r^N E!li;''V'))^''''';r''i'''f- w?fe'' '■■■'' Columbia 5BnitJers^itp intlieCttptjflrtogork College of ^Ijpsiiciang anb burgeons! ILitirarp Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/pathologicalsurg02brod PATHOLOGICAL /^ SURGICAL OBSERVATIONS / f'i^i ON a©iiii©ii OF THE JOINTS. By B. C. BRODIE, F. R. S. ASSISTANT SURGEON TO ST. GEORGe's HOSPITAL, AND LECTURER ON THE THEORY AND PRACTICE OF SURGERY. ILLUSTRATED BY COLOURED ENGRAVINGS. PHILADELPHIA: PUBLISHED BY BENJAMIN WARNER, AND SOLD ALSO AT HIS STORED IN RICHMOND, VA. AND LOUISVILLE, KEN. AKD BY W. r. BASON, CHARLESTON, S. C. 1821. fBAKKISH, PRINTER. ':> \ t^V H \ -\ TO SIR EVERARD HOME, BART. V.P.R.S. SENIOR SURGEON TO ST. GEORGE's HOSPITAL, 8cc. &C. &C. Dear Sir, In dedicating to you the follow- ing observations, I am anxious to avail myself of the first opportunity, which has occurred, of publicly expressing my grati- titude far the numerous favours, which I have received from you, from the time of my first commencing my professional pursuits; and of acknowledging the obli- gations, which I owe, to your example, to your instructions, and to your fiiendl}^ assistance, on many and various occa- sions. IV Independently of these private consi- derations, I should have been desirous of prefixing your name to this volume, as a mark of my respect for one, whose talents and unwearied exertions have so essentially contributed to the advance- ment of surgery, and of those interesting branches of philosophy, which are con- nected with it. I remain, Dear Sir, Your faithful friend and servant, B. C. BRODIE. Sackville Street^ October 19, 18(8, CONTENTS. Introduction _ > _ - Page 1 CHAP. I. ON INFLAMMATION OF THE SYNOVIAL MEMBRANES OF JOINTS. Sect. I. Pathological Observations - - 6 Sect. II. On the Causes and Symptoms of this ^ Disease - - - - 18 Sect. III. On the Treatment - - - 30 Sect. IV. Cases - - - - - 39 CHAP. II. ON ULCERATION OF THE SYNOVIAL MEMBRANE, 64 CHAP. III. ON CASES, IN WHICH THE SYNOVIAL MEMBRANE HAS UNDERGONE A MORBID CHANGE OF STRUCTURE. Sect. I. Pathological Observations - - 68 Sect. II. On the Symptoms of this Disease - 93 Sect. III. On the Treatment - - - 98 vi CONl'ENTS. CHAP. IV. ON THE ULCERATION OF THE CARTILAGES OF JOINTS. Sect. I. Pathological Observations - Page 101 Sect. II. On the Symptoms of this Disease 138 Sect. III. On the Treatment - . . i63 Sect. IV. Cases 192 CHAP. V. ON A SCROPHULOUS DISEASE OF THE JOINTS HAVING ITS ORIGIN IN THE CANCELLOUS STRUCTURE OF THE BONES. Sect. I. Pathological Observations - - 209 Sect. II. On the Symptoms of this Disease 229 Sect. III. On the Treatment - - - 239 Sect. IV. Cases . » - . - 250 CHAP. VI. ON CARIES OF THE SPINE. Sect. I. Pathological Observations - - 259 Sect. II. On the Symptoms of Caries of the Spine - _ . - 276 Sect. III. On the Treatment - - 287 CHAP. VII. ON SOME OTHER DISEASES OF THE JOINTS. 295 CONTENTS. vii CHAP. VIII. ON INFLAMMATION OF THE BURS^E MUCOSAE. Sect. I. History and Symptoms of this Dis- ease - - - Page 305 Sect. II. On the Treatment . - - 312 Sect. III. Cases .. . > - 318 Explanation of the Plates - - - 325 INTRODUCTION. The following pages contain a series of obseiTations, which were begun several years ago, and which have been con tinned, not without considerable labour, up to the present period. They relate t(i a class of diseases, which have strong claims on the attention of the surgeon; since they are of very frequent occur- rence; are a source of serious anxiety to the patients; and, for the most part, if ne- glected, proceed to an unfavorable terr mination. There are other circuii>§t^nces also, which seemed to render tll^ morbid affections of the joints a fit subject of in- vestigation. They have scarcely met with the attention, whicl^ they merit from former pathologists^ The terms, white swellings, scrophulous joints, §c. have ; ( 2 ) ])een used without any well-defined mean- ing, and almost indiscriminately; so that the same name has been frequently applied to different diseases, and the same disease lias been distinguished by different appellations. Confusion with respect to diagnosis always gives rise to a corresponding confusion with re- spect to the employment of remedies; and hence I was induced to hope, that, if it were possible to improve our pa- tliological knowledge of the diseases to which I have alluded, this might lead, not indeed to the discovery of new methods of treatment, but to a more ju- dicious and scientific application of those which are already known, and a conse- quent improvement of chirurgical prac- tice. The joints, like the other animal or- gans, are not of a simple and uniform, but of a various and complicated structure. Although in the advanced stages, the dis- eases, to which they are liable, extend to ( ^o all tlie dissimilar parts of which they arc composed, it is to be presumed that such is not the c^se in the beginning. We cannot doubt, that here, as elsewhere, 'the morbid actions commence, sometimes in one, and sometimes in another texture; and that they differ in their nature, and are variously modified, and of course re- quire to be differently treated, according to the mechanical organization, and the vital properties of the part, in which they originate. It was under the influence of these impressions that I endeavoured to pursue ray enquiries into the subject of the pre- sent treatise. Believing, that nothing has contributed in a gTcater degree towards the modern improvements 'in surgery, than the practice of investigating by dis- section the changes of anatomical struc- ture, which disease produces, I availed myself of every opportunity which oc- curred of making such examinations. In particular, I was anxious to do this, where ( 4 ) the rtiorbid changes were still in an early stage, and where I had the opportunity of jQOting the symptoms by which the in- cipient disease was indicated; and the knowledge which was thus acquired be- came the basis of my future observations. In laying the results before the public, I cannot be otherwise than conscious, that these researches are still imperfect. But I feel assured, at the same time, that those who are engaged in the study of pathology, will make due allowance for the difficulties, which belong to this most complicated of all the sciences, and will not be disposed to criticise my labours severely, because they find, that there is still an ample space left for those, who may be willing to engage in similar enquiries. Some of my readers will recognize in the present work the substance of some papers, which were published in the fourth and two subsequent volumes of the Medico-Chirurgical Transactions; but ( 5 ) they Mill also find a, considerable propor- tion of new matter. I have met with no reasons for altering my former arrang<^- ment of those affections of the joints which are of most frequent occurrence. Indeed it has been to me a source of much satisfaction, that all my subsequent observations, founded on numerous addi- tional cases and dissections, have tended to confirm the accuracy of those patho- logical views, which I was led to adopt several years ago, and which 1 ventured to bring forward in the first of those pa* pers, to which I have alluded. CHAP. I. ON INFLAMMATION OF THE SYNOVIAL .MEM- BRANES OF JOINTS. Sect. I. Fatlwlogical Observations. The soft parts, which, added to the bones and cartilages, constitute the structure of the joints, are, the synovial membranes hy which the lubricating fluid is secreted; the ligaments, by which the bones are connected to each other; and the fatty substance, which occupies what in cer- tain positions would otherwise be empty spaces. It is to be supposed, that the adipose membrane belonging to the joints may be inflamed; that it may be the seat of abscesses and tumours, as well as that which is situated beneath the skin or in the interstices of the muscles; and the ( 7 ) Kgaments cannot be regarded as more exempt from disease tlian the fibrous membranes, which they very nearly re- semble in their texture. It is not improbable that the pains and slight tumefactions of the joints, which occa- sionally take place in syphilitic affections, may depend on some diseased action of the ligaments; and there can be little doubt that the long continued symptoms, which sometimes follow a severe sprain, depend on these same parts being in a state of slow inflammation, in conse- quence of some of their fibres being