritation must
be excited ; this will also ensure a more
powerful mercurial influence.

When the cartilages are the structures
primarily affected, the loss of blood is

146

certaialy of service ; but as they are less
readilyacted upon by remedies than either
the soft parts or the bones, the greatest
benefit is derived from a much more con-
siderable degree of counter-irritation than
is applicable to the other forms of dis-
ease. These cases are also very much
relieved by the application of the paste-
board splints, so as to impede as much as
possible the motions of the joint.

When the disease commences in the
bones, as long as it is confined altogether
to them, I do not think that the loss of
blood is attended with so much benefit
as it is capable of affording after the soft
parts have become affected. In this form
of disease, the local use of mercury is
most especially beneficial ; it should,
therefore, be applied without delay, and
its operation favoured by exciting a con-
siderable cutaneous irritation. It is neces-
sary also, in this case, to prevent all move-
ment of the joint, in order that the bone,
in its softened state, may not be injured

147

by the contusion it would experience in
the exercise of the limb.

When the synovial membrane is the
seat of the more acute form of disease,
the loss of blood should be repeated
more frequently, and continued for a
greater length of time, than in other
cases. The mechanical support must be
very accurately applied, and in a very
moderate degree. The counter- irritation
should be comparatively slight, merely
sufficient to favour and expedite the mer-
curial action. If much inflammation be
excited in the skin, it will extend to the
disease in the membrane, and aggravate
it. This disease being naturally more
acute than the other forms, is more liable
to participate in any inflammatory action
which may exist in the neighbouring
structures. The slight forms of this dis-
ease may be arrested by tlie repeated ap-
plication of leeches and poultices, to-
gether with the unguentum hydrargyri
L 2

148

fortius rubbed on the part every night,
if absolute rest be enjoined.

The combination of the foregoing
means is infinitely more efficacious than
any other remedies with which I am ac-
quainted. It is applicable to every con-
stitution, and, under the various modifi-
cations of which it admits, to all the
forms of the disease. It causes little
or no pain, produces no constitutional
excitement, and maintains incessant and
extensive influence on the disease. If we
trust to mercurial friction, we are alto-
gether deprived of the advantage arising
from mechanical support, and as there is
usually either an original or acquired ir-
ritability of the system, the constitution
becomes affected by the remedy before it
has produced a sufficient local effect. If
any mercurial plaster be employed, the
firm cohesion of its particles prevents the
powerful influence it is capable of pro-
ducing in the form of ointment.

149

The emplastrum ammoniaci cum hy-
drargyro, I have sometimes thought, has
produced a good effect in indolent habits,
and in chronic disease of the cartilages
and synovial membrane. It is not, how-
ever, adapted to produce mercurial influ-
ence on the disease, but is beneficial in
exciting a greater degree of cutaneous
irritation. It will often blister to the ex-
tent of its application, and in some irritable
habits induce inflammation of an erysi-
pelatous character over the whole surface
of the body ; an effect that is very dis-
tressing to the patient. The application
of sea water is in some cases beneficial,
by exciting a mild degree of cutaneous
inflammation ; and, on the same prin-
ciple, poultices composed of sea weeds
are of service. They are not, however,
adequate of themselves to control the
disease, and I think that the benefit attri-
buted to them has often arisen from the
effect produced on the constitution by a
residence on the sea-coast during the time
L 3

150

of their employment. In two cases, con-
sisting merely of slow inflammation of
the synovial membrane, and effusion of
fluid into the joint, the local application
of vapour, conjoined with absolute rest
and a I'esidence on the sea-coast, com-
pletely removed tlie disease.

When matter is formed in the cavity
of a joint, is it desirable to evacuate it or
not? My experience would lead me to
conclude that to make an opening into
the cavity of a joint is, in almost all
cases, an injurious mode of practice.
When there is considerable action going
on in the diseased structures, attended
with acute symptoms, and a great degree
of pain arising from distention, the open-
ing of an abscess in this state is almost
invariably followed by very serious con-
sequences. The aperture thus made heals
by the first intention, the parietes of the
joint inflame, and pus, mixed with a small
quantity of blood, is subsequently secreted
with so much rapidity, that in a few days

151

the cavity is more distended than before,
and the pain, with the constitutional dis-
turbance, is violently increased.

Mr. Brodie, in speaking of this subject,
remarks, " I have seen cases where, after
a great deal of pains having been taken
to obtain complete evacuation of the con-
tents of the abscess, and the puncture
having healed, in a few days the tumour
has become as large as ever, attended
with pain in the limb, and a fever, resem-
bling typhus in its character, and threat-
ening the life of the patient." *

I have generally found, too, that the
acute and distressing symptoms which,
while they seem to require such a mea-
sure, almost preclude the propriety of
its adoption, may be removed by the ju-
dicious application of the foregoing re-
medies, and which I have shown are as
well adapted to the suppurative as to any
stage of the disease. When, however, the

* Brodi^ p. 201.
L 4

152

abscess is thus reduced to a chronic state,
I cannot see what can be gained by open-
ing it ; the disease is not thereby moder-
ated ; but, on the contrary, even if not
increased to an alarming degree, it in-
variably proceeds with greater rapidity.
This is manifest by the quantity of pus
that is daily discharged from an abscess
when opened, which previously increased
in size but very slowly, if at all. By per-
severing in the use of the remedies before
described, I have repeatedly found that
the secretion of matter may be diminished
so materially, as to be reduced within the
quantity that the absorbents have the
power of removing, and that very large
collections of matter have been thus ab-
sorbed without either breaking or being
opened. In other instances, in which the
abscess had made its way towards the
surface of the limb, so far as to inflame
the skin itself, the inflammation, excited
m the latter structure by the remedies,
has arrested the action going on in the

153

deeply- seated parts, and thus the abscess,
after having been very materially reduced
in size, has ultimately broken sponta-
neously, without any unpleasant symp-
toms.

In other cases, too, a similar diminution
of the abscess has occurred, the contents
of which consisted of curd-like substance,
mixed with serum : the latter has been
almost entirely absorbed, and the skin
ulcerated to allow the evacuation of the
former, so that scarcely any fluid has
escaped at the opening. Under these cir-
cumstances, the abscess points and breaks
very gradually, at the same time that it
diminishes in sine, the diseased action
existing in a greater degree on the sur-
face than at the fundus of the abscess.
The aperture thus formed by the absorb-
ents being conical, remains open, allows
the matter to escape as long as it con-
tinues to be secreted, and is attended with
no bad consequences of any kind. I
would also observe, that I think it highly

154

injurious to squeeze the matter out of an
abscess when opened in any way ; at the
same time that it can be of no service
whatever, the tension being removed by
the escape of that which flows spon-
taneously ; and, further, healthy pus is
by far the least irritating application that
can be applied to any diseased surface.
Even the evaporation produced by its
exposure to the air, when the matter is
pressed out, will, in some instances, con-
jointly with the pressure thus employed,
excite inflammation in the cyst. If, how-
ever, the matter be allowed to escape
without any interference, and the parietes
of the abscess be moderately supported
by a bandage, they will gradually contract
and diminish the cavity, at the same time
that its contents are as gradually expelled.
When, therefore, matter is formed in
the cavity of a joint, instead of opening
it, I always endeavour to reduce the de-
gree of diseased action, and thus to dimi-
nish the secretion of pus, and conse-

155

quently the size of the abscess, as well as
all urgent symptoms. By these means,
we may often succeed in dispersing an
abscess entirely, and in other instances
cause it to break under the most favour-
able circumstances.

That air admitted into any cavity which
is in a state of health, as the abdomen,
does not there produce inflammation, is
no more a proof that its being applied to
a diseased surface may not increase the
action of its vessels, than that the admis-
sion of cold air into the lungs will not in-
crease disease in them, because It does not
excite it when they are in a state of
health.

At all events, it is manifest that, when
an abscess has broken,or has been opened,
it is a much greater source of irritation to
the constitution than it had been pre-
viously, because, generally speaking, hec-
tic fever is not produced until this has
taken place.

156

With regard to the treatment of the
sinuses that so frequently result from ab-
scesses in the neighbourhood of scrofulous
joints, and in general communicate with
the surface of the bone, it is manifest that
they were produced, and are kept open,
by the disease in the latter structure, to
the state of which, therefore, our remedies
must be directed. It has always appeared
to me, that to inject them with stimulate
ing lotions, for the purpose of inducing
a healthy action at the bottom of the
sinuses, or of promoting the exfolia-
tion of bone, as well as to attempt the
removal of the latter, before it is com-
pletely separated, is almost invariably
injurious.

It very frequently occurs, that the bone
is merely carious ; that is, in a state of
ulceration, and not of mortification. In
these cases it is very easy to excite such
a degree of inflammation as is incompa-
tible with the vitality of the bone, and
cause exfoliation when it would not other-

157

wise have taken place. If, however, a
portion of the bone be actually dead, and
you attempt to remove it before the ab-
sorbents have effected its separation, the
violence thus inflicted on the contiguous
part, already inflamed, will be very likely
to induce more extensive exfoliation in-
stead of effecting the separation of that
which is already deprived of its vitality.
When, however, the diseased action in a
bone that has caused either ulceration or
death of its substance shall have been ar-
rested, these effect s ofcourse instantly cease
to be produced ; this, therefore, should
be the object of our treatment. When
the latter of these effects has supervened,
the separation of the dead portion will
take place, if not as rapidly as that of the
sofl; parts when similarly circumstanced,
as much so as the nature of its structure
will admit, and consequently it cannot be
accelerated by any means. You cannot
apply a more powerful stimulant to the
absorbent vessels than that of a deadpor-

158

tion of the structure of which themselves
constitute a part.

As the death of the bone is the result
of such excessive action as is incompatible
with its vitality, one is at a loss to con-
ceive on what principle the injection of
stimulating lotions can have been adopted,
as they must necessarily cause an exten-
sion and aggravation of the disease, if so
applied as to produce any effect at all.

The length of time that will be requi-
site for the cure of any of these forms of
disease will be chiefly regulated by its
duration, the rapidity of its progress, and
the changes it has produced in the struc-
ture of the part. When the vessels of
any structure have been for a considerable
period the seat of disease, they will be-
come proportion ably debilitated, and in-
disposed to resume a healthy action. If
lymph has been long effused and organ-
ized, it will require a much longer time
to effect its removal, than if recently de-
posited. If ulceration and suppuration

159

have taken place, these changes indicate
a greater degree of vascular derangement,
which it will be more difficult to con-
trol.

Although disease, in an active form, is
more dangerous if allowed to pursue its
progress, and will produce more serious
consequences in a given time, it will ge-
nerally yield to suitable remedies more
speedily than disease of an indolent na-
ture, in which similar organic changes
have taken place*

CASES,

CASE 1.

On the 4th of June, 1826, a little boy,
between two and three years old, was
brought to me from Hatfield, with disease
in the left knee, which was in the follow-
ing state on my first examination of it ; —
When viewed anteriorly, the joint ap-
peared broader than natural, the swelling
extended some way over the ends of the
bones, and felt firm ; but there was no
fluid in the joint. Above and below the
swelling, the limb was wasted, the leg
contracted to a right angle with the thigh;

• The applications described at page 134. were
renewed at each time that the notes of the following
cases were token.

162

the joint was exceedingly tender, so pain-
ful that he could not bear the slightest
motion, and even when the limb was at
rest he frequently cried out from pain.

I was informed by the parents, that
they had for a long time perceived that
there was something the matter with the
child, and were unable to find out what
it was ; but about a month before, a swell-
ing was discovered in his left knee. The
joint was at first tender, but capable of
being moved and fnlly extended without
producing pain. They immediately ap-
phed to Mr. Osbaldestone, with whom I
had the pleasure of conferring on the
case J and every thing had been done by
that gentleman which the nature of
the case suggested. Absolute rest was
enjoined, leeches were applied, then
blisters, and, lastly, embrocations of
various kinds, and remedies calculated
to improve the general health were
internally administered. Notwithstand-
ing the most judicious use of these
means, the disease proceeded with great

163

rapidity, until it arrived at the state which
lias beea above described.

I ordered him an occasional purgative
of calomel and rhubarb, and soda dis-
solved in some bitter infusion ; his diet
was to be light and nutritive, and his
knee was dressed in the way described at
p. 134. ; he was sent back into the coun-'
try, and desired to return in a fortnight.

June 18. On taking off the dressings,
which had remained undisturbed for the
last fortnight, during which the knee had
been much easier, for he had scarcely
ever cried out on account of pain, a very
visible amendment was discovered. The
knee was less swelled, less tender, and
could be bent and extended with much
less pain ; it was therefore done up again
for another fortnight.

July 4. On his return the swelling
was very much reduced : scarcely any ten-
derness remained. He had never com-
plained of uneasiness since his last visit,
and could bend and extend the joint,
M 2

164

and even walk on itwithout assistance,and
without feeling pain; his health was visibly
improved. I did not see him again for
three weeks, at the end of which time he
was much better in health, his joint was
restored to its natural size and flexibility;
it was quite free from pain and tender-
ness. Indeed, he could now walk so well,
that it was with the greatest difficulty he
could be kept oiF his feet. To prevent a
relapse, howevei', which is so often occa-
sioned by premature exercise, his parents
were advised not to permit him to walk,
for he was too young for crutches, and
the mechanical support was continued for
some time longer.

CASE 2.

William Rowe, six years and a half
old, was brought to me on the 6th of
June, 1824, with a disease in the right
knee. The joint was swelled, and its

165

width, when viewed anteriorly, appeared
to be increased by the tumefaction ex-
tending over the condyles of the femur.
There was no fluid in the cavity. The
joint was tender when pressed ; the pain
was constant, chiefly distressing at night,
and extending particularly down the shin
bone. He could move the joint, and
walk up stairs or on a level surface,
without uneasiness; but he could not walk
down stairs without great pain. The leg
was contracted, and he could not endure
any attempt to straighten it.. His health
did not appear to be impaired, but he was
rather a deHcate child.

About three months before, he was
kicked just below the knee that is now
affected : from that time he had constantly
limped, and the lameness and difficulty
in walking had been gradually increasing.
This case was now treated in the same
manner as the last.

June 20. In a few days after I first
saw him, the pain began to subside. The
M 3

166

swelling and tenderness are much re-
duced. Tlie joint is now free from pain,
and less contracted.

July 4. He can straighten the limb
entirely : the joint is greatly improved in
every respect and m^cli diminished in
size.

July 18. The swelling is quite reduced,
and the joint has regained its natural ap-
pearance; it remains, however, rather
weak.

August 10. The joint is now quite
recovered, and he can use it as well as
the other.

CASE 3.

I was consulted on the 23d of May,
1826, on the case of a young lady, thir-
teen years of age, residing in Henrietta-
Street, Russell-Square, who was the sub-
ject of disease in the left knee. The joint
was somewhat swelled and tender, more
particularly on the inner condyle of the

167

femur. She suffered a good deal of pain
at night, but it subsided before the morn-
ing. The motion of the limb was limited,
and the pain, ■which prevented the full
extension and bending of the leg, was
increased by exercise.

There was no obvious constitutional
disorder ; she was of a light complexion
and delicate appearance ; the bowels were
regular, and the tongue clean. About
ten years before, she had an abscess above
theinner condyle of the os femoris, which
burst, and healed after being open about
six months. At this time the joint was
not at all affected, and she could move it
in either direction without the slightest
pain.

About a twelvemonth before she ap-
plied to me, she first experienced pain in
the joint, which was tender and painful
on exercise. These symptoms were re-
lieved in some degree by the treatment
adopted ; but she had felt them more or
M 4

168

less from that time, and they had been
graduallyincreasingfor some months past.

She was directed to take the pilula
ferri composita, and the knee was dressed
in my usual manner.

June 7. The application has produced
considerable irritation on the skin, the
joint is less swelled, the pain and tender-
ness are much diminished, and the mo-
tion of the limb is more extensive, and
attended with less pain.

June 23, The joint is in every respect
considerably improved.

July 28. She has been at the sea-side
since I last saw her, and has been using
the limb so freely, as to have occasioned
an accession of diseased action, so that
the joint is now in fully as bad a state as
when I first saw it.

August 12. She has rested the limb
since I last saw her walking on crutches,
and it is much improved in every respect.

September 10. The pain, swelling,
and tenderness have entirely subsided ;

109

she can move the joint to the full extent,
and walk on it without the least pain.
The same means were pursued in this
case for another month, when the joint
appearing quite well, they were discon-
tinued, and there has been no return of
the complaint.

CASE 4. :

Robert Davies, thirteen years of age,
residing at Chelsfield, applied to me on
the 26th of April, with a disease in the
knee. There was considerable tumefac-
tion of the joint, extending some way
over the extremities of the bones, causing
them to appear wider than natural, but
not arising from eifusion into the cavity.
It was tender, particularly on the inner
condyle, very painful during the early
part of the night, as well as in walking or
in moving the joint in either direction.
The limb was contracted, and limited in

flexion as well as in extension. The dis-
eased joint measured thirteen inches in
circumference, the other twelve inches.
His bodily health was tolerably good.
About a year and a half before finding
his knee painful, he perceived that it was
swelled ; but was not aware how long it
might have been enlarged before the pain
directed his attention to it.

From that time the pain, swelling,
tenderness, and difficulty in walking, had
been gradually increasing, notwithstand-
ing the use of various remedies.

My usual mode of treatment was now
adopted in this case.

May 10. He has had much less pain
since he has worn the present application.
The joint is not so tender, and is reduced
in size at least a quarter of an inch in
circumference. He can extend the limb
more fully, and the attempt to straighten
it is attended with less pain. There is an
uniform blush on the surface of the skin
to the extent of the application.

171

May 24. He has felt no pain since
his last visit, except a slight smarting
produced by the application. The joint
now measures twelve and a half inches, is
straighten, and the tenderness is confined
to the inner condyle of the femur. The
limb can be moved without any uneasi-
ness, and his nights are no longer dis-
turbed by pain.

August 2. The joint has been gra-
dually diminishing in size, and improving
in every respect, so that he can now walk
on it without the slightest pain, although
it is still weak.

August 30. The joint is now reduced
to its natural dimensions ; he has not the
least feeling of uneasiness in it, and can
walk on and use it perfectly; but he can-
not bring the leg in a right line with the
thigh, although very nearly so. In the
following January this case continued
quite well.

172

CASE 5.

Thomas Croot, aged fourteen, residing
in London Wall, applied to me on the
3rd of November, 1826, with a complaint
in his left knee. There was a general
fulness of the joint, which was tendei* to
the touch, and painful when bent or ex-
tended ; so that he limped in walking,
and the motions of the limb were con-
fined to a very small sphere. He was
hot and feverish during the early part of
the night, when the pain was so great as
to deprive him of rest. His appetite was
impaired, his tongue clean, and bowels
open.

There was also a hard elastic tumour
on the head of the tibia, presenting to
the finger the feel of coagulable lymph
effused on the periosteum : it was of the
size of a crown piece, painful, and tender,
but unattended with any superficial red-

173

The disease had been of eight months'
duration, and he could not account for
its origin. It commenced, as he de-
scribed, with a deeply-seated aching pain,
three months prior to any swelling ; both
of which had continued to increase, not-
withstanding the constant use of such
remedies as were calculated to relieve the
complaint. The means that had been
employed were the frequent application
of leeches, poultices, blisters, and several
stimulating applications, together with a
variety of internal medicines. The means
that were adopted in the last case I had
recourse to in this.

November 17. The pain ceased almost
immediately after the application of the
dressings I made use of on his last visit.
The swelling is much reduced, and he
can now walk without either pain or
limping.

December 5. He can now straighten
and bend the joint perfectly. He has
been free from pain since his last visit,

lit

excepting for a short time on Thursday
last, when he fell down, and so ^verely
bruised the skin on the head of the tibia,
as to cause its ulceration to the extent of
a sixpence. No inflaniuiation, however,
beyond the point of skin actually de-
stroyed, has resulted from this accident.

December 19. A small portion of
bone has escaped at the wound on the
head of the tibia, and the swelling is en-
tirely gone. The wound healed very
shortly after this ; and some months after-
wards the boy called to show me that he
continued quite well.

CASE 6.

J. M., residing at Kingsland, between
five and six years old, was brought to me
on the 2d of September, 182G, with a
disease in the left knee. It was much
swelled, from effusion of lymph into the
parietes of the joint and the surrounding

175

ceJlular membrane, but without fluid in
its cavity. The joint appeared to be wider
than natural, was exceedingly tender, and
so painful as to destroy his rest. The
motions of the limb were very much con-
fined by the deposit, and were still more
limited by the great pain experienced in
any attempt to straighten or bend the
joint. There was a sinus on the outside
of the leg, just below the head of the
fibula ; the leg was permanently bent
upon the thigh at a considerable angle,
and the whole limb much wasted. The
health and appetite of the patient were
impaired ; he was emaciated, and troubled
with a constant cough and expectoration
of mucus ; the bowels were regularly re-
lieved every day, and the tongue clean.
He had been previously subject to glan-
dular swellings in the neck, and about
three years before he fell down and broke
Lis arm and bruised his knee. The for-
mer readily united ; but the latter was not
particularly attended to, and in a few

176

months began to be swelled, somewhat
tender, and occasionally painful. Leeches
were applied, succeeded by poultices, and
subsequently blisters were four or five
times repeated, absolute rest being ob-
served. These means reduced the swell-
ing in a very trifling degree only, and at
this time he could not bear the smallest
alteration in the relative position of the
limb. Some time afterwards, adhesive
plasters and a bandage were applied, with-
out any alleviation of the symptoms.
Poultices were again had recourse to for
two months, during which time an abscess
formed, and produced the sinus that has
since remained open. This sinus was
injected with stimulating lotions every day
for a month ; but they produced consider-
able Inflammation, and did not at all
promote its healing.

My usual treatment was now adopted ;
but conceiving that the state of constitu-
tional irritation was produced entirely by

177

the local disease, I did not prescribe him
any medicine.

September 30. Since the joint has
been so effectually supported, although
he could not bear it to be bent or straight-
ened, he has been able to use such a de-
gree of exercise, with the limb perfectly
stiff, as has counteracted any benefit that
he might otherwise have derived from the
means adopted. The complaint, there-
fore, is not at all relieved.

October 28. He has walked on crutches
ever since his last visit, and I never saw
greater improvement in any similar dis-
ease than has taken place in this case*
The tumefaction, tenderness, pain, and
contraction of the leg are all diminished ;
he can bear the joint to be moved more
extensively, and the sinus is perfectly
healed : his health and appetite are very
much improved.

November 20. Very great amendment
has taken place since his last visit. He
can now walk on the limb, bend and

ITS

straighten it to the fullest extent that a
healthy joint will admit of, without the
least pain, and it is not at all tender to
the touch. He has some eruptions be-
hind the ears and on the head, of a scro-
fulous character.

December 14. The joint is in all re-
spects quite as well as the other. The
only difference that can possibly be dis-
covered between the two is that it ap-
pears to be rather wider, arising from the
muscles not having yet recovered their
natural size, although they have very ma-
terially increased in bulk. The eruption
h^ been removed for some time, he
has been in the country for the last month,
and has perfectly recovered his health.

CASE 7.

H. W., eleven years of age, residing at
Walworth, applied to me in January,
1826, with a disease in the left knee.

179

which was very much enlarged. The
swelling was produced by the effusion of
]ymph, there being no fluid in the cavity.
There was a sinus just at the extremity
of the inner condyle, communicating with
the joint, and another above the outer
condjle. The leg was permanently bent
at a right angle to the thigh, and they
were both very much wasted. Any at-
tempt to alter the relative position of the
limb was intolerable. The joint was so
tender, that he could scarcely suffer it to
be touched. The pain was incessant, and
so severe as altogether to destroy his rest
during the early part of the night, when
he was constantly disturbed by spasmodic
muscular contractions, and subject to
violent perspirations.

He was of a fair complexion, with light
hair and eyes, the pulse quick, the skin
moist, tongue foul, bowels irregular, and
the appetite impaired. The disease had
been of two years and a half standing. In
July 1823, the joint being so weak as to
N 2

occasion him to limp in walking, was first
observed to be somewhat swelled, and
slightly tender ; but it was not painful,
and could be perfectly straightened. It
Was rubbed with a white ointment, which
brought out a great many pimples, and
by which the skin was kept sore for six
months ; adhesive plasters were after-
wards employed ; but they aggravated the
complaint from being, as he supposed,
too tightly applied. Subsequently, leeches
and poultices were had recourse to, and
afforded him some relief. A perpetual
blister was next recommended, and kept
open for three weeks. During the use of
this remedy, the leg became contracted
nearly as much as it now is, having been
quite straight before the application of
the blister. Various other applications
Were also adopted, notwithstanding the
use of which, the pain, swelling, and con-
traction continued to increase. Thejoint
became enormously distended, and burst
at the extremity of the inner condyle in

181

November 1825. At this time, and sub-
sequently, it discharged very much, and
a quantity of substance resembling curds
escaped at the wound. Some time after-
wards an abscess on the outside of the
femur formed and burst, leaving the sinus
there situated.

January 1. 1826. The following medi-
cine was prescribed :

R. Hydrarg. SubmuriaL gr, ij.
Rhei Pulv. gr. v^.
njl ft, Puivis sumend. in melle bis septimane.
R. Magnesi^e Sulphatis ^j.
Infus. HosiB 3 X.
Tinct. Cardam. Comp. 3J.
191 ft. Haiistus bis quotidie sumeiidus.

Eight leeches were directed to be ap-
plied to the knee twice a week for a fort-
night, and fomentations and poultices
were constantly employed.

January 14. The tenderness, pain, and
swelling are so much reduced, that the
knee is now in a fit state for mechanical
support, conjointly with the other means

N 3

Ig2

that have been detailed. The bowels
have been regularly relieved by the me-
dicines, the tongue is less coated, and the
appetite somewhat improved.

January 25. The swelling, pain, and
tenderness are very much relieved. He
is now entirely free from pain, except
on motion, and can even make an eiFort,
when in bed, to straighten the limb,
which is consequently less contracted.
He cannot bear to have the joint moved,
but can now walk on crutches without any
inconvenience.