rup- tured, or over=stretched. I cannot say that I have never seen a case, where dis- ease, independently of these causes, has originated in the ligaments; but I cer- tainly have never met with a case, where it has been proved to have done so, by dis- section; and it may be safely asserted, that this is a rare occurrence, and not what happens in the ordinary diseases to which the joints are liable. ( 8 ) On the other hand, no part of the body is much more frquently diseased than the synovial membranes. This is what their anatomical structure and functions might lead us to expect, since we find that living organs are more subject to have their natural functions deranged, in pro- portion as they are more vascular, and as they are employed in a greater degree in the process of secretion. The synovial membranes of the joints have not been well described by the ma- jority of the old, nor even of modern anatomists. A sufficiently accurate ac- count of it has been published by Dr. W. Hunter, in a communication to the Royal Society on the structure of cartilage, pub- lished in the forty-second volume of the Philosophical Transactions, and since then h\ M. Bichat, in his Traite des Mem- hranes; and to these authors I may refer those of my resulers, who wish to see its iinatomy more fully explained. At pre^ .4;ent it is sufficient for me to observe, that ( 9 ) its office is to secrete the synovia, by wliich tlie joints are lubricated; that it lines the ligaments, by which the bones are held together; covers the bones them- selves for a small extent, taking the place of the periosteum; and that from thence it passes over the cartilaginous surfaces, and the inter-articular fat. Where it ad- heres to the bones and soft parts, it very much resembles the peritonaeum in its structure, and possesses considerable vas- cularity; but where it is reflected over the cartilages it is thin, and readily torn;— its existence, however, even here, may be always distinctly demonstrated by a care- ful dissection. The synovial membrane of a joint forms a bag, having no external opening; in this respect resembling the peritonaeum, the pleura, and the pericar- dium; which it also resembles in its func- tions; and to which it bears some analogy in its diseases. Cases occasionally (but not often) occur in which a joint is swollen from a pre* 3 ( io ) ternatural quantity of fluid collected in its cavity, without pain or inflammation* This may be supposed to arise, either, from a diminished action of the absorbents, or an increased action of the secreting ves- sels. The disease may be compared to the dropsy of the peritonseum, or pleura; or more properly, to the hydrocele; and it has been not improperly designated by the terms, " Hydarthrus" and " Hydrops articuli." It more frequently happens that there is swelling from fluid in a joint with in- flammation and pain. Here we may pre- sume that the disease consists in an inflammation of the synovial membrane, with a consequent increase of the secre- tion from its surface; and this is con- firmed by the appearances observed in those cases, in which there is an oppor- tunity of examining the affected parts after death. In many instances, while there is still pain and inflammation in the joint, the ( 11 ) iliiid is felt indistinctly, as if a consider- able mass of soft substance lay over it. Often, when the inflammation has subsi- ded, and the fluid is no longer to be felt, the joint remains swollen and stiff; pain- ful, when bent or extended beyond a cer- tain point, and liable to a return of inflam- mation from slight causes. The appear- ances observed in the following cases, in which there was an opportunity of ex- amining the effects which the disease had produced, seem to throw light on this sub- ject. CASE I. A middle-aged man was admitted into St. George's Hospital in September, 1810, on account of a disease in one knee. The joint was swollen and pain- ful, with slight stiffness, and with fluid in its cavity. The swelling extended some way up the anterior part of the thigh, behind the lower portion of the extensor ( 12 ) rjiuscles. It subsided under the use of blisters and liniments. Two months after his admission into the hospital, lie was seized with a fever, apparently unconnected with the disease in the knee, of which he died. On examining the effected joint, the synovial membrane was found much diseased, and more ca- pacious than natural, extending up the anterior surface of the femur at least an inch and a half higher than usual. Throu«:hout the whole of its internal sur- face, except where it covered the car- tilages, the membrane was of a dark red colour; the vessels being as numerous, and as much distended with blood, as those of the tunica conjunctiva of the eye in a violent ophthalmia. At the upper and anterior part of the joint, a thin flake of coagulable lymph was effused from the inner surface of the synovial membrane, of the size of a half-crown piece. There was no other appearance of disease, except that at the edge of one ( 1^ ) or the condyles of the femur the car tilage adhered to the hone less firmly than usual. CASE II. A. B., a young man, in the spring of the year 1808, in consequence (as he sup- posed) of exposure to damp and cold, be- came affected with a painful swelling of one of his knees. Under the treatment employed by the practitioner whom he consulted, the pain and swelling in great measure, but not entirely, subsided. Three months after the disease first took place, he was admitted into St. Oeorge's Hospi- tal. At this time the knee was swollen, painful, and tender. The swelling had the form of the articulating ends of the bones. The leg was confined to nearly the straight position, and admitted of very little motion on the tliigh. His general health was unaffected. ( *^ ) Blood Mas taken from the kuee by cup- ping; and afterwards it was rubbed daily with mercurial ointment and camphor. The pain and inflammation subsided: and the swelling and stiffness were in some measure lessened. It afterwards became necessary to amputate the limb on ac- count of another disease. The operation was performed on the 15th of December 1808, and I did not neglect the opportu- nity of examining the joint. The bones, cartilages, and ligaments, were in a natural state. The synovial membrane was increased in thickness to about one-eighth of an inch, and was of a gristly texture. It was closely attached to the surroundinsc cellular membrane and fascia by means of coagulable lymph, which had been formerly effused on its external surface. These cases seem to explain the usual consequences of inflammation of the sy- ( 15 ) novial membrane. It occasions, 1 st, a pre- ternatural secretion of synovia; 2dly5 ef- fusion of coagulable lymph into the cavity of the joint; 3dly, in other cases a thicken- ing of the membrane; a conversion of it into a gristly substance; and an eifusion of coagulable lymph, and probably of serum, into the cellular texture, by which it is connected to the external parts. I have seen several cases where, from the appearance of the joint, and other circumstances, there was every reason to believe that the inflammation had pro- duced adhesions, more or less extensive, of the reflected folds of the membrane to each other; and I have observed occa- sionally in dissection such partial adhe- sions as might reasonably be supposed to have arisen from inflammation at some former period. These effects of inflammation of the synovial, very much resemble those of inflammation of the serous membranes. There are however some points of dif- ( 1« ) ference. In the latter, it is not very uncommon for suppuration to take place independent of ulceration. I hare had an opportunity of examining one case, where the same thing had occurred in the synovial membrane of a joint. The elbow was found filled with pus, although there was no ulcerated sur- face. Here the inflammation followed a small wound, which had penetrated into the articular cavity; but I believe that inflammation of the synodal mem^ branes, which has not had its origin in mechanical injury, seldom terminates in this manner. Inflammation of the peritonaeum or pleura, though very sliglit in degree, and of short duration, is suffi- cient to produce an eff'usion of coagulable lymph; but it is only violent or long- continued inflammation which has the same result in the membranes of the joints. The slight adhesion of the caililage to the bone in one of the cases which have ( 17 ) been related, we must suppose to have proceeded from the greater disease in the synovial memhi*ane. I shall have occa- sion hereafter to remark, that the same thing may sometimes be observed, where the cartilage is about to ulcerate. I have known some cases, in which there was extensive destruction of the cartilages of a joint, and which, from the previous history and symptoms, seemed to have been the consequence of neglected in- flammation of the synovial membrane. That this should happen is no more re- markable, than, that ulcer of the cornea should occasionally be induced by in- flammation of the tU7iica conjunctiva of the eye. At the same time, I believe it will be found in the great majority of cases, where ulceration of the cartilages is combined with inflammation of the sy- novial membranes, that the former is the primary affection, and that the latter takes place subsequently in consequence of the formation of an abscess in the articular cavity. 