February 8. The joint is much reduced
in size, and there is a proportionate dimi-
nution of the symptoms. He can bear
the limb to be moved in either direction,
but the motion of the joint is extremely
limited. It is not at all tender, and the
sinus on the outside of the thigh is en-
tirely healed.

From this time, the joint continued in
a progressive state of amendment ; in the
following April he was allowed to use It,

183

and could not only bear the weight of the
body on it as well as on the sound limb,
but could also walk up stairs with the
greatest facility. The limb Is very much
contractedj and the joint allows of but
very little motion. His health is quite
restored.

CASE 8.

A young gentleman, of light com-
plexion, thirteen years of age, residing
near Market Harborough, in Leicester-
shire, was brought to me on the 8th of
January, on account of a disease in his
right knee. The joint was very much
swelled and very tender ; the synovial
membrane was thickened in its texture,
adherent to the surrounding cellular
membrane, and considerably distended by
the effusion of fluid into its cavity. There
was a sinus on each side of the head of
the tibia, the result of previous abscesses ;
N -1

the tumefactions of the soft parts extend-
ed considerably over the head of the
tibia, and the condyles of the femur. The
shghtest movement of the articulating
surfaces on each other gave him so great
pain, that he could not endure it : the
joint was quite easy, except when touched
or moved. The leg and thigh were
wasted, and he had profuse nocturnal
perspirations; he was very thin andema^
ciated, his countenance pale, pulse weak
and frequent.

There was a sinus on the metatarsal
bone of the little toe of the aifectedlimb.
The disease in the knee had been nearly
of two years' duration, from an injury he
received in March 1822. He felt no in-
convenience from the accident until the
beginning of April. The joint then first
became swelled and painful when touched
or moved ; at other times, it was entirely
free from pain, but very weak. These
symptoms rather increased, so that in the
beginning of May he began to limp, but

185

continued to use exercise until June, when
he rested the limb altogethei*. Leeches
and a bread-and-water poultice were ap-
plied, and continued till the following
August, without affording any benefit.
An issue of the size of a half crown was
then made over the tendon of the rectus,
and soon after he went into the country j
but the issue was kept open for about two
months. Subsequently, a dozen leeches
were repeatedly applied, and an ointment
was used that brought out a great many
pimples, and destroyed his rest. These
remedies were continued till the follow-
ing April, when he returned to town with
the disease worse than when he left it.
Poultices were again applied, and subse-
quently two issues, each of the size of a
half crown, were made; one in the situa-
tion of the former, and the other on the
head of the tibia. In .July he went to
Margate, where he remained four months ;
the lower issue was healed, the upper one
only remaining open. In October he re-

186

turned to town, and the upper issue was
kept opeu until the following January.
These means, however, were inadequate
to control the disease, which continued
its progress in an uninterrupted course.
The tenderness, tumefaction, and difficulty
of moving the joint gradually increased,
and his general health, which had been
previously good, declined. During the
greater part of the time he was taking
such medicines as were considered to be
calculated to remove the disorder of his
digestive organs, and to improve the state
of his constitution ; but they were of course
incapable of counterbalancing the irrita-
tion and debility resulting from local dis-
ease so extensive and so long continued.

The treatment that has been before
related was now had recourse to in this
case, and small doses of calomel and rhu-
barb, conjointly with neutral salts, were
prescribed.

January 15. The joint is much less
swelled, and less tender, he can bear it

187

to be moved without suffering so much
pain as on his last visit, and he has been
able to walk on crutches without incon-
venience, since the mechanical support
was afforded to the joint.

His tongue is less coated, and the
bowels have been more freely opened.

January 29. Since his last visit the
joint is impi'oved in all respects, as well
as his general health.

February 12. He can now raise the
limb by its own muscles ; the tumefaction
and tenderness have in a great degree
subsided, and the discharge from the
sinuses is very much diminished.

June 11. The sinuses that resulted
from the abscesses on each side of the
head of the tibia are healed. The ten-
derness of the joint is not now complained
of: he can move it without the least pain,
and bend and straighten it much more
extensively. It is nearly reduced to its
original size, and he is sufficiently re-
covered to return into the country.

188

The event of this case was a complete
restoration of the limb, which increased
in strength very rapidly during his resi-
dence in the country, and he has not had
any return of the disease. The motion
of the joint is very limited.

CASE 9.

In August, 1824, I was consulted on
the case of a young gentleman residing
at Derby, whose left knee-joint was the
seat of disease. The joint was much en-
larged, very tender, and very painful,
more especially at night ; he could not
bear the least movement of the joint.
The leg and thigh were much wasted,
and indeed the whole body greatly ema-
ciated. There were two deep sinuses,
one extending considerably upwards on
the inside of the femur ; the other, at
which a large portion of the inner con-
dyle of the bone protruded, in a atate of

189

exfoliation, leading directly into the ca-
vity of the joint. The discharge was pro-
fuse and very offensive, and the leg con-
siderably bent upon the thigh.

His bowels were disordered, and his
stools clay-coloured ; the appetite impair-
ed, and tongue foul. Perspiration was
frequent in the day, and profuse at night.

It was stated that in February, 1824,
the natural small-pox left the child in a
very reduced state, and was succeeded by
glandular swellings in the neck. An
abscess then formed above the inner con-
dyle of the thigh-bone, and was opened,
the sinus still remaining. Another ab-
scess formed In the vicinity of the shoul-
der-joint, but has since healed. Soon
afterwards, the left knee-joint became
swelled and tender, attended with pain on
motion, which increased so as shortly to
deprive him of the power of walking.
Another abscess then formed just on
the front of the knee, and was also open-
ed. After this, both the local symptoms

190

and the constitutional disturbance were
most materially augmented. The joint
became so painful, that he could neither
rest, nor bear it to be touched or moved ;
it increased in size very much, and dis-
charged through the sinus at the end of
the inner condyle of the bone.

During all this time, though leeches,
poultices, fomentations, and a variety of
other applications were used, as well as
such medicines as were considered to be
adapted to the case, no diminution of the
disease, and consequently no improve-
ment in the state of his constitution, took
place. The sinuses were opened, probed,
and stimulating injections employed,
without inducing healthy action, or even
preventing their extension.

About the end of June he was brought
to town, when a surgeon of eminence
gave it as his opinion that, in the event
of the child recovering from the com-
plaint (of which there was not much
probabihty), it would eventually be a

191

stifF joint. In order to promote this
result, he directed a splint, somewhat
curved, to be constantly worn, to fix the
joint at such an angle as should be con-
venient for his using the limb in future.

I prescribed small doses of calomel
and rhubarb to be taken every third day,
and Epsom salts, with sulphuric acid, in
the intermediate time ; the knee was
dressed in my usual manner.

September 13. The mode of treatment
I first adopted has been continued to this
time, with a gradual although not a rapid
improvement in the complaint. The
joint is now much less tender, except on
motion ; it will admit of being moved ex-
tensively without pain. He sleeps well
at night, his stools are of a better colour,
his appetite somewhat but not much im-
proved, and his bowels have been kept
regularly open by the medicine pre-
scribed.

October 1. I removed a portion of
the bone, which came away with facility ;

192

and the joint is improved, the discharge
is diminished, and the perspirations are
less profuse. Small doses of Hydr. c.
creta were now prescribed to be taken at
bed-time, and the powder of sarsaparilla
in the day.

October 12. Another portion of the
bone was removed, and the knee is much
reduced in size.

October 22. There has been a very
decided amendment in all respects during
the last three weeks ; his appetite and
general appearance are much improved,
his strength is increased, perspirations
lessened, and the discharge very much
diminished. He was now directed to
take the sulphate of quinine. Mr. Ham-
mond of Edmonton was good enough to
visit the patient with me this morning,
and found the disease much more reduced
than he expected. I consider that the
successful issue of this case was essentially
promoted by the kind attentions of Mr.
Hammond, and his judicious manage-

193

ment of the patient while under our
joint care. ^

November 5. There has been an uni-
form and gradual amendment of the
complaint, and the patient has been able
to use the limb so freely, that he has
altogether loosened and displaced the
applications since his last visit ; he is
now in much better health, and the sinus
on the inside of the thigh is healed.

December 18. A large piece of bone
was removed this morning, and a small
piece still remains, which is not yet quite
loose. The thickening is almost absorbed,
and his health is perfectly good.

Soon after this date, the remaining
portion of the bone came away ; the sinus
healed very shortly afterwards, and the
boy regained the use of the limb ; and so
far from his having a stiff joint, lie can
bend and straighten the leg very nearly,
although not quite as fully as the other.

When I last heard of this patient, No-
vember 24, 1826, he continued quite

194

well, and was able to run about on the
limb as much as before he had had any
disease.

CASE 10.

Maria Green, thirteen years of age, was
brought to me on the 6th of January,
1822, having a disease in the left knee.
There was a general fulness and swelling
of the articulation, which was painful and
tender when pressed, particularly on the
inner condyle of the femur. The joint
was much contracted, and the swelling
chiefly prominent on each side of the
ligament of the patella. The pain was
most distressing at night, and much ag-
gravated, by exercise, and by the flexion
or extension of the limb. The health
was not affected.

Five months before, she fell down and
bruised her knee, in consequence of
which accident it became swelled, tender.

195

and painful. These symptoms subsided
in a great degree ; but atlerwards they
became more severe, and gradually in-
creased until she could neither walk on the
limb, nor straighten it when in bed, her
rest also was much disturbed. This case
was now treated in my usual manner.

January 20. The application has pro-
duced its full eifect, and is attended with
a marked diminution of the symptoms.

February 4. The joint is considerably
improved since her last visit, and is now
entirely free from pain when at rest.

February 21. The swelling is much
reduced, there is very little tenderness,
and the motion of the joint is more ex-
tensive.

March 10. The joint is not at all ten-
der, and she can walk on it without pain ;
but it is still very weak.

March 27. The swelling is entirely
removed, there is no pain in the joint,
even when fully extended, but it still re-
mains very weak.

196

April 18. She has acquired much
strength in the limb since her last visit,
and is now able to use it tolerably well
without inconvenience ; but it appears de-
sirable to continue the mechanical sup-
port, as the joint is not sufficiently strong
to leave it oif.

CASE 11.

A young gentleman, fifteen years of
age, residing at Clapham, consulted me
on the ^d of February, 1822, on account
of a disease in the right knee. There was
considerable tumefaction of the joint, aris-
ing principally from the effusion of fluid
into its cavity. The swelling was chiefly
prominent beneath the tendon of the ex-
tensor muscles. He complained greatly
of tenderness on pressure, and of pain in
the joint, which was increased by exercise
or motion, so as to occasion him to walk

■

197

very lame, and prevent him from straight-
ening the knee. He was in good health.

He informed me, that for the last
twelve months he had experienced stiflF-
ness and difficulty in moving the joint,
attended sometimes with a grating sensa^
tion, and with pain on straightening the
limb, more particularly on first exercising
it ; subsequently he observed the joint to
be somewhat swelled ; the enlargement,
however, subsided in a great measure, and
again appeared. He did not pay much
attention to the complaint until about a
month ago, when the symptoms became
more inconvenient, and they have since
been gradually increasing in severity.

I adopted my usual treatment in this
case.

February 11. During the last two days
he has felt much less pain and inconve-
nience in the joint, and it is also reduced
in size.

February 25. He ia now altogether free
from pain ; the stiffness and grating sens-
o 3

198

atlon on moving the joint are removed ;
he can walk on, and straighten the Hmb,
without the least inconvenience, and the
swelhng is very much reduced.

March 7. The joint is now reduced
to its natural size ; he can use it perfectly,
and it is to all appearance quite free from
disease.

In this case there has since been no
return of the complaint.

>i CASE 12. ■*

Anne Slowe, sixteen years of age, ap-
plied to me, on the 26th of March, with
a disease in the right knee. The joint
was considerably enlarged, both from ef-
fusion into the cavity, and from thicken-
ing of its parietes. Pressure just beneath
the patella gave extreme pain : she could
not bend nor straighten the limb, nor even
walk with it in the half-bent position.
The swelling was chiefly prominent on

I \

199

each aide of the ligament of the patella ;
her health was tolerably good, but some
years before, she had had an enlarge-
ment in the glands of the neck. About
seven years ago, she fell down, and cut
her knee, just below the patella : the
wound soon healed of itself, but the joint
continued very painful and swelled for
a month or more. When rested, it be-
came better ; when exerted, worse. The
joint continued in this state, occasionally
better and worse, until she went to ser-
vice, which she was soon obliged to
leave, on account of the increased pain in
the knee. It became much more swelled
and tender, so that she could not walk
upon, or use the limb, and at length she
was unable even to straighten it in bed.

Eight ounces of blood were abstracted
by cupping-glasses, before my applications
were put on.

April 10. The joint has been gradu-
ally improving ; the pain, tenderness, and
swelling are much reduced. She is quite
o 4

200

free from pain, except on moving the
limb, and can sleep all night. The mo-
tion of the joint is more extensive.

April 23. The swelling of the joint is
entirely removed; it is much stronger,
free from pain, and capable of perfect
flexion and extension.

Mechanical support was continued for
some time longer, and the joint has re-
mained perfectly well.

CASE 13.