4 ( i^ ) Sect. II. On the Causes and Symptoms of this Disease. It is evident that inflammation may affect the synovial membrane of a joint, by extending to it from some of the other textures of which the joint is com- posed, or that it may have its origin in the membrane itself. My present ob- servations are intended to relate chiefly to cases of the latter description; and what little is to be said in addition re- specting those of the former, will be better introduced hereafter. Although no period of life is altogether exempt from this disease, it does not occur equally in persons of all ages. It very seldom attacks young children; be- comes less rare as they approach the age of puberty; and is very frequent in adult persons. This is the reverse of what ( 19 ) happens with respect to some of the other diseases, to which the joints are liable, and a knowledge of these circum- stances will be found of some importance to the surgeon, in assisting him to form a ready diagnosis. Inflammation of the synovial mem- branes may take place, as a symptom of a constitutional affection, where the sys- tem is under the influence of rheuma- tism; where mercury has been exhibited improperly, or in too large quantities; and under a variety of other circum- stances. But, in these cases, the disease for the most part is not severe; it occa- sions a preternatural secretion of synovia; but does not in general terminate in the effusion of coagulable lymph, or in thick- ening of the inflamed membrane. Some- times it attacks . the greater number of the joints at the same instant, and even extends to the synovial membranes, which constitute the bursai mucosa? and sheaths of the tendons. At other times it leavo^ ( 20 ) one part to attack another, and several joints are affected in succession. In other cases, the disease is entirely local; produced by a sprain or other in- jury; or the application of cold; and sometimes arising from no evident cause. The application of cold is, on the whole, the most frequent source of the com- plaint; and hence it is easy to explain, ifhy it occurs much more frequently in the knee than in any other joint; and why it is rare in the hip and shoulder, which are defended by a thick mass of muscles from the influence of the exter- nal temperature. Where the inflamma- tion is thus confined to a single joint, it is more probable that it will assume a se- vere character; and that it may be of long duration. It leaves the joint with its functions more or less impaired; and oc- casionally terminates in its total destruc- tion. In itself it is a serious disease, but it is often confounded under the alarming name of white swelling, with other dis- eases, which are still more serious. ( 2* ) Inflammation may attack the synovial membranes in different degrees of inten- sity; but for the most part it has the form of a chronic or slow inflammation; which, while it impaii's, does not alto- gether destroy the functions of the joint; and which, if not relieved in the first in- stance by active and judicious treatment, may, like a chronic ophthalmia, continue for weeks or months, and with occasional recoveries and relapses may even harass 2,nd torment the patient during several successive years. In the first instance, the patient ex- periences pain in the joint, which al- though it affects the whole articulation, is often referred principally to one spot, where it is felt more severely than else- where. The pain usually continues to increase during the first week -or ten days, when it is at its height. Some- times even at this period the pain is trifling, so that the patient experiences but little inconvenience from it; at other ( 22 ) times it is considerable, and every motion of the joint is distressing and difficult. In the course of one or two days after the commencement of the pain, the joint may be observed to be swollen. At first, the swelling arises entirely from a pre- ternatural collection of fluid in its cavity. In the superficial joints, the fluid may be distinctly felt to undulate, when pressure is made alternately by the two hands placed one on each side. When the in- flammation has existed for some time, the fluid is less perceptible than before, in consequence of the synovial membrane having become thickened; or from the effusion of lymph on its inner or outer surface; and in many cases, where the disease has been of long standing, al- though the joint is much swollen, and symptoms of inflammation still exist, the fluid in its cavity is scarcely to be felt. As the swelling consists more of solid substance, so the natural mobility of the joint is in a greater degree impaired. ( 23 ) The form of the swelling deserves no- tice. It is not that of the articulating ends of the bones, and therefore it differs from the natural form of the joint. The swelling arises chiefly from the distended state of the synovial membrane, and hence its figure depends in great mea- sure on the situation of the ligaments and tendons, which resist it in cer- tain directions, and allow it to take place in others. Thus, when the knee is affected, the swelling is principally observable on the anterior and lower part of the thigh, under the exten- sor raiuscles, where there is only a yielding cellular structure between those muscles and the bone. It is also often considerable in the spaces between the ligament of the patella and the lateral ligaments; the fluid collected in the cavity causing the fatty substance to pro- trude in this situation, where the re- sistance of the external parts is less tlian elsewhere. In the elbow the swelling ( 24 ) is principally observable in the posterior part of the arm, above the olecranon, and under the extensor muscles of the fore-arm; and in the ankle it shews itself on each side, in the space between the lateral ligaments, and the tendons, which are situated on the anterior part. In like manner in other joints, the figure of the swelling, whether it arises from fluid alone, or joined with solid substance, de- pends in great measure on the ligament? and tendons in the neighbourhood, and on the degree of resistance which they afford; and these circumstances, though apparently trifling, deserve our attention, as they enable us more readily to form our diagnosis. In the hip and shoulder the disease occurs less frequently than in the super- ficial joints. The effused fluid here can- not be felt to undulate, but the swelling is perceptible through the muscles. When the hip is affected, in the first instance a tumefaction may be observed in the groin ( 25 ) and in the nates also; but where the disease has existed for some time, the nates assume a flattened appearance, in consequence of the glutsei muscles be- coming wasted from want of use. The pain is usually confined to the hip itself; but I have known some cases, in which it was referred to the knee also. These symptoms to a certain degree correspond to those which take place where the cartilages of the hip are ulcerated; but attention to the following circumstances will enable us to distinguish the two diseases from each other. Where the synovial membrane of the hip is inflamed, the pain is more severe in the beginning than in the advanced stage of the disease, and it never amounts to that excruciating sensation, which exhausts the powers and spirits of the patient, who labours under the other affection; the pain is aggra- vated by motion, but not by pressing the cartilaginous surfaces against each other; so that it does not prevent the weight of 5 ( 2b ) ttie body being supported on tbe ufiectcd limb; and the wasting of the glutaji muscles is preceded by a swollen appear- ance of the nates. After inflammation of the synovial membrane has subsided, the fluid is ab- sorbed, and in many instances the joint regains its natural figure and mobility; but in the majority 6f cases, stifiness and swelling remain. Sometimes thie swel- ling has the same peculiar form, Avhich it possessed while the inflammation still ex- isted, and while fluid was contained in the joint; and we may suppose, that it depends principally on the inner surface of the synovial membrane having a thick lining of coagulable lymph; at other times the swelling has the form of the articulating extremities of the bones, that is, nearly the natural form of the joint, and it pro- bably arises from the thickened state of the synovial membrane. From which- ever of these causes a swelling remains after the inflammation has subsided, the ( 27 ) j)fitient is very liable to a reciiiTence of the disease. Whenever he is exposed to cold, or exercises the limb in an unusual degree, and often, without any evident reason, the pain returns, and the swellinjj; is augmented. In those cases, where the synovial membrane is tliickened, although the fluid which had been eftiised is ah-' sorbed, and the principal swelling has disappeared, it occasionally happens not only that a certain degree of inflam- mation still lingers in the part, but (hat it continues until the morbid action ex- tends to the other textures; and ulti- mately ulceration takes place in the car- tilages; suppuration is established, and there is complete destruction of the ar- ticulating surfaces. In this advanced stae*e, if we wish to know whether tl»e inflammation of tlie svnovial membrane, or the ulceration of the cartilages, has been the primary affection, we must form our judgment, not from the present symptoms, but from the proious history ( 28 ) of the case. It is indeed, often difficuil to procure a history on the accuracy of which we can rely, particularly in hos- pital practice; but this is of the less im- portance, as whatever the disease may have been in its origin, where it has pro- ceeded so far as has been described, there is no difference respecting the treatment,* and for the most part, when suppuration has taken place, there is little prospect of advantage from any thing, except the removal of the limb by amputation. I believe, that the above history will be found applicable to the majority of cases, in which this disease exists. But I have before observed, that inflammation may affect the synovial membranes in dififerent degrees of intensity; and oc- casionally it will be found to be more urgent in its symptoms, and to be more rapid in its progress, than what has been described; having the characters of ah acute instead of a chronic inflammation. Under these circumstances, the swelling ( 29 ) takes place immediately after, or at the same instant witli, the first attack of pain; there is redness of the skin; the pain is more severe, and it is so mach aggravated by the motion of the parts, that the pa- tient keeps the joint constantly in the same position, and usually, in an inter- mediate state, between that of flexion and extension. In addition to these symp- toms there is more or less of symptoma- tic fever of the inflammatory kind. In a few days the disease, if left to itself, assumes the chronic form; or perhaps, under proper treatment, it subsides al- together. It must be observed, however, that the boundaries of acute and chronic inflam- mation do not admit of being very well defined. These terms accuratelv enou«:h express the two extremes; but there are numerous intermediate degrees of inflam- mation, of which it is difiicult to deter- mine, whether they should be considered as being of the acute or clironic kind. On ( ^0 ) this and ou many other occasions tlic pathologist must be conteiit, if he can succeed in pointing out tlie principal va- rieties of morbid action which occur, and the symptoms, wliich they produce, in such a manner as will enable others, with the assistance of a certain degree of ori- ginal observation, to distinguish those nicer shades in the characters of disease, which language is inadequate to explain, but a knowledge of which is of consider- able importance in medical and surgical practice. Sect. III. Oil the Treatment of this Llsease. In those cases, in which inflammation of the synovial membrane has arisen from a protracted, or ill-conducted course of mercury, sarsaparilla may be given with some advantage, although it does not exhibit those singular powers which it is known to possess in some other com- C 31 ) plaints, which spring from the same source. When the inflammation is con- nected with rheumatism, opium conjoined with diaphoretics, preparations of the colchicum autumnale, and such other remedies, may be employed, as are ca- pable of relieving rheumatism in other textures. In some other instances, when several joints have been affected at the same time, it has appeared to me that the patient has derived benefit from the use of moderate doses of some mercurial preparation. The principal remarks, however, which I have to make at present, relate to the local treatment of the disease; and it is w orthj of notice, that even in those cases where it is evidently dependent on some constitutional affection, topical remedies are on the whole of more importance than any other. In the acute form of the inflammation leeches may be applied in the neighbour- hood of the part; and if there is much ( 32 ) symptoriiatic fever, blood may be taken from the arm, and the bleeding may, or may not, be repeated according to cir- cumstances. Attention should be paid to the state of the bowels, and saline draughts may be given with some dia- phoretic medicines. If the swelling has rapidly risen to such a height, as to occa- sion considerable tension of the soft parts, the pain will be best relieved by means of warm fomentations and poultices; but otherwise cold evaporating lotions seem to produce a better effect. Under this treatment tlie acute inflammation in ge- neral speedily subsides. The chronic inflammation is relieved more slowly. In the first instance the joint should be kept in a state of perfect quietude. Blood should be taken from the part, by means of leeches or cupping. It has appeared to me, that the latter method is preferable; the sudden ab- straction of blood, which can be thus effected, being more beneficial than the ( 33 ) more gradual lifemorrhage, which is pro- cured by leeches. It will in general he right to repeat the hlood-letting twice or three times, or even oftener; and in the intervals compresses may he laid on the part, moistened with some cold lotion. After the violence of the inflammation is suhdued, a hlister may be applied; and (if necessary) several blisters may he used in succession, with more advantage than a single hlister kept open by means of savine cerate. The blisters should be of a considerable size; and if the affected joint be deep-seated, they may be applied as near to the joint as possible; but other- wise a blister is frequently of more ser- vice when applied at a little distance. For example, if the synovial membrane of the hip be inflamed, the blister may he placed on the groin aiid nates; but if the disease be in the wrist, it may be applied to the lower part of the fore-arm. Under this treatment the pain is usually relieved, and in a few days the swelling, as far as 6 ( 34 ) it depends on fluid collected in the joint. is much diminished. Even when the tumor is solid, arising from the effusion of coagulahle lymph, it will in a consider- able degree subside, and sometimes be en- tirely dispersed, provided that the lympli has not yet become organized. Blisters are of more service, with respect to the removal of the swelling, than any other- remedies; but they should not be em- ployed without the previous abstraction of blood, except when the inflammation is slight, and when fluid is effused with- out any admixture of solid substance. ^Yhen the inflammation is in great measure relieved, a moderate degree of exercise of the joint is beneficial, rather than otherwise. Liniments, which irri- tate the skin, may be rubbed on