Mr. S., thirty-one years of age, residing
at Royston, applied to me on the 17th of
January 1823, on account of a disease in
the right knee. The joint was very much
swelled, and its cavity distended with
fluid. The swelling was chiefly promi-
nent on each side of the ligamentum pa-
tellse; the tendon of the rectus muscle was
also elevated, and the cavity distended on
each side of it. The synovial membrane

201

appeared to be thickened in its texture.
Pressure on the ligament of the patella
caused great pain, the chief seat of which
was referred in that direction to a spot in
the centre of the joint Every movement
of the joint was attended with great pain ;
the patient was unable to bend or
straighten his knee corapletely,and walked
with it in the half-bent position.

About six weeks previously he felt
pain in the knee ; it was rather swelled,
and tender, which caused him to limp in
walking, and he could neither bend nor
straighten the limb without inconve-
nience. About four days from the time
of his first feeling pain, he strained the
knee in walking down a ladder, which
occasioned a blackness down the calf of
the leg : after this, the complaint became
much worse. The pain was so riolent
for a few hours on the following day as
to be almost intolerable : as it subsided,
tlie joint became more swelled and very
stiff. The next day, the joint having been

202

subjected to exercise, a violent accession
of pain ensued, succeeded by an increase
of swelling. These symptoms were in
some degree alleviated by resting the
limb, and applying leeches and foment-
ation. As the inflammation did not sub-
side, cupping was had recourse to, suc-
ceeded by liniments, which gave some
relief to the symptoms. He stated that
from the first, great inconvenience had
been occasioned by the patella not mov-
ing freely over the bones beneath ; the
surfaces, I suppose, not being sufficiently
lubricated in consequence of the inflam-
mation.

The joint was cupped previously to my
applications being used, and some saline
purgative medicine was prescribed.

January 31. The joint has been in
much less pain, and is reduced in size;
it can be more easily and extensively
moved, but is still tender, and will not
admit of being fully bent or straightened.
The cupping and applications repeated.

203

February 14. The fluid is entirely
absorbed; the synovial membrane is still
somewhat thickened and tender, particu-
larly when pressed in the situation of the
ligamentum patellee; he can fully bend
and straighten the joint, and can walk
without much inconvenience. The free
motion of the patella is still obstructed.

February 28. The joint is nearly
restored to its natural state : the only
complaint he now makes is, that it is
rather weaker than before.

This case has since remained quite
well.

CASE 14.

A lady, residing in Charlotte Street,
Bloomsbury Square, consulted me on the
10th of April, 1822, having the following
complaint in her left knee: — There was
excessive tumefaction of the joint, arising
entirely from distention of the synovial

204

membrane, with scarcely any thickening
of its texture. It was tender when
pressed, very paini'ul, more particularly
on using exercise, and so extremely weak
that she walked with the greatest diffi-
culty.

She informed me that about six years
before, a violent swelling of the joint
suddenly occurred. It was excessively
tender, very painful, and as hard as a
stone. A number of leeches were ap-
plied without any good effect, and then
blisters were employed to a considerable
extent. Under this treatment the disease
was relieved, and the joint restored to its
natural state.

It remained quite well for about four
years; and In October, 1821, from the
effects of cold, as she believed, the joint
became stiff and uneasy ; tenderness and
pain were subsequently experienced, and
then it began to enlarge. The swelling
continued to increase gradually for about
six days, when it gradually subsided. The

205

reduction of the joint to its natural size
required rather a longer time than was
occupied in arriving at its height ; so that
the whole time, from the commencement
to the dispersion of the swelling, was
about a fortnight. As soon, however, as
the joint was reduced to its natural dimen-
sions, it began to increase in size, and
continued to enlarge for about six days ;
at the end of which time the parietes of
the joint were distended to the utmost
degree they were capable of bearing. The
swelling then began to give way, and in
about eight days the joint was restored to
its natural size. While the tumefaction
was at its greatest height, the joint was,
very tender, and so painful that the patient
could scarcely set her foot to the ground ;
as soon, however, as the swelling began
to abate, the pain was relieved in an equal
degree, and indeed it appeared to be pro-
duced solely by the great distention of
the synovial membrane.

206

No sooner, however, was the fluid re-
absorbed, than it would begin to accumu-
late, and again subside ; the whole process
being carried on in the same manner, and
occupying the same time, as before. The
disease had continued to pursue the same
course from the above-mentioned time,
without any deviation.

In the first instance, leeches were em-
ployed, and blisters, six or seven in suc-
cession : each one, however, appeared to
make the joint weaker than before. Sti-
mulating embrocations, hemlock, and
other poultices, and various other reme-
dies, were used, without producing the
slightest alteration in the progress of the
complaint. I treated this case in my
usual manner : as the patient invariably
neglected to take the medicines which
were repeatedly prescribed for her deli-
cate state of health, the complaint cannot
have been influenced by any constitu-
tional remedies ; they need not, there-
fore, be transcribed.

207

April 24. The joint is in much the
same state as when I saw it a fortnight
since. She states that the swelling has
subsided and re-appeared in the usual
manner. The applications have not pro-
duced much effect on the skin.

May 8. The disease has not under-
gone the slightest alteration, although the
effect of the applications on the skin has
been more considerable.

May 22. The former progress of the
disease appears to have been influenced ;
the joint is certainly less swelled than
when I last saw it, and the tumefaction
has not reached the height which it pre-
viously attained. There is considerable
irritation on the skin.

June 5. The joint is much stronger
than it was on her last visit, and is not
nearly so much swelled. She states that
the swelling subsided much sooner after
I last saw her than it was accustomed to
do, and that, after its subsidence, there

208

was an interval of a day before it again
began to enlarge.

June 19. Although the joint still con-
tinues to enlarge, the swelling, when at
its greatest height, has not attained above
half its accustomed size ; and there is
now an interval of two or three days
after its subsidence, before there is any
appearance of re-accumulation.

July 30. The size of the swelling has
been gradually diminishing on each ac-
cession, and the hiterval between the
reduction of the joint and the recom-
mencement of the tumefaction has been
continually augmented. It has now alto-
gether ceased to swell, and though the
joint is much stronger, still it requires to
be supported, to enable her to take her
accustomed exercise, which, indeed, she
has continued to the present time.

The joint continued quite well until
January, 1826, when she had an attack
of similar disease in the right knee, and
the left knee also became affected. By

209-

pursuing the same mode of treatment for
between two and three months, the dis-
ease was arrested in both knees, and thej
have continued free from it to this time,
January, 1827.

CASE 15.

Francis Emmerton, thirty years of age,
residing in Bartholomew Close, came un-
der my care on the 5th of February, 1821 ,
with a disease in the left knee.

There was in this case greater tume-
faction of the joint than I ever remember
to have seen before. The cavity was
amazingly distended ; its parietes were
thickened, and adhered to the suiTound-
ing integuments. It presented the ap-
pearance of an oval tumour, excluding
entirely from view the natural promi-
nences of the joint. The tendon of
the rectus muscle was elevated by the
fluid contained in its bursa, and it was

210

equally distended laterally. The joint
was so painful, that he could neither
rest night nor day. Any attempt to
alter the relative position of the limb
was attended with agony, and he could
not even bear to walk on crutches with
his foot in a sling. The leg was very
much bent, and the whole limb was
greatly wasted. The joint was more par-
ticularly tender just beneath the lower
edge of the patella, which part he de-
scribed as being the cliief seat of the pain.

He was dreadfully emaciated and ex-
hausted by the continuance of disease,
and was drenched in perspiration at
night.

In June, 1814, he strained his knee;
it remained weak, stiff, and swelled, but
not painful. An ointment, which pro-
duced a great many pustules, was rubbed
on to the knee, with which it was kept
sore for six months. Strengthening plas-
ters were then applied ; but neither of
these remedies were productive of any

211

benefit, nor did he derive relief from cup-
ping. He continued in this state for
nearly a year. The joint first began to
be painful during exercise ; it was quite
easy when at rest, nor did it prevent him
from pursuing his employment as a brick-
layer for between two and three years.

In November, 1816, he went into an
hospital, and remained there for thirteen
weeks. During this time, by means of
blisters and issues, conjointly with abso-
lute rest, the disease was so much relieved
that, after he had left the hospital a
twelvemonth, he was able to resume his
employment, although it was attended
with considerable pain. He continued
to walk on the limb for three years, but
was obliged to keep the issue open during
the whole time ; for, whenever it began
to heal, the disease became worse.

In October, 1820, having injured the

joint by trifling accidents at different

times, it became so painful, that he was

obliged to give up his employment ; even

p 2

21S

now, however, he could walk on the
limb, although with great inconvenience;
it was but little swelled.

He then returned to the hospital, and
remained there four months, duringwhich
time poultices were employed, leeches
applied twice a week, and a large issue
was made on each condyle of the femur.
Notwithstanding the use of these reme-
dies, the disease became rapidly worse,
and the joint distended to the enormous
size before described. * His health suffered
very materially, and the powers of his
constitution wei'e so much exhausted by
the disease, that amputation was proposed
to him as the only means of saving his
life ; but he refused to submit to the ope-
ration, and left the hospital with great
pain and difficulty. His strength was so
excessively reduced, that I did not like
even to repeat the local bleeding which
had been employed so frequently without
arresting the disease ; and, indeed, I en-
tertained very little hopes that any means

2] 3

would be able to control it. I thought
it right, however, to make the attempt,
and adopted the plan of treatment that
has been alreadydetailedwith the greatest
care and precision, and desired that I
might be informed if he did not find
himself relieved by it.

March 2. He has been more free
from pain, the joint is less swelled, and
his health is rather improved, sufficiently
so to encourage me to proceed in at-
tempting to save the limb.

March 15. He is much better, is now
able to walk on his crutches without much
pain ; the joint is reduced in size, less
tender, and less contracted.

March 29. The joint is not much
better : twelve ounces of blood were
taken from the knee by cupping, before
the renewal of the applications.

April 11. He is now much improved

in health ; the pain and tenderness have

been materially less since he was cupped ;

the swelling is also reduced, and he can

p 3

214

move the limb with greater ease. Cup-
ping was again had recourse to before
the applications were renewed.

April 25. He has been gradually im-
proving since his last visit, and the limb
is less contracted : the cupping and ap-
plications were repeated.

May 9. He states that he has had
much less pain, and the joint is evidently
more materially improved ; it is less ten-
der, much straighter, and he can bear a
little weight on the toes. Cupping and
applications renewed as before.

May 22. On the 12th instant, his
crutch slipped as he was ascending a
staircase, and, in order to save himself
from falling, he was obliged to tlirow his
whole weight on the diseased limb, which
was thus so much strained, as to occasion
very great pain. He removed the dress-
ings, and re-applied them, after having
put on some leeches. The pain gradually
subsided, and, in a week's time, he was as

215

well as before the accident The cupping
and applications repeated.

June 19. The joint is much less swell-
ed, and straighter ; the bursa under the
tendon of the rectus muscle does not
appear so prominent, notwithstanding the
uniform diminution of the swelling. The
integuments, instead of being in a state
of tension, are now quite relaxed, and he
can bear more weight on the limb than
on his last visit. The applications were
repeated.

July 15. The joint has not continued,
to make the same rapid progress towards
recovery as before, and he is not yet free
from pain. Cupping and applications
repeated.

August 9. He is now entirely free
from pain, excepting what he occasionally
feels when turning in bed. He can bear
his weight on the limb, the effused fluid
is entirely absorbed, and the joint nearly,
if not quite as small as the other. There
remains the slightest tenderness, on pres-
p 4

216

sure, just on the outer side of the head of
the tibia, but not on any other part ; the
leg is very nearly straight, but the joint
quite stiff.

Although the disease and its conse-
quences were so speedily removed in this
instance, almost a year and a half elapsed
before the knee had acquired sufficient
strength to enable him to walk on it with
that degree of confidence which could
induce me to allow him to throw aside
his crutches altogether. I presume that
the bones had become so much softened
in their texture, by disease of seven years'
continuance, that a considerable time
after its subsidence must necessarily have
elapsed, before ossific union could take
place. At the expiration of the time I
speak of, this was accomplished ; the limb
is firmly anchylosed, and is not more bent
than is desirable to enable him to walk
with ease on a stifFjoint. He soon after
returned to his avocations, and has pur-

217

sued them from that time to the present
(1826) without any interruptionwhatever.

CASE 16.

A lady residing in the neighbourhood
of Brunswick-Square consulted me on
account of a disease in the left knee, on
the 10th of March, 1826.

There was no tumefaction of the joint,
but it was slightly tender to the touch.
She complained of a constant shooting
pain deeply seated in the joint, and much
increased by any attempt to bend or
straighten the limb, the least movement
of it being attended with extreme pain.
She suffered so much at night, that her
rest was much impaired, and she could
find no easy posture for the limb, the
half-bent position being that in which it
was the least uneasy. The pain pro-
ceeded up the thigh, to the hip, very
frequently ; the joint was so excessively

218

weak, that she could scarcely bear any
weight on it. She was a stout, middle-
aged woman, in tolerably good health.
She had frequently felt pains in various
parts of the limb for a very considerable
time ; but the symptoms had of late in-
creased with rapidity to the degree just
described. I treated this case in my
usual manner.

March 24. The limb is stronger, the
pain much less severe, and confined alto-
gether to the knee : she no longer feels
any pain in the hip, and the joint is not
tender on pressure.

April 8. She is now quite free from
uneasiness, except on moving the joint,
and is not at all disturbed at night : there
is still some pain in flexion and exten-
sion, more especially the latter.

April 22. The joint has been gra-
dually improving and becoming stronger,
and is perfectly free from pain ; on first
rising in the morning, it appears quite
well, until it has been used during the

219

day ; in the evening, it is rather stiff and
uneasy.

May 5. She now feels no inconve-
nience whatever in the joint beyond what
arises from a slight degree of stiffness
after the too free use of it. This case
continued quite well in January, 1827.

CASE 17.

Mr. W. W , twenty-eight years of

age, residing in the Regent's Park, con-
sulted me on the 4th of January, 1826,
on account of a disease of the left knee.

The slightest movement of the joint
was attended with extreme pain : he was
utterly unable to raise his leg by its ex-
tensor muscles, but could bear to have
it elevated by his hand, provided that in
so doing there was neither friction nor
pressure upon the cartilaginous surfaces.
The synovial membrane was neither
swelled nor tender ; there appeared to

be some effusion into the cellular mem-
brane above and around the patella; and
if this bone were rubbed against the con-
dyles of the femur, a grating noise and
extreme pain were produced. He could
walk with his leg, when straight, toler-
ably well, and without very material
inconvenience, until he bad continued to
use it for a short time, after which the
pain became very severe. He was com-
paratively easy when the leg was straight ;
but the bent position was always painful.
He was much troubled with spasmodic
starting of the affected limb at night ;
the leg and thigh were much wasted, the
nates being in a natural state.

In the winters of 1821 — 1822, when
travelling on the continent, and in the
habit of using violent exercise, he first
perceived pain in the knee after exertion,
and the whole limb was fatigued sooner
than the other. From that time the limb
had always been affected in a greater or
less degree i after undergoing much exer-

221

tion it would be so painful, swelled, and
tender, that he has been repeatedly
obliged to rest it entirely, after which it
became better, so that he could walk
with only the ordinary pain he was accus-
tomed to. He said he had never been
free from pain for the last four years,
and that the symptoms, together with
the weakness of the limb, and the diffi-
culty of using it, had been gradually
increasing, until they incapacitated him
from pursuing his usual avocations. Ten
ounces of blood were I'emoved by cup-
ping piior to my applications being used.

January 25. The pain continued
equally severe for some days ; but it is
now considerably abated : he can bear
the limb to be bent and straightened
without pain, and it is much less severe
when the patella is moved on the con-
dyles of the femur.

April 25. He can bend and straighten
the knee, and elevate the leg, by its ex-
tensor muscles, without the slightest

inconvenience. He can walk on the

limb perfectly, nor does lie suffer any

pain from nibbing the patella on the
condyles of the femur.

In this case an accession of disease
was subsequently brought on by a too
free use of the limb. The means be-
fore detailed were persevered in ; but it
was not until October following that the
joint was completely recovered. He then
went into the country, and left off his
crutches. Since that time he has had no
return of the disease, but has been gra-
dually acquiring strength, and has been
able to walk a distance of five miles with-
out inconvenience.

March 7, 1827. The joint is in all
respects perfectly well.

CASE 18.

A lady, forty-five years of age, resid-
ing in one of the principal market towns
in Essex, applied to me on the 16th of
May, 1823, on account of a disease in her
left knee.

A spot on the inner side of the head
of the tibia was so excessively tender, that
she could not bear to have it touched.
There was neither pain nor tenderness
throughout the remainder of the joint,
although there was a general fulness and
tumefaction over the whole synovial
membrane. She could neither straighten
the limb, nor bend it, without great
pain, nor could she raise or extend
the leg by its own muscles. The
slightest motion of the joint, or any at-
tempt to bear weight on it, occasioned
very great pain. The limb was much
wasted ; she was greatly distressed at
night by spasmodic contractions of the

muscles. All these symptoms she de-
scribed as gradually increasing.

She was evidently labouring under
considerable disorder of tlie digestive
organs, which the medicine she had
been taking failed to remedy.

When a child, she was affected with
glandular swellings in the neck. In Au-
gust, 1S22, she injured her knee by bruis-
ing the part that is now so tender against
a bedstead. From that time she had
always felt pain, weakness, and inconve-
nience in it, in a greater or less degree.
The pain was not constant, nor the incon-
venience very great, until about Christ-
mas last, when she was unable to place
the left leg foremost in going up stairs,
and the symptoms becoming more se-
vere, she attributed them to rheumatism.
The joint was then excessively weak, and
very painful on first moving the Hmb in
the morning; she also experienced more
inconvenience after exercise than during
its continuance. At this time tliere was

225

not the least swelling perceptible, but
she was much distressed by spasmodic
muscular action.

She used various stimulating applica^
tions, expecting, that as the weather be-
came milder, the complaint would sub-
side, instead of which it became gra-
dually worse, and early in the spring she
first perceived that the joint was swelled.
The joint was dressed in my usual way,
and the following medicine was pre-
scribed :

R Hytlrarg. Submur. gr, ij.

Extract! Colocynth. Comp, gr. viij.
tiji. et divide iq pllulas ij. aUernis noctibus sumendas.
R Magnes. Siilphatis ^j.
Tincturai Humuli 3 j.
Infusi Caryopli. ^iss.
- Ii)i ft. Haustua bis quolidie sumendus.

• May 31. She has had no pain nor
spasmodic action of the muscles since
the joint has been mechanically support-
ed, but the spot is equally tender to the

touch. The applications have not pro-
duced sufficient irritation.

April 14. The joint is not improved,
nor have the applications yet produced
the requisite degree of irritation on the
skin, which is excessively indolent.
Twelve ounces of blood were now re-
moved from the knee by cupping, and
some tartar emetic ointment was rubbed
on to the part before the dressings were
applied.

April 28. The applications have pro-
duced their full effect on the skin, and
the joint is very much improved in all
respects ; the pain, swelling, and tender-
ness are considerably relieved, and she
can extend and bend the leg by its own
muscles.

From this time, by persevering in the
same means, the disease gradually sub-
sided, the flexion and extension of the
joint were attended with less pain, the
swelling soon subsided entirely, and the
joint was restored to its natural state.

227

It remained, however, very weak, and
as she was a heavy woman, I was anxious
to prevent her from using the Umb for a
considerable time. There still remained
a slight grating noise on moving the pa-
tella on the bones beneath it, but this
was unattended with pain or any incon-
venience.

CASE 19.

For the notes of the following case I
am indebted to Mr, Smith, of Grace-
church Street, as well as for his able
assistance, which essentially contributed
to its favourable termination.

In January, 1824, I was requested to
visit a young gentleman, thirteen years
of age, residing in the city, in consulta-
tion with Mr. Smith. The patient com-
plained of great pain in the right hip ; it
was so severe as to deprive him entirely
of rest during the early part of the
Q 2

night ; and the tenderness of the groin
and nates was great. There was con-
siderable swelhng on the outer part of
the thigh by the side of the great tro-
chanter, with evident fluctuation of mat-
ter deeply seated, and any attempt at
the flexion or extension of the thigh
caused extreme pain. The limb was
elongated and inclined forward ; the nates
as well as the muscles of the leg and
thigh were flabby and wasted ; and he had
experienced occasional rigours in an
evening.

He stated that about May, 1823, he
first felt pain in the right thigh, which
was so weak and painful as to cause him
to limp in walking. Some stimulating
applications were used at this time, and
leeches were afterwards employed, to-
gether with internal remedies, for six
weeks, when another surgeon was con-
sulted. Leeches were again prescribed,
together with fomentations, succeeded
by a strengthening plaster to cover the

229

whole hip, and the patient was directed
to lie constantly on an inclined plane.
This plan was pursued until the following
January, when I first saw him.

As the inflammation was considerable,
I directed that twelve leeches might be
applied to the hip, succeeded by foment-
ations and poultices, which were con-
tinued for two days, and on the Thurs-
day the hip was dressed in my usual
manner. From the day on which the
joint was thus supported, the pain alto-
gether ceased, and tlie swelling and ten-
derness began gradually to subside. He
was allowed to take exercise on crutches,
but not to set his foot to the ground :
ten drops of the tincture of iodine were
directed to be taken twice a day, and
the applications were renewed every fort-
night. After pursuing this plan for six
months, he was able to walk on the limb
without the slightest pain ; the muscles
had nearly recovered their natural appear-
Q 3

ance, and the limb was scarcely, if at
all, shorter than the other.

In August he had a severe attack of
typhus fever, which confined him to
his bed for six weeks, and left him in
a very reduced state, but without any
return of disease in the joint The hip
continued well until the following April,
1825, when he fell down and bruised
it against the step of a door. This
accident occasioned a violent acces-
sion of disease in the head of the os
femoris, which proceeded with great
rapidity. The thigh was forcibly bent
upon the pelvis ; he not only could not
bear the limb to be moved, but even the
least alteration in the position of his body
was attended with extreme pain, so that
he was altogether confined to his bed.
He was freely purged ; leedies were ap-
plied to the hip in as great numbers, and
repeated as frequently as his strength
would allow ; fomentations and poultices
were also employed in the first instance.

231

As soon as the diminished violence of
the symptoms would admit, the applica-
tions were again had recourse to, and
bark was given internally. These means
were pursued for three months from
the time of the accident, before the dis-
ease was sufficiently abated to allow of
his leaving his bed. After this period the
disease subsided so rapidly, that he very
shortly resumed the use of his crutches,
and by the end of the following Sep-
tember was able to walk on the limb
without the slightest pain, but he was not
allowed to discontinue the use of his
crutches for some time. Although the
thigh was forcibly bent at a right angle
with the body, as the disease subsided, it
was gradually restored to its proper posi-
tion, merely by his favouring its return
to this position as much as he could with-
out pain, and the bone is now firmly
anchylosed in a direction perpendicular
to the body.

232

Notwithstanding that the head and
neck of the bone have been so com-
pletely absorbed as to reduce the length
of the limb two inches, mattei" was not at
any period of this second attack secreted
in sufficient quantity to give evidence of
its presence in the cavity.

August 1. 1827. This patient remains
perfectly well at this time, and is able to
walk on the limb without any difficulty.

CASE 20.

On the 12th of February, 1824, I was
consulted about a young gentleman, be-
tween six and seven years old, who
had disease in the left hip. When I first
saw him, the joint was much swelled, con-
taining a large collection of matter, ex-
tremely tender, and so painful that he
could get no rest. The slightest move-
ment of the joint caused agony, he would
scarcely allow himself to be moved with-

233

out crying. The body was so much con-
torted as to have led to the opinion that
the spine was also diseased ; but this was
not the case. The thigh was constantly
bent at a right angle with the body ; it
was considerably shortened, and the two
knees closely approximated. The matter
had made its way as low as the middle of
the vastus esternus. He was a delicate
child ; his appetite was so much impaired
that it was very difficult to induce him
to take food ; he was feverish, thirsty,
had a hot skin, a coated tongue, and
irregular bowels.

About four years before, he had strained
the hip, so as to render him lame for a
few days ; this soon subsided, and he felt
no more of it for a year and a half; he
then complained of pain in the same
limb, but it was only of short duration ;
until midsummer, 1823, when he re-
turned from school, nothing further was
observed, except that he was not so
capable of exertion as tlie other children.

234

and frequently complained of his legs
aching ; he now began to limp after
exercise, but not when he first rose in
the morning ; he suffered pain in various
parts of the limb during the night, but
he was quite easy in the day.

Leeches were now applied to the hip,
succeeded by blisters ; some opening me-
dicine was given, and absolute rest strictly
enjoined. Warm bathing and alterative
medicines were afterwards employed ; but
the lameness gradually increased, and the
limb appeared to elongate ; a blister was
then applied and kept open. Hitherto
he had been tolerably free from pain dur-
ing the day, when the limb was motion-
less, though always restless and uneasy at
night ; the above means having failed to
afford relief, a caustic issue, of the size of
a dollar, was made behind the great tro-
chanter. From this time he continued
incessantly in such extreme pain, that
he could not rest a moment, nor even
bear a person to walk across his room.

The hip now swelled rapidly ; the whole
body was drawn down on the affected
side; the thigh became permanently bent,
and was soon observed to be getting
shorter ; the leg was bent upon the
thigh, and his health was greatly affected.
The eschar separated in a week from the
application of the caustic ; peas were
inserted into the wound ; but the pain
was so severe, that they were discontinued
after a few days. The issue was allowed
to heal, and fourteen leeches were ap-
plied to the hip : the change was at-
tended with very little alleviation of
the symptoms ; opiates failed to pro-
cure sleep ; and he was so exhausted
by pain, that his life was despaired
of, and no further efforts were made to
arrest the disease. The healing of the
issue was attended with some alleviation
of his sufferings, and his strength was in
some degree recruited by a more nutri-
tious diet. Still, however, the disease
was making progress, the swelling in-

creasing in size, and the limb diminish-
ing in length. I directed twelve leeches
to be applied to the part, and I'epeated,
if the pain was not relieved ; fomenta-
tions and poultices were also used ; small
doses of calomel and rhubarb were given ;
a better diet was allowed ; fermented
liquors and stimulants of every kind being
interdicted.

February 17. The bowels have been
sufficiently acted on, and the violence of
the symptoms is in some degree miti-
gated, so that I can now have recourse to
my usual mode of treatment.

February 24. The child has been able
to rest much better at night since I last
saw him ; he can bear to be dressed and
moved without pain, and the joint has
not increased in size.

March 3. His appetite and general
appearance are much improved ; he can
now stand upon the sound leg to have his
dressings removed; the swelling is re-

237

diiced, and he can bear the limb to be
gently moved.

March 1 7. There has been a gradual
improvement in his health and strength;
the bowels are regulated by small doses
of Epsom salts, combined with sulphuric
acid : the joint is considerably reduced
in size : the tension of the integuments,
and contraction of the limb, are much
diminished.

April 2. The thigh is much less bent
upon the pelvis ; he is now able to walk
on crutches without pain or inconve-
nience, and his health is very good ; he
now takes the carbonate of iron, the
bowels being regularly relieved without
any opening medicine.

May I. The joint is much reduced in
size, but there is every appearance that
it will soon burst ; it is quite free from
pain, but the matter is more superficial,
though greatly diminished in quantity,

June 2. The abscess has burst, but a
very small quantity of thin matter has

238

escaped, and the aperture is plugged by
a piece of curd-like substance. He is
quite free from pain, and there is not the
slightest constitutional disturbance j the
wound is defended with a piece of lint,
and the limb dressed in the same man-
ner as before.

June 9. There has been an incon-
siderable discharge from the wound ; the
hip is quite free from inflammation ; and
he has not had the slightest pain.

June 28. The complaint is going on
very well ; the wound is nearly closed j
there is scarcely any discharge; and he can
bear the limb tobe moved in any direction.
This case continued to mend until the
limb became perfectly well ; of course, it
was anchylosed, and considerably reduced
in length.

When I last heard of this patient, he
was seen in a garden driving a spade into
the ground with the affected limb, which,
being shorter than the other, was very
convenient for such a purpose.

CASE 21.

A young gentleman, twelve years of
age, residing at Kingsland, was brought
to me on the 1 st of February, 1 826, on
account of a disease in the left hip. It
was painful, swelled, and tender, and so
excessively weak, that he could not bear
the least weight on the limb. All mo-
tion was attended with an increase of
pain, which was so severe at night as to
disturb his rest. His appetite was toler-
ably good, his tongue clean, and bowels
regular. There was a collection of mat-
ter, which pointed just on the outside of
the rectus femoria muscle, at the distance
of one-third of its length from the hip ;
at this part the skin was discoloured, and
of a livid purple hue, to the extent of a
sixpence.

When he was eighteen months old, he
had disease in the left hip, attended with
the formation of matter, and the disloca^

240

tion of the bone, which is anchylosed on
the dorsum ilii. Early in last Novem-
ber he was kicked by his brother at
sdiool, on the same hip ; this was fol-
lowed by a great degree of pain and ten-
derness, which partially subsided in a few
days. Afterwards the symptoms gra-
dually increased (notwithstanding the use
of various remedies) until they became
so severe as to confine him to his bed for
some time. My usual dressings were
now applied.

February 8. The application has pro-
duced extensive irritation on the skin,
attended with considerable itching, while
the pain and tenderness have subsided in
a corresponding degree, and the strength
of the limb has increased, the discolour-
ation of the skin has almost disappeared,
and the collection of matter is diminished
in quantity.

February 15. There is now no mark
of the previous discolouration of the skin,
the pain is entirely relieved, the matter

241

diminished in quantity, and the strength
of the limb much increased.

This case continued in a state of pro-
gressive amendment : on the 9th of
March no fluid at all could be felt, and
the limb was so perfectly recovered, that
the patient could walk on it, and move
it in any direction, witliout the slightest
pain or inconvenience.

CASE 22.

Elizabeth Edwards, twenty years of
age, applied to me on the 13th of Fe-
bruary, 1825, on account of a disease in
the right hip. She experienced in the
joint very considerable pain, which was
aggravated by exercise, and by moving
the limb in any direction. There was a
general tenderness over the whole of the
hip ; but she complained more particu-
larly of pressure in the groin and behind
the great trochanter, and could not bear

242

to lie on the affected side. The whole
limb was much wasted, and it was also
somewhat elongated ; she had not any
pain in the knee nor down the leg. About
three months before I saw her, she first
felt pain in the hip: this, however, was
inconsiderable at its commencement, and
preceded by a weakness of the limb,
which was also more easily fatigued than
usual. From that time the pain had been
gradually increasing in severity, until she
could scarcely bear any weight at all on
the limb.

Twelve ounces of blood were taken
from the part previously to the applica-
tions being employed.

February 20. The pain and tender-
ness are relieved in some measure, but
not entirely. The cupping to be re-
peated before the applications are re-
newed.

February 27. She has had no pain
since her last visit, but there is still some

243

tenderness on pressure and in moving the
joint.

March 26. There is not the least ten-
derness on pressure, and she can bear to
move the joint without inconvenience :
the elongation of the limb is less ap-
parent.

April 20. The joint is much improved
in appearance, the limb is not so much
wasted, and the muscles are firmer than
before.

May 13. There is not the least pain
or tenderness, and she can move the
joint in every direction with perfect ease;
there is no perceptible elongation of the
limb, but the joint still feels rather weak ;
on this latter account, the mechanical
support is to be continued for some time
longer. In the following August the
joint had so completely recovered, that
she resumed her occupation — that of
a servant — without experiencing any
return of disease.

R 2

244

CASE 23.

January 16, 1827, I was consulted on
the case of J. H., a delicate girl, fifteen
years of age, who was affected with dis-
ease in the right hip. The elongation of
the limb was very apparent, to the extent
of an inch and a half below the left limb ;
the nates were flabby, and the cleft at the
inferior part lower than that on the op-
posite side by an inch and a half. The
thigh was somewhat bent on the pelvis,
and the leg was bent upon the thigh.
The spine of the ilium was drawn down
on the affected side, and any attempt to
put the flexors of the leg on the stretch
was productive of pain. The joint was
very stiff, and its motion very limited.
Slight movements of the joint, however,
were not immediately attended with pain,
although it invariably succeeded to the
smallest exertion. She suffered constant
pain in the knee, which extended down

^245

the calf of tlie leg, was aggra\'ated by
walking, and became so severe at night
as to disturb her rest.

She stated that about two years and a
half before, she had felt pain in the right
leg and thigh, which was relieved after a
few months by rest, blistering, and stimu-
lating embrocations. It remained well
until last May, when she again felt occa-
sional pain in the same knee ; it extended
down the leg, and continued to increase
in constancy and in severity in propor-
tion to the degree in which the limb was
used. In the autumn the limb was first
perceived to be elongated, and all the
symptoms were gradually increasing in
severity.

She was directed to take the pilula
ferri composita, and the hip was dressed
in my usual manner.

January 30. Since her last visit she
has generally been free from pain during
the day ; but there has been a slight acces-
sion of it at night, although much less
It 3

246

severe than (brmerlj ; and she has walked
the distance of two streets to my house
without feeling any inconvenience.

February 27. She is now quite free
from pain, and the elongation of the limb
is evidently diminished.

March 27- She is very much im-
proved in health, has had no return of
pain, the limb is straighter, its motions
more free, and unattended with pain, and
the contraction of the leg and thigh are
also less perceptible.

April 24. The elongation is scarcely
perceptible, the flabbiness of the nates is
much less manifest, and the movements
of the joint are more free and extensive.

.July 28. There has been a uniform
and gradual amendment of the hip for
the last three months, and it has been
attended with a proportionate improve-
ment in her general health. She can
now move the joint, and walk on it as
well as ever. The muscles have greatly
recovered their firmness, the hmb is

247

restored to its natural position, and the
only complaint she now makes is, that it
feels rather weaker than the other.

CASE 24.

Some years ago, a lady, about 30 years
ot" age, residing at that time at Hanwell,
consulted me on account of a disease in
the hip-joint, attended with the largest
collection of matter I ever saw in such a
case. I regret very much that, not having
taken any record of the case at the time,
the only description 1 can give must be
from memoi-y, and this, after the lapse of
so long a time, must necessarily be very
imperfect ; I am unwilling, however, to
pass unnoticed so remarkable an instance
of recovery under very unfavourable cir-
cumstances.

In July, 1812, she fell down an area,
and bruised her hip severely. She did
not experience any serious consequences
R 4

248

from this accident, and in October, 1817,
she slipped down stairs, and injured the
same hip very much: it continued swelled
and painful for some time. Soon after
this second accident, she began to feel
pains in the hip and knee, particularly in
the latter, which, after walking but a
short distance, became so weak, as to
render her incapableof proceeding. These
symptoms continued to become more and
more distressing until the following year,
when she applied to a surgeon of emi-
nence in town, who told her that there
was a gatiiering in her hip, which, in all
probability, would soon break : he pre-
scribed some medicine to be taken, and
directed the hip to be poulticed until it
should break. The disease continued its
progress ; the hip increased in size ; the
pain was very severe and constant in the
knee; she was much distressed by spas-
modic action of the muscles ; and at last
was unable to raise or move her leg in
the least, as she lay upon her bed. The

249

leg became much elongated; it was at
one time (according to her description)
three inches longer than the other. I
need not observe, that such extensive
local disease could not exist without very
marked and serious disturbance of the
constitution. Among other distressing
symptoms, she was very much troubled
with vomiting, which caused great agony
in the hip. I never saw any case in
which the nates and upper part of the
thigh were so enormously distended as
in this.

Tiiis case was treated in the manner
and upon the principles detailed in the
preceding pages. Such internal remedies
were employed as the circumstances of
the case appeared to indicate, and the
local means were precisely those that I
have so much insisted on.

She informs me, that in three months
after the time I first had recourse to them,
there was so decided an amendment, as
to lead me to express an opinion that

250

the matter might possibly be absorbed.
This opinion was ultimately verified ;
and, after a very long confinement, she is
now perfectly recovered, without the
slightest deformity, and has regained the
complete use of the joint, without any
impediment whatever.

CASE 25.

Mrs. K., residing at Clapham, con-
sulted me on the 30th of July, 1821, on
account of a disease in the right ankle.
The swelling presented the appearance
of an enlargement of the joint, retaining
its natural figure, and extending consider-
ably over the extremities of the tibia and
fibula. It was very tender when pressed,
and so painful, that she could not bear
the slightest weight on the limb, nor the
least movement of the joint. There was
a large sinus just at the extremity of the
fibula. Her health and strength were

251

very much impaired, and she was two
months advanced in pregnancy.

She informed me, tliat nine months
before, she first felt pain in her right
ankle, having, the preceding day, remain-
ed some time in wet shoes ; and soon
after, slie perceived that the joint was
swelled. It remained in this state for
some time, and then the weakness, pain,
swelling, and the difficulty in walking,
gradually increased. After the lapse of
a month, an embrocation and a bandage
were had recourse to, without affording
relief. Blisters were next applied ; but
they caused so much inflammation, that
she could scarcely set her foot to the
ground. She was afterwards recom-
mended to try the effect of leeches, seven
of which were applied every other day
for a considerable time, without any
alleviation of the complaint ; indeed, she
fancied that they made her foot weaker
than before, and less capable of bearing
the weight of her body : at this time she

252

was so much reduced, that she could
only sit up a part of the day. The swell-
ing was now nearly stationary. Poultices
were subsequently applied; but the dis-
ease continuing its progress, she became
so incapable of bearing the least weight
on the limb, that she was obliged to have
recourse to crutches. About the same
time, an abscess formed, and was opened
just at the lower extremity of the fibula:
a small quantity only of matter was eva-
cuated, and the swelling was but very
little reduced. A. cold lotion was next
applied, and, during its use, the orifice of
the sinus healed ; but the pain was very
distressing until it again opened, and
from that time it continued to discharge.

She was directed to take a drachm of
the powder of bark twice a day, in water,
and the ankle was done up in my usual
manner.

August 31. Her health and appetite
are improved. She has had much less
pain, the swelling and tenderness are

253

diminished ; she can move the joint more
extensively, and with greater facility.

September 30. The joint has conti-
nued to improve in every respect since I
last saw it : she is now entirely free from
pain, and can move the foot in every
direction with perfect ease, and the swell-
ing is more considerably reduced.

October 31. Tlie sinus is healed, and
the joint is so far recovered, that she has
thrown aside her crutches, being able to
walk, and to attend in her shop without
them, notwithstanding she is pregnant.

The joint soon after this was restored
to its natural size, and perfectly recover-
ed ; of course, it was necessary to keep it
supported until she was confined. She
had, however, no relapse of the disease,
and has remained quite well to this time
(August, 1826).

254

CASE 26.

A young maiij residing at Lambeth,
consulted me on the 23d of July, 1826,
on account of a disease in the right ankle.
It presented the appearance of a uniform
enlargement of the joint, and was not
tender to the touch ; it allowed only of
very limited motion, and that was attend-
ed with a grating sensation. The whole
limb was much wasted, and the leg, from
the knee to the heel, was at least an inch
ahorter than the other. There were five
scars in the vicinity of the joint, the re-
sult of successive abscesses ; the tumefac-
tion was of a yielding, elastic nature, as
if arising from the effusion of solid sub-
stance, and it was rather more prominent
on the anterior part than elsewhere. He
could extend the foot in a slight degree ;
but its motion was altogether impeded
in the opposite direction, although not
attended with pain.

255

The foot, from the heel to the end of
the great toe, was shorter than the other
foot by three quarters of an inch, and the
length, from the point of the ankle to the
sole of the foot, was half an inch shorter
than from the same point of the other
ankle.

In the year 1817, in consequence of a
sprain, the joint first became swelled. A
few months afterwards, a small abscess
formed and burst just behind the inner
ankle, notwithstanding the use of leeches
and blistering.

In January, 1818, a simdar abscess
formed in front of the joint : this was
attended with much more pain than the
former, and he could not put his heel to
the ground, but was obliged to walk with
a crutch.

In December of the same year, an
abscess appeared behind the two former ;
his foot was much turned inward, and so
completely extended, that he could not
bring his heel within five inches of the

2S6

ground. In the spring of 1819, he went
to Margate, and then, in addition to the
foot being permanently extended, the leg
was forcibly bent upon the thigh : any
attempt to straighten it, occasioned the
greatest pain.

The joint remained in this state, without
much alteration in appearance, for three
or four years ; and the heat was so great,
that a rag, doubled eight times, wetted
in a cold lotion, became dry in a few
minutes.

During this time, leeches, blisters,
hemlock, and other poultices and foment-
ations were employed ; sarsaparilla, and
alterative doses of mercury, were pre-
scribed, conjointly with a well-regulated
diet, without any amendment of the
complaint. Flannel bandages and cold
lotions were afterwards applied with some
advantage. Mechanical support was sub-
sequently adopted by means of adhesive
plasters, and, although it afforded him
only a partial relief, not being extensively

257

and uniformly applied, it was of more
service than all the preceding remedies.

The effect of my usual mode of treat-,
ment in this case, was first to give
strength and firmness to the joint, and
to enable him to use it with greater
confidence, so that he continued his
avocation, that of a warehouseman,
during the whole time he was under
my care. A gradual diminution of the
swelling, and a proportionate increasa of
the sphere of motion, were produced;
and, in the course of four months, the
joint was restored to its natural size and
figure. In consequence of his subjecting
the joint to a degree of exertion it was
unequal to bear, it remained weak, and
he continued to experience some stiff-
ness and difficulty when he first set it to
the ground in the morning, for a consi-
derable time.

JMl^iti

CASE 27.

Henry Anscome, aged 18 years, ap-
plied to me on the 25th of October, with
a disease of the ankle. The joint was
swelled from thickening of its parietes,
and not from effusion into its cavity : it
was very tender, and so painful, that he
could not even set his foot to the ground,
but walked on crutches, carrying it in a
sling. The slightest movement of the
joint was productive of great pain ; and
this was so severe, when his ankle became
warm at night, as to cause him to lie with
it out of the bed. The leg was very much
reduced in size.

He stated, that two years before, he
strained his ankle in walking, in conse-
quence of which accident it was swelled
and painful, and was occasionally better
and worse for about nine months. At
the expiration of this time it became
much more swelled, and so painful, that

he could not walk without the assistance
of two sticks. He was then obliged to
desist altogether from using the limb for
four months.; after which time, by re-
peated blistering, it was so far recovered
that he could again walk upon it. The
swelling, however, was little, if at all,
reduced, and lie could not set his foot to
the ground without feeling pain. He
continued to follow his employment
as a gardener, with great pain and dif-
ficulty, until the following January, when
the disease had become so much worse,
that he was obliged to desist from using
the limb. The joint was then exceed-
ingly swelled, tender, and painful ; the
calf of the leg was wasted, as well as
the thigh. Poultices were applied for
four months ; but the symptoms became
gradually more severe, and bis health
began to decline. An abscess formed
and burst just behind the inner ankle ; it
did not discharge much, and at this time
he was in the country,
s 2

This case was now treated in my usual
manner.

November 20. The disease is consider-
ably relieved, the symptoms have all
subsided in a marked degree, and he has
now much less pain at night.

December 18. He states that he has
been able, since I last saw him, to walk
across a room, without crutch or stick ;
the swelling is reduced, and he is entirely
free from pain.

January 17- He is now able to walk
on the limb, and to use it without the
least pain ; but it is still very weak. '

The joint, from this time, continued
gradually to improve, and to increase in
strength. In the following April, it was
reduced to its natural size, and was so
perfectly recovered, that he returned to
his employment, without the least pain
or inconvenience.

October 28. The joint has remained
perfectly well to this time ; he has conti-
nued his occupation, and has walked on

261

the limb this morning twenty-three miles,
and intends to return the same distance
this evening.

CASE 28,

C. L., 26 years of age, residing at
Camberwell, applied to me on the 4th of
November, 1825, on account of a disease
in the left ankle-joint.

The pain was constant, and so severe
at night, as to disturb her rest ; she was
also much distressed by spasmodic action
of the muscles. The joint was consider-
ably swelled, the tumefaction presenting
an elastic feel to the touch. She could
not bear the slightest motion of the joint,
which was attended with a grating sensa-
tion. The leg was much wasted, and it
was with the greatest difficulty that she
could set her foot to the ground. She
complained that there was great iaternal
(iL'ii ii- ^ 3 - ' -1

262

heat in the joint, while the rest of the
limb was always pale and cold.

About a year before, she first felt
pain in the joint, whicb had been very
weak for some months previously. There
was not, however, any perceptible swell-
ing for nearly six months after the
pain had become constant. The pain
and difficulty of moving the joint had
been gradually becoming more severe
from its commencement. The remedies
that had been employed were fomenta-
tions, leeches, cold lotions, stimulating
embrocations, cold pumping, and stimu-
lating plasters, which produced excessive
irritation on the skin. Salt water had
been applied on cloths to the joint ; and
during a residence for some time at the
sea^side, warm and cold baths had been
used. These means, however, failed to
arrest the disease.

I dressed her ankle in my usual manner.

November 18. The pain is so much
reduced as to enable her to rest at night

lit: M

she still suiFers very much on moving the
joint, and it is very tender to the touch.
The applications have produced consi-
derable irritation on the skin, attended
with great itching, and a diminution of
the chilliness she complained of so much
on her last visit.

December 1. The joint is improved
in every respect ; the swelling is reduced ;
there is no pain when the limb is at rest,
and much less than formerly when moved.

December 15. The joint has been
gradually improving since her last visit,
and she can now bear it to be moved,
without the slightest pain.

The subsequent history of this case
may be comprised in a few words. She
continued to gain strength in the limb
every week ; in three months from the
time I first saw her, she could use the
diseased joint as well as the other ; and
to the present time (June, 1826) she has
used that limb as much as ever, without

S "* .nidi .

any return of disease, or even the slightest
inconvenience.

CASE 29.

A gentleman, residing in Devonshire-
Place, consulted me on the 7th of Fe-
bruary, 1827, having a disease in the left
ankle.

The joint was so tender, that he
could scarcely bear it to be touched or
moved ; there was considerable tumefac-
tion, arising partly from effusion into the
cavity, and partly from that of serum
into the cellular membrane. There
was great tenderness of the perios-
teum both of the tibia and fibula, and
the swelling extended nearly halfway up
the leg. There was a small swelling just
at the lower end of the tibialis anticus
muscle, the action of which was attended
with pain at this part, as well as in the
joint itself

265

About a month before, as be was step-
ping out of a carriage, his foot shpped,
and his ankle was twisted; it immediately
swelled, and remained weak. In a short
time the pain became so much aggra-
vated, that he had scarcely had any rest
for a fortnight. The leg was almost
entirely covered with small scars, the
result, as I believe, of scrofulous ulcers.
Some embrocation was employed, and a
flannel bandage applied. He afterwards
went to Brighton, to make use of vapour
baths, without deriving any benefit.

He was now directed to take a drachm
of the powder of sarsaparilla twice in the
day, and the ankle was dressed in my
usual raannei".

February 14. He has been free from
pain from the time when I first saw him,
and has been able to sleep well at night;
the swelling is very much reduced; he
can move the joint, and walk on it with-
out pain, but it is still somewhat tender
on pressure.

February 28. There is now scarcely
any appearance of disease ; the swelling,
pain, and tenderness being entirely re-
moved : the joint remains rather weak, so
that it is desirable to continue the me-
chanical support for a short time longer.

CASE 30.

T. Somson, a confectioner, 48 years of
age, applied to me on the 28th of Fe-
bruary, 1827, with a disease in the right
ankle. Tlie joint was swelled, painful,
and tender to so great a degree, that he
could scarcely set his foot to the ground.
The least movement of the joint occa-
sioned extreme suffering, and hewas quite
exhausted for want of rest. The swelling
was confined to the inner side of the
joint, and consisted in the deposition of
solid substance. The calf of the leg was
much wasted.

267

Last October he twisted his ankle ; this
accident produced a slight degree of pain
in the first instance, and, in about a fort-
night, it became so severe as to attract
attention. Soon afterwards, the joint was
so much swelled and inflamed, that he
was unable to set his foot to the ground.
By the use of leeches and fomentations,
with constant rest for two months, the
redness and swelling were in some degree
abated, so that he was able to walk on
crutches ; the pain, however, was very
little relieved, and latterly it had gra-
dually been increasing in severity.

I dressed his ankle in my usual manner,
and desired him to come to me again in
a month.

March 27. The pain began to subside
in a few days after the applications were
put on ; and for the last fortnight lie
has been almost free from it, except
when he has used the limb too freely,
for he has since that time resumed his
occupation. The swelling and tender-

ness are much diminished, and the motion
of the joint is more extensive, and unat^
tended with pain.

April 29. The swelling and tender-
ness are much reduced, and the joint is
greatly improved in every respect.

May 30. The swelling, pain, and ten-
derness have entirely subsided, and he
has been able to walk a distance of two
miles to his business every day, withou^-
the assistance of crutches.

CASE 31,

Mary Mason, twenty-two years of age,
applied to me on the 18th of April,
1827, with a disease in the left ankle. It
was in constant pain, so tender that she
could scarcely bear the slightest pressure,
and the least movement of the joint pro-
duced a great increase of suffering ; the
swelling was considerable, and extended

completely over the tarsus, as well as
around the joint.

On the 9th of November, in jumping
off a coach, she strained her ankle very
severely. This accident produced so
violent an inflammation, that she could
not set her foot to the ground. Leeches,
cooling lotions, and poultices were em-
ployed, and by these means the pain was
in some degree relieved, but the swelling
did not subside. Subsequently leeches
were applied, succeeded by blisters, in
consequence of the pain having increased,
but they produced only temporary relief.
Since that time various plasters and other
applications had been employed, never-
theless the pain and swelling had gra-
dually increased, as well as the difficulty
in moving the joint.

I immediately had recourse to my
usual treatment in this case.

May 6. She has been quite free from
pain since her first visit ; the swelling and
tenderness are much diminished ; the

270

movement of the joint is more extensive,
and unattended with pain.

May 18. The swelling is quite reduced,
the joint is altogether free from pain, and
she is able to walk across the room with-
out any inconvenience but that of weak-
ness in the joint.

June. 14. She has been able since her
last visit to use the limb very freely, and
the joint is quite restored to its natural
state ; but as it still feels weak, I have
once more applied the bandages.

■^- CASE 32.

-j'-

John Cutts, thirty-three years of age,
residing at Poplar, consulted me on the
25th of February, 1825, on account of a
disease in the left ankle. The joint was
much swelled, so tender that he could
not bear it to be touched, and could not
endure the least motion. The pain was
constant, and particularly severe at night ;

271

there was also a sensation of burning heat
in the joint. The swelhng appeared to
arise from the effusion of fluid into the
joint, as well as from thickening of the
synovial membrane. The limb was much
wasted, his whole body much emaciated,
and his health impaired. His tongue was
clean, and his bowels regularly open ;
but he was subject to constant nocturnal
perspirations.

In the year 1819 he first felt pain in
the joint, uncertain in its seat and dura-
tion, and unattended by any swelling.
The pain used to remit for some time,
and then return, each accession being
more severe than the preceding attack.
In the year 1820 the swelling of the
joint first appeared, more especially after
exercise ; but it subsided in a great mea-
sure during a night's rest : the pain also
now became both fixed and permanent,
and, together with the other symptoms,
gradually increased.

272

Leeches were applied to the part, and
at first relieved the pain ; but they did
not reduce the swelling, and subsequently
ceased to afford any relief. Fomenta-
tions, poultices, and a variety of stimu-
lating applications were used without
benefit, the limb being at the same time
in a state of perfect rest.

The patient was directed to take a
drachm of the powder of bark twice a
day with some tincture and diluted sul-
phuric acid, and the ankle was dressed in
my usual manner,

March 4. The pain continued equally
severe for the first five days and nights
after the application, for the last two
it has been very trifling when the joint is
at rest. The application has produced
sufficient irritation ; the motion of the
joint is very limited, and attended with
considerable pain. The night sweats are
relieved.

March 18. He has been entirely free
from pain since I last saw him ; the swell-

273

ing and tenderness are reduced, and the
former now appears to consist chiefly of
solid substance. The motion of the joint
is more extensive, and attended with less
pain.

From this day he continued gradually
to improve, and in four months from the
time of his first applying to me the joint
had quite regained its natural shape and
appearance, and he could walk on and
move it in every direction without the
slightest pain.

It has remained quite well to this time,
January, 1827.

CASE 33.

Mr. R., forty-four years of age, residing
in the Strand, consulted me on the 1st
of November, 1825.

The left ankle was swelled from the
effusion of solid substance, without any

274

fluid in the cavity. It was very tender,
excessively stiff, and the motion very li-
mited. It was with the greatest diffi-
culty he could set his foot to the ground,
and the pain was so severe at night as
to destroy his rest.

There was also on the centre of the
tibia a small swelling, resembling in size
and figure the half of an egg divided
longitudinally. It was exceedingly ten-
der, and incorapressibly hard. His tongue
was coated, bowels confined, appetite im-
paired, and urine high coloured.

He stated, that having been previously
subject to gout, in November, 1824, he
had in both ankles an attack, which con-
tinued in an atonic form until the fol-
lowing May, notwithstanding the employ-
ment of various medicines. He then
went to Margate, and having remained
there a month without receiving any be-
nefit, he came home, but returned in the
beginning of July. The shin bone now
became affected. Warm baths were of no

275

service ; but he derived some relief from
blisters, and from the pumping of warm
water on the joint. The pain and ten-
derness were now somewhat less acute,
but the swelling did not abate. He
returned home early in Octoher, and then
became worse. Leeches were applied, suc-
ceeded by a perpetual blister. These re-
medies afforded some relief to the pain ;
but the swelling was not in the least dimi-
nished. During the greater part of this
time he was taking various medicines
under the direction of different medical
men.

I directed him to take five grains of
the Plummer's pill every night, a drachm
of the carbonate of soda twice a day, to
keep his bowels open, and my usual reme-
dies were applied to the diseased parts.

November 7. He is certainly im-
proved in health, and has been able to
walk better and with less pain since his
last visit.

T 2

270

November 14. He suffers no pain at
night, and the swelhng and tenderness,
both on the tibia and ankle, are much
diminished. Sarsaparilla was now pre-
scribed instead of the soda.

November 28. He is now so much
improved, that he has been able to walk
from his house to mine. He is entirely
free from pain in the joint, which is not
at all tender to the touch ; the swelling
is materially diminished, and he sleeps
well at night.

He continued gradually to improve,
and to acquire strength in his limb, and
in the course of another month all swell-
ing had subsided, and he was able to walk
from Hampstead to London without pain
or difficulty.

It is remarkable that although the con-
stitutional disorder could not be relieved
by the internal remedies he had taken
for a twelvemonth, it yielded rapidly on
the subsidence of the local source of irri-
tation. In a very short time after the

277

amendment took place in his ankle and
shin, his appetite, which, together with
his powers of digestion, had been con-
stantly impaired, became exceedingly
good, and he had all the feelings of
returning health.

CASE 34.

In April, 1824, Mrs. H., residing in
the neighbourhood of Cavendish- Square,
consulted me, having a disease in her
right foot. She complained of extreme
tenderness on pressure, just in the situa^
tion of the strong ligament extending
from the os calcis to the os naviculare on
which the astragalus is supported. This
spot, however, which was so exceedingly
tender when pressed, was not larger than
a sixpence. She suffered great pain at
night ; and there was a swelling, of the
form and size of the longitudinal section
of an egg, in the hollow of the foot. The
T 3

278

pain in walking extended to the hip, and
was so severe, that she could not set her
foot fairly to the ground, but was obliged
to walk on its outer edge, and even this
was attended with great difficulty. The
calf of the leg was considerably reduced
in size, and tlie tumefaction and tender-
ness had extended as far as the great toe.
About a year before her consulting me,
she had struck her foot violently against a
pail, in going down stairs. On the follow-
ing morning she was unable to set her
foot to the ground, and was obliged to
rest it altogether for a few days, during
which time the inflammation subsided
in a great degree. The swelling still
continued, together with great pain,
which was much increased by walking.
Various applications were employed, not-
withstanding the use of which, the disease
became rather worse j and, by the follow-
ing Christmas, the whole foot was very
much swelled and inflamed, and so pain-
ful, that she could not set it to the ground.

279

This accession of inflammation subsided,
leaving the foot nearly in its previous
state : the pain and difficulty in walking
still continued. She came to town in the
lattei- end of February, when repeated
blisters, and subsequently the tartar eme-
tic ointment were freely used ; absolute
rest being at the same time enjoined.
These means, however, failed to afford
any relief, and the pain continued un-
abated.

In this case, by pursuing the mode of
treatment so often described, the pain
and swelling gradually subsided ; and in
the following June, when she returned
into the country, had altogether disap-
peared.

In the July following, a chair slipped
from under her, and she fell with great
force on the affected foot. This accident
occasioned violent pain, which continued
unabated for a month, when she'returned
to town. At this time cupping was had
T 4

280

recourse to, succeeded by the mode of
treatment I before employed, and the
applications were renewed every week.
At the end of five weeks the pain had
entirely subsided, and was not re-pro-
duced by the hardest pressure I could
make on the affected spot. Having,
however, suffered so severely, she could
not be prevailed on to walk on the foot
until the following March, though she
had no return of the symptoms.

She was then induced, by great per-
suasion, to make the attempt ; and, find-
ing that it did not produce any inconve-
nience, she has since continued to use
the limb very freely, without experiencing
any return of the disease.

CASE S5.

Ann Bell, 21 years of age, consulted
me on the 24th of February, 1821, on
account of a disease in the right elbow.

281

There was great tumefaction and ten-
sion of the soft parts surrounding the
articulation, and they were very much
inflamed, in consequence of a seton that
had been passed through a sinus just
above the inner condyle of the humerus,
directly across the joint, to the onter con-
dyle. In consequence of this treatment,
the pain was so violent, particularly at
night, that she had sat up for a week
together, dreading to go to bed. She
could not move the arm in the least, nor
even lift it from her side, nor move her
fingex's without extreme suffering. There
was some motion in the joint. The dis-
charge was profuse, and her health very
much impaired. There was no rough
surface of bone discoverable on intro-
ducing a probe, to ascertain the direction
in which the seton had been passed.

About three years before, she fell down
and hurt her elbow : it was swelled and
painful for two months, after which it was
so much better, that she could resume

282

her occupation (that of a servant) ; the
joint, however, still continued enlarged,
and always inconvenienced her more or
less. It continued in this state until
April, 1820, when it became more pain-
ful, and a swelling commenced just above
the inner condyle of the humerus. It
continued to increase in size until the
following August, when it broke, and has
ever since continued to discharge. The
pain, swelling, and difficulty in moving
the arm, gradually increased until the
seton was passed, which greatly aggra-
vated her sufferings.

I immediately withdrew the seton, and
had recourse to mechanical support alone,
thinking that local bleeding would not be
of service in her reduced state, and that
the inflammation would subside in a
great degree as soon as the source of the
irritation was thus removed.

March 10. She states that her arm has
been improving daily, and that she has ex-
perienced great relief; the discharge has

been profuse ; a thick, healthy pus. The
swelling and tenderness are very much
reduced ; she ean now rest at night, and
move her arm without pain when in the
shng. Her health and appetite are also
much improved. The arm was now
dressed with the cerate, in my usual
manner, the mouths of the sinuses being
defended by a small piece of lint dipped
in the black wash.

March 24. There is very great im-
provement in her general appearance, as
well as in her arm : it is free from pain
and tenderness; she can move it much
more freely, and is now able to discon-
tinue her sling. The discharge and
swelling are both materially diminished.

April 21. The arm is in aprogressive
state of amendment.

May 12. The discharge has now en-
tirely ceased ; the swelling is reduced,
and she is able to use the arm very freely
without pain.

284

July 30. Her arm is now so far re-
covered, that she can use it nearly as
much as the other : it is free from pain
and tenderness, and there remains but a
very trifling thickening of the synovial
membrane. She has very little move-
ment in the joint; but this is altogether
unattended with pain, and she is in per-
fectly good health.

CASE 36.

Sarah Butcher, fifty-two years of age,
applied to me on the 14th of April, 1826,
with a disease in the right elbow.

The joint was swelled, from a thicken-
ing of its parietes, tender, and in constant
pain, which was most severe at night :
the fore arm was permanently bent, at a
right angle to the humerus. There was
very little motion in the joint, and that
was attended with great pain, and with
so decided a crepitus, as to evince that

285

the bones were denuded of their car-
tilage. She complained of great heat in
the joint ; and the motion of the fingers
was attended with so much suffering, as
to deprive her entirely of the use of
them. The articulation of the head of
the radius was not ineluded in the dis-
ease. Her bowels were irregular, and
her appetite not very good ; but there
was no great constitutional disturbance.

It was between four and five years
since she first perceived a great heat and
swelling in the joint, succeeded at inter-
vals by considerable pain. The disease
continued much in this state for nearly
two years, the pain and swelling occa-
sionally increasing, and at other times
being less distressing. The pain then
became constant and more severe ; the
swelling increased ; she was soon alto-
gether deprived of the use of the limb,
and it gradually became more contracted.
In the first instance she went to South-
end, and had recourse to hot bathing :

subsequently, a great variety of stimulat-
ing remedies were employed, some of
which, according to her account, aggra-
vated the disease, and none of them had
been able to arrest its progress.

I directed her to keep her bowels open
with rhubarb and magnesia ; and my
usual treatment was adopted.

April 28. She has had less pain since
I saw her, and has been able to use her
hand and fingers a little : the joint has
felt stronger, the thickening is somewhat
reduced, but the arm is in precisely the
same state with regard to motion.

May 16. The joint is better, in re-
spect both to the pain and swelling, and
can be moved with less inconvenience.

June 14. She has been entirely free
from pain, and is able to cut her food,
but I have cautiously abstained from
moving the joint : the swelling is entirely
reduced.

July 12. The joint is so much im-
proved, and the strength of the limb so

287

greatly increased, that she can now follow
her usual avocations, which are those of
household work.

August 10. The elbow is now quite
stiff, and firmly anchylosed, and alto-
gether free from pain. The rotation of
the radius is unimpeded.

September 15. She has remained
quite well since her last visit, and has
continued to use her arm very freely,
without any ill effect, except a little oc-
casional pain after exerting it too much.

CASE 37.

J. G,, forty years of age, residing at
Stockwell, applied to me on the 4th of
March, 1826, on account of a chronic
disease in the left wrist. The synovial
membrane was thickened and swelled,
presenting a yielding elastic feel to the
touch. There was not any fluid in the
cavity : it was very tender when pressed,

288

and very painful, particularly at night, or
on moving the joint.

She complained that the whole hand
and fingers were numb, and affected with
a sensation similar to that she has expe-
rienced in half the ring-finger, and in the
little finger, when the ulnar nerve has
been pressed upon behind the inner con-
dyle of the humerus. The pain extended
up the arm as high as the elbow.

She stated, that about the middle of
last December, she fell down and frac-
tured the lower extremity of the radius
and ulna. The fracture was reduced,
but the pain and swelling of the soft
parts, together with the numbness and
unpleasant sensation in the fingers, con-
tinued unabated.

My usual mode of treatment was
adopted in this case.

March 18. The tumefaction and ten-
derness of the joint are considerably re-
duced : she can move it better ; the prick-
ing sensation is removed ; but the numb-
ness in the fingers still continues.

289

April 2, The joint is much reduced
since I last saw it, and the numbness in
the fingers is considerably relieved.

April 16. The joint is reduced to its
natural size ; she can move it freely, in
every direction ; the natural sensation of
the fingers is entirely restored, and she
can use this hand as well as the other.

CASE 38.

A lady, residing in Long Acre, con-
sulted me on the 14th of December,
1822, having a disease in the left wrist.
The eiFusion of lymph had occasioned
much swelling of the joint, which was
tender when pressed, and so painful
when moved, as nearly to deprive her of
the use of her hand. She did not feel
pain when the hand was at rest, except
after it had been too freely used, but the

290

motion was much limited. There were
two fistulous orifices at the outer extre-
mity of the radius, and one just at the
styloid process of the ulna.

In the year 1813 she first perceived
the joint to be swelled ; it had been weak
for a long time previously, and she had
felt an aching pain when it was much
used.

The first indication of disease was the
occurrence of a small swelling on the
back of the wrist, which continued in an
indolent state for a long time, and subse-
quently broke, leaving a fistulous orifice.
This was succeeded by two similar foi'm-
ations of matter, which gave rise to the
sinuses that still continue.

This case was now treated in my usual
manner.

December 28. The joint has been
free from pain, although she has used it
much more freely than before, having
been able to do so in consequence of the

■

291

mechanical support it has derived from
the applications.

January 13. The motion of the joint,
which is improved in every respect, is
more extensive, less painful ; the swelling
is diminished, and the discharge from the
sinuses is reduced in quantity.

January 30. There is considerable
amendment since the last visit ; one of
the sinuses on the outer side of the radius
is healed.

The two remaining sinuses were healed
about a month after the closing of the
former one, but the recovery of the joint
was much retarded by the free use to
which it was subjected. By the latter
end of July, however, it was entirely
restored to a natural state, and has since
remained free from any return of disease.

THE END.

London :

rriutcd by A. & R. SpotUswoode,

New- Street-Square.

tmmmm

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Full text of "Surgical observations on the treatment of chronic inflammation in various structures ..."

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