twice or three times in the day. The lini- ments of the Pharmacopceia are not sufficiently stimulating for this, nor in- deed for most other purpose^. The lin'unentum sapcnh^ or Unlmcniiim caui- ( 35 ) phorx compositum^ may be made stronger by the addition of liquor ammonix and tinctura lyttae; and tlie powers of the li- nimentum ammonige may be augmented in the same manner, or by tiie addition of the oleum terebinthins;. The following liniment is more stimulating than those in common use, and seems to me in many cases to be productive of mucli better effects with respect to the disease. R Olei Olivse § j fs« Jicidi Sulphurici § fb. M. Fiat linimentum* It may be used of this strength for the class of persons who apply at a hospital for relief; but for those of a higher class in society, in whom the cuticle is generally thinner, and the cutis more tender, the proportion of olive-oil should be greater. The effect of this liniment is to excite some degree of inflammation of the skin: the cuticle becomes of a brown colour, and separates in thick, broad scales, and the ( 36 ) iuii'ciinijiation of the internal parts is re- lieved, probably on the same principle as by a blister. Another liniment, which is also very useful, is one frequently recom- mended, consisting of a dram (or more) of the antimoniiim tartarisatum to an ounce of the unguentum cetacei. This produces a pustular eruption of the skin^ which, like other eruptions of the same kind, runs its course, and during a cer- tain period of time operates very be- neficially by absti'acting the inflammation from the other parts. IS^o other remedies seem to be produc- tive of much benefit. Plasters of gum ammoniac, and others of a similar nature, are of little efl&cacy, while inflammation still exists; but after- wards they are sometimes of use in pro- tecting the joint from the influence of the external cold, and preventing a relapse. Issues and setons are of no service, except, when there is reason to believe that a secondary disease has begun to ( 37 ) take place, in the form of ulceration of tlie cartilages; and of their use, under these circumstances, I shall have occasion to speak hereafter. The swelling and stiffness, which re- main after the inflammation has subsided may be relieved by the free exercise of the limb, and by friction. The mercurial ointment with camphor may be rubbed on the joint; or friction may be made by the hand, with starch or other fine powder. The friction, however, should be employed with caution, as, when used too freely, it sometimes occasions a re- turn of the inflammation. Whenever there is the slightest indication of this being the case, the friction should be omitted, blood should be taken from the part, and some time should elapse before the friction is resumed. Friction is some- times productive of very essential benefit, but not unless it be employed to a con- siderable extent; as for two or three hours daily, and during a long period of time. ( 38 ) As, however, when employed in this? manner, it is likely to induce a return of inflammation in parts in which the inflam- matory disposition may still linger, it evi- dently is a remedy, which is applicable only under certain circumstances. For these reasons it is that friction appears to be more efficacious where the stiffiaess of a joint depends on a contracted state of the muscles or tendons of the limb, and on these being glued to each other, and to the surrounding parts, than where it is the consequence of disease in the joint itself. I have sometimes tried the effect of pumping hot water on a stiff joint, as recommended by Le Dran, and as now practised at some watering places. The blow of a column of water, falling froin a height of several feet, produces con- siderable friction, even so as to excoriate the surface, with which are combined the relaxing powers of heat and moisture. This practice is certainly productive of ( S9 ) benefit; but the observations just made apply to tliis as well as the other modes of producing friction. Sect. IV. Cases of Inflamed Synovial Membrane, The cases which I am about to relate, will serve to illustrate some of the ob- servations respecting the inflammation of the synovial membrane, which I have al- ready made; and also to explain sorae circumstances, which will be found to occur in practice, and which ccuM not so well be introduced in the general history of the disease, contained in the preceding pages. TVhoever will take the pains to compare these cases with each other, and with those which I shall relate hereafter, will, if I am not exceedingly mistaken, be convinced, that the distinction of the different diseases of the joints is not a mere matter of curiosity, whicli may be ( JO ) interesting to the morbid anatomist; but that these diseases are different in their progress; that they produce different symptoms, by which they may be known from each other in the living person; and which indicate the employment of differ- ent remedies, for their relief. CASE III. John Adams, forty-seven years of age, on the 21st of August, 1811, was seized with a pain in his left knee, and in the course of a few hours he found the joint to be swollen. This was accompanied by a slight attack of fever. On the 28th of August he was admit- ted into St. George's Hospital. At this time the knee Avas extremely painful and tender, and much swollen; the swelling not having the form of the articulating ends of the bones, but being most pro- minent on the anterior and lower part of the thigb, underneath the lower portion ( '^1 ) of the extensor muscles. The fluctuation of fluid might be distinctly felt, within the synovial membrane. Eight ounces of blood were taken from the knee by cupping. The loss of blood was immediately followed by an abate- ment of the pain, tenderness, and swelling. On the 30th of August a blister was applied. The cupping was repeated on the 9tb and iSth of September, and on the 4th of October, and each time was followed bj ihe application of a blister. On the 10th of October the joint was free from all pain and tenderness. It was stifl^j and still slightly swollen, but no fluid was perceptible, the swelling appear- ing to arise entirely from solid substance. He was directed to' use a stimulating liniment twice in the day. On the l8th of October there had been no return of inflammation, and the stiff- ness and swelling were diminished. Fric- tion was now employed, by means of the 7 ( -i^ ) hand >vith starch powder ever^ inoniing and evening; and in a few days after- wards, it was directed, in addition to the friction that hot water should be pumped on the joint, so as to fall on it from a htischt of several feet, for half an hour every morning. About the middle of November he w as dismissed from the hospital; the joint being now nearly as small, and as move- able as before the inflammation had taken place. CASE lY. Robert Stewart, eighteen years of age, was admitted into St. George's Hospital on the 26th of January 1814. He said, that about seven weeks before his admission, the right knee had become swollen and painful without any evident cause. The pain and swelling took place about the same time. The pain was severe, and attended with some degree ( 43 ) Of fever. About a fortnight before liis admission, the joint was cupped, and the swelling and pain became much dimi- liished, and the leg more moveable. The cupping had been repeated on the day previous to his* coming to the hos- pital, and again aflorded him relief. At the time of his being admitted into the hospital, the knee was still much swollen, the swelling extending up the anterior and lower part of the thigh under the extensor muscles: and it ap- peared to arise chieHy from solid sub stance eifused within the articulation, very little ildid being to be distinguished. There was but little pain or tenderness; the joint admitted of a limited motion; he said, it was less stiifj than it had been :>, short time before. On the 27th of January eight ounces of blood were taken from the knee by cup- jilng. and afterwards a blister was apph'td. On the 5th of February the blislei- \\ as healed. The swelling' was n^ucli di- C 44 ) minished. The solid substaricej nlucb had been effused, was in great measure absorbed, so that the form of the articu lating ends of the bones could be distin- g'uished. The blister was repeated. On the 48th of February, the joint was scarcely larger than natural, but it was still atiff in a slight degi-ec. The stiff- ness disappeared under the employment of friction with mercurial ointment and camphor, and on the 23d of February he was dismissed from the hospital as ci:red, CASE y. John Hannam, a stout middle-aged man, was admitted into St. George's Hos- pital under Mr. Keate, on the 22d of Ma> , 1811. He said that six years ago he had wrenched his right knee, which in a few hours became swollen and painful. In the course of a month the pain and the ( 4f, ) £wellirxg gubsided, and he returned to his duty as a soldier, in one of the regiments of Life Guards: but from that period he experienced, what he termed, a weakness of the joint, and he had a return of pain and swelling, whenever he made any unusual exertion, A year and a half previous to his coming to the liospitaL he was ill of a fever. From this time the knee was more sv/oiien and painful: and he continued in this state, sometimes better, sometimes worse, so that be was unable to do his dutj^ and he was in con- sequence discharged from his regiment. , At the time of his admission the knee was swollen; partly from fluid in its cavity, partly from thickening of the soft parts. The svrelling extended some way up the anterior part of the thigh, and was prominent on each side of the liga- ment of the patella. The Joint was stiff, but admitted of an imperfect i3exiou and extension. He complained of some de- gree of pain when at res(. but the paifi ( "5 ) was more severe, whenever he aUeiiipted to exercise the limb. There was an en- larged lymphatic gland in the groin. The knee was cupped several times, wldle the patient remained in the hos- pital. Blisters and stimulating liniments were employed, and about the end ot* September he left the hospital, better than when he was admitted; but there was still pain, whenever he made Any unusual exertion, and the joint was swollen and stiff, though in a less degree than formerly. The swelling now appear- ed to arise altogether from solid sub- stance, no fluid being perceptible. Fifteen months afterwards I had an opportunity of seeing him again. Theie was very little alteration in the state of the knee. He said that whenever lie took more exercise than usual, or was ex- posed to cold, inflammation took place, and the sv> elling was increased; but tliat by remaining for a sliort time in a state of quietuflc iliesc symptoms were abun s 3'elievcd. ( 47 ) The iliree preceding cases are euIK cient to illustrate the ordinary character^., and the ordinary progress of this disease. Those which follow are intended to explain certain circumstances, which although of h*ss frequent occurrence, are occasionally met with, and which it is of much conse- quence for the surgeon to understand. CASE VI. A young gentleman, about thirteen years of age, in July 1817, was seized with inflammation of the synovial mem- brane of one knee, attended with the usual symptoms. Blood was taken from the knee by means of leeches and cupping.; and cold lotions were applied; and the vio- lence of the inflammation subsided. In the beginning of October a blister was ap- plied; and at the end of 0€to])er, the knee Ivas in the following state. It was larger ( 48 ) than the other; the swelling having the form of the articulating extremities of the bones, and appearing to arise from a thickened state of the synovial mem- brane. The joint admitted only of a limited degree of motion, and the motion of it beyond a certain point was pro- ductive of pain. He was now directed to employ friction with a stimulating liniment. The complaint continued very nearly in the same condition until the middle of I^ovember, when the swelling became suddenly reduced, and almost wholly dis- appeared. But on the same day he com- plained of an acute pain in his head, shooting from the temples to the forehead just above the eyebrow. This pain went off in a few hours, leaving only a slight soreness^ and for several days it returned periodically, in the form of a nocturnal paroxysm, of great severity, but of only a few minutes' duration. Leeches and blis- ters were applied both to the head and ( 49 ) Jegs; and purgatives were administered. At the end of a week tbe pain ceased; ])nt he was seized with great somnolencjj which was soon followed by strabismus, partial blindness, and almost total cessa- tion of speech; and after remaining in jhis state about a week he died. The body was not examined. CASE VII. James Burton, forty years of age, was admitted into St. George's Hospital oa the 2d of June, 1813, labouring under a complaint of his left knee. He said, that two years ago the joint became painful and swollen, at first in a slight degree, but afterwards the pain and swelling increased; and he observed that the symptoms were always aggravated on the coming on of cold or wet weather. For the last nine months he had been unable to use the joint, sufficiently to enable him to attend to his usual occupuv ( 50 ) lions. Blisters and issues bad been em- ployed at various times, and as he thought Avith some temporary relief. At the time of his admission the knee was swollen in consequence of fluid being collected Avithin the cavity of the synovial mem- brane. The fluid miojht be distinctly felt to fluctuate underneath the patella when the two hands were placed, one on each side of the joint. The soft parts were somewhat, but not considerably thickened. He had very little pain ex- cept on motion; was unable to bend the leg beyond the right angle, but could extend it completely. The swelling of the joint appeared greater than it really was, on account of the wasting of the muscles of the thigh and leg. Blood was taken from the knee by means of cupping; and afterwards several blisters were applied in succession. He took five grains of the pihila hydrargyri submuriatis every night. On the 2d of August a blister was applied, and kept ( 51 ) open by dressing it with the sayine cerate. At the end of three weeks he complained of pain; and a sense of irrita- tion, extending up the thigh and down the leg. These symptoms were attri- buted to the open blister, and were im- mediately relieved when the blistered surface was allowed to skin over. On the 20th of September he quitted the hospital, being free from all his former symptoms, except that there was still a slight degree of stiffness of the joint. In the beginning of July, 1815, the same patient came again under my ob- servation. At this time, both knees were distended with fluid; the right shoulder was swollen, but in a less degree: and there was a collection of fluid in the synovial membrane, which forms the sheath of the tendons, on the posterior part of each wrist. On examining the right knee, which was the most swollen of the two, a sensation was communicated to the hand. as if produced by a number of small ( 52 ) loose substances, of a soft consistence, within the canity of the joint; and just perceptible to the touch. The joints were moveable, and very little painful. He said that all these swellings had be- gun about three months after he formerly quitted the hospital, with a slight degree of pain, and had gradually increased. I suspect the loose substances, which Avere felt within the knee in this case, to have been portions of coagulable lymph, which had been effused on the inner sur- face of the synovial membrane, and after- wards had become detached; similar to those, which are sometimes formed in the cavity of an inflamed bursa mucosa, and which I shall have occasion to describe hereafter. I had not the op- portunity of observing the subsequent progress of the disease in this patient; and I have never been able to ascertain the correctness or incorrectness of this opinion, respecting these loose substances, by dissection. They are certainly of a ( 53 ) different nature from the loose cartilagesj tvhich are met with in other cases. CASE VIII. Amy Brookes, fifty-four years of age^ Was admitted into St. George's Hospital on the 10th of June, 1818. Three years ago, her right knee became swollen and painful, and the pain and swelling had existed ever since, some- times in a greater, sometimes in a less degree. At the time of her admission, the knee was much swollen, in conse ijuence of fluid collected in its cavity. There was pain in the joint, which was aggravated by motion; but which was not sufficient to interfere with her rest at night, or to prevent her going about her usual occupations. On examining the knee, a sensation was given to the hand, as if some soft loose substance was formed within the joint; and a crepitus was dis- tinguished, on moving the patella from one side to the other. ( 54 ) During tlie time of her stay in the hospi^ tal, blood was taken from the knee twice by cupping, and once by leeches; and two blisters were applied. July ISth, she was discharged as cured; there was no pain nor swelling; the loose substance was no longer perceptible, and the cre- pitus could scarcely be distinguished. The crepitus which was observed in this case, occurs only in a few instances, and I know not from what cause it proceeds. It is different from that which I ha>e met with where there has been reason to believe that the cartilages are destroyed so as to expose the bone underneath. The followinsc case furnishes an e\- ample of a disease, which, as far as I know, has not been described by any pathological or surgical writer. One of the most remarkable symptoms, which the disease produces, is an inflammation of tlic synovial membranes; for whitli ( 55 ) • reason it Is to be rco'arded as connected with the present subject, and may be pro- perly introduced in this place. CASE IX. A gentleman, forty-five years of age, in the middle of June, 1817, became af- fected with symptoms resembling those of gonorrhoea. There was a purulent discharge from the urethra, with ardor urinse and chordee. On the 23d of June he first experienced some degree of pain in his feet. On the 24th the pain in the feet was rather increased, but not in a sufficient degree to prevent his walking four miles. There was some appearance of inflammation of his eyes. June 25th, the pain in his feet was more severe; the tunicse conjunctiva; of his eyes were much inflamed, with a pro- fuse discharge of pus. These, symptoms increased in violence, the pulse varying from SO to 90 in a ( 5b ) minute; the tongue being furred; and tlie patient being restless and uncomfort- able during the niglit. The whole of each foot became swollen; there was inflam- mation of the synovial membranes of the ankles; and it appeared to me, that the affection of the feet themselves arose from inflammation of the synovial mem- branes belonging to the joints of the tarsus, metatarsus, and toes. He said that he could compare the pain, which he experienced, to nothing else than that which might be supposed to arise from the feet being squeezed in a vice. On the 27th of June the left knee be- came painful, and on the following day the synovial membrane of this joint was found exceedingly distended with syno- via. He was now completely crippled; compelled to keep his bed, and scarcely able to vary his position in the smallest degree without assistance. The inflam> mation of the eyes and urethra was 8ome« what abated. ( •" ) June 30th, the inflammation of tlie eves and urethra had much subsided, and the purulent discJiarj^'e was dimi- nished. The pains of his joints were less severe; and the feet were less swollen. On the following day the knee was less swollen also. He continued to mend, and on the lOlh of July the swelling of the feet was still further diminished, and that of the knee had almost wholly disappeared. His pulse continued to vary from 80 to 90 in a minute, and his tongue was still furred. He had pain in the feet and knee, but less severe than formerly, and he was restless at night. July 13th, he complained of pain in the right knee, and on the following day there was pain also of the right elbow ^nd shoulder. The right knee afterwards became swollen from fluid within the cavity of the synovial membrane, but not in the same dea:ree with the other knee, and ( 58 ) the swelling soon subsided. There was never any perceptible swelling of the shoulder and elbow. August 1st, all his pains were abated. The eye and the urethi'a were nearly free from inflammation, and the purulent dis- charge was scarcely perceptible. August 5th, he was free from pain ex- cept on motion: the joints, which had been affected, were stiff; but he was able to move about on crutches. From this time he progressively mended. The stiffness of the joints di- minished very slowly; but he was free from all uneasiness. He was longer in recovering the use of the shoulder, than that of the other joints. In the following December. 1817, (at wbich time he had nearly, but not com- pletely recovered the use of his limbs,) he had another attack of the complaint. The symptoms were the sa:iie as for- merly, taking place in the same order, and pursuing the same course, but with ( 59 ) a much less degree of violence. This second attack lasted about six weeks; and left him again considerably crippled. In March, 1818, he became affected with an ophthalmia, but of a different nature, from that which he laboured imder in the preceding summer. The inflammation was seated in the proper tunicks of the eye; and it appeared pro- bable, that it would speedily haye ter- minated in adhesions of the iris, and destruction of the powers of vision, if it? progress had not been arrested, by repeated blood-lettings, and the use of mercury. In order that the history of the dis- ease might be rendered as simple as possible, I have described the symptoms in this case without hitherto adverting to the treatment, which v.as employed. — Leeches, and blisters to the knee; lini- ments rubbed on the knees and shoul- ders; and fomentations when there wa^j severe pain; formed the principal to- ( 60 ) pical remedies. Of the various medicines, which were exhibited, none seemed to he productive of benefit with the exception of the vinum colchici. It was under the use of this medicine, that not only the pains and swellings of the joints; but that even the purulent inflammation of the eyes and urethra first began to sub- side: and I am on the whole inclined to believe that my patient was indebted to it for a much more speedy recovery than he would have had other^vise. I have had the opportunity of seeing four other cases, in which a similar train of symptoms took place. One gentleman lias had as many as eight attacks of this complaint. Tlie first took place when lie v.as under twenty years of age, and tlie others at various intervals in the course of the next seven- teen years. In one of them the first symptom was inflammation of the urc- ( 61 ) thra^ attended with a discharge of pus, although from particular circumstances he could not helieve that he had been ex- posed to the risk of infection. This was followed by purulent ophthalmia, and that by inflammation of the synovial mem- branes. In three of the attacks a puru- lent ophthalmia was the first symptom; which was followed by inflammation and discharge from tlie urethra; and then the synovial membranes became affected: and in the other four attacks the affec- tion of the synovial membranes took place without any preceding inflammation either of the eye or urethra. The dis- ease was not confined to the synovial membranes of the joints, but those of the bursffi mucosae were inflamed also. In some of the attacks the muscles of the abdomen were painful and tender, and subject to spasmodic contraction; and there was an occasional impediment to breathing, which seemed to arise from a similar affection ol'the diaphragm. The acute form of the disease, in this case, ( 62 ) lasted from six weeks to three months, but nearly a year generally elapsed before the use of the limbs was perfectly re- stored. The last attack began in July, 1817; and in the beginning of May, 1818, while he was still lame, he was seized with a very violent inflammation of the sclerotic coat and iris of one eye, which was suhdued by very copious hlood-letting, and the exhibition of mer- cury. Another gentleman gave the following history of his complaints: In the year 1809, he had symptoms resembling those of gonorrhoea, and, when these had con- tinued for some time, one testicle became inflamed and swollen. This was followed by a purulent ophthalmia, and inflam- mation of the synovial membranes. In the year 1814, he had a similar attack, Avith the exception of the swelled tes- ticle; and in the year 18 16, when I was consulted, he still laboured under a chronic inflammation of the synovial membranes of the knees and ankles, the ( es ) ity of tlie joint, about four ounces of a pale yellow fluid, having Hakes of coagulablc lymph ( 71 ) floating in it. The synovial membrane, where it formed the loose folds, extending from one bone to the other; where it was reflected over the bones themselves, the crucial ligaments, and the fatty sub- stance of the joint; had completely lost its natural appearance. It was converted into a pulpy substance, in most parts about a ^juarter, but in some parts, nearly half an inch in thickness, of a light brown co- lour, intersected by white membranous lines, and with red spots formed by small vessels injected with their own blood. The synovial membrane on the edge of the cartilaginous surfaces had undergone a similar change of structure, but only for a small extent. The semilunar carti- lages were entire, but in a great measure concealed by the pulpy substance project- ing over them. The cartilages covering the bones, in a few places were in a state (Of incipient ulceration. C 72 ) CASE XIII. Martha Manners, twenty-six years of age, was admitted into St. George's Hos- pital on the 6th of March, 1813, on ac- count of a disease in her right knee. She said that in June, 1811, she first observed the joint to be swollen and stiff; and from this time, the swelling and stiff- ness increased; but in the first instance by very slow degrees. About IVIichael- mas, 1812, she caught cold, and the swelling increased more rapidly, but it was not attended with any considerable quantity of pain. At the time of her admission into the hospital, the right knee measured about two inches in circumference more than the left. The swelling was elastic; pro- minent at the upper and lower part of the joint; not having the form of the articu- lating ends of the bones. The joint ad- mitted of motion, but the leg could not ( 73 ) be completely bent or extended on tlie thigh. Various remedies were employed with- out the smallest benefit. The stiffness of the joint increased. About the middle of May, she began to experience consi- derable pain, and soon afterwards an abscess presented itself by the side of the ligament of the patella, which was opened on the 15th of June. The orifice made by the lancet healed in a few days; but she continued to suffer severe pain; her health became much affected, and on the 6th of August the limb was removed by amputation. On examining the joint, about an ounce of thick matter was found in its cavity. The ligaments were in a natural state. The synovial membrane had un- dergone precisely the same alteration, as in the case which has just been related. The only point of difference that could be observed, was, that the whole of that portion of the membrane, which is re- 11 ( 74 ) fleeted over the cartilages, had become affected, presenting the same appearance as elsewhere, but being thickened in a less degree. The cartilages had begun to ulcerate in a few spots; but the ulceration had made so little progress, that it might not have been noticed on a superficial in- spection. CASE XlV. Samuel Langford, 24 years of age, was admitted into St. George's Hospital on the 22d of April, 1812. At the time of his admission, one of his knees was swollen to nearly twice its natural size. The swelling was promi- nent on the anterior and lower part of the thigh. It was soft and elastic, so that at first it appeared to contain fluid, but on particular examination, the ab- sence of fluid was ascertained, by the want of fluctuation. The leg was kept in the half-bent state, and the joint ad- ( 75 ) mitted of only a very limited degree of motion. He had no pain, even when attempts were made to move tJie limh. The skin, over the diseased part, was of a pale colour, with some dilated veins ramifying in it. On each side of the joint, a small orifice was observed, through which the probe might he introduced into a sinus; hut the sinuses appeared to be of small extent. His general health was unimpaired. He said, that two years ago, he first experienced some pain in the knee, but it was not sufficient to pre- vent his going about his usual occupa- tions. Soon afterwards the joint began to swell, and the enlargement gradually increased from that period. Several ab- scesses had formed at different times, but the greater number of them had healed. About two months after his admission into the hospital, the limb was amputa- ted. On dissecting the diseased joint, the li- gaments were found in a perfectly natural ( 76 ) State. The whole synovial membrane, except where it was reflected over the cartilages, was converted into a pulpy, elastic substance, of a brown colour, in- tersected by white membranous lines, in some places half an inch in thickness, in others more; and in those parts, where the membrane was reflected over the bones, near the border of the cartilages, it was destroyed in spots by ulceration. The semilunar cartilages were in a natural state, but in a great measure con- cealed, in consequence of their being en- veloped in the mass of substance formed by the diseased synovial membrane. The cartilaginous surfaces of the femur and patella .were extensively, but not entirely destroyed by ulceration; the ulceration being greatest towards the circumference. On the internal portion of the head of the tibia, the cartilage was destroyed only for a very small extent, the ulceration being entirely confined to the margin. On the external portion of the liead of ( " ) the tibia, the cartilage was absorbed to a greater extent. The bones possessed their natural structure and hardness. The cavity of the joint contained matter, and the sinuses communicated with it. CASE XV. , Michael Purcel, sixteen years of age, was admitted into St. George's Hospital, on the 10th of July, 1811, on account of a disease in the right knee. He said that in the summer of 1807, he had received a blow on the inside of the joint. Some time afterwards a swel- ling formed and burst, and some fluid was discharged. In about a week the orifice healed; a slight degree of stiffness only remained, and he was able to follow his usual occupations. He continued well till December, 1810, when the joint was observed to be increased in size. From this time the swelling increased, but ' with no other inconvenience than ( 78 ) stifthess of the joint, and a slight degree of pain in walking. At the time of his admission into the hospital, there was a large swelling of the knee, extending an inch or more up the anterior part of the thigh, under the extensor muscles. The swelling was more prominent in some parts, than in others. It was soft and elastic, and g^ve to the hand an indistinct sensa- tion, as if it contained fluid. The leg w as kept in a half-bent position, and was nearly immoveable on the thigh. He had no pain, except on motion or pressure. On the 28th of November, an abscess burst on the outside of the joint, and dis- charged a small quantity of pus. After this other abscesses formed, and burst at various times. The swelling continued to increase. Amputation was performed on the 6th of April. On dissecting the amputated joint, all the ligaments were found in a natural state. The synovial membrane had pre- ( 79 ) (fisely the same appearance as in the last case. In some parts it was half an inch, in others more than an inch in thickness. The cartilages were for the most part destroyed by ulceration, and ^carious surfaces of bone were exposed. The ab- scesses appeared to have formed in the substance of the synovial membrane, and did not communicate with the cavity of the joint, nor did the joint contain pus. CASE XVI. A boy, six years of age, was admitted into St. George's Hospital, in March, 1808, on account of a disease in one knee. * In using the term caries on this and on other occasions, I have considered it as synonimous with ulceration; or, at least, as expressing that state in bones, which corresponds to ulceration in soft parts. Some confusion has been produced in pathological nomenclature in consequence of this term having been employed by some, to express, not only bone, which is ulcerated, but that whose surface has been exposed from other causes. ( 80 ) The joint was larger than the natural size. The leg was bent at a right angle to the thigh, and admitted of no motion. The skin on the outside was ulcerated to a considerable extent. Various remedies having been employed without success, the limb was amputated on the 29th of April. On examining the joint, the sy- novial membrane was found to have undergone a morbid change of structure similar to that in the preceding cases, but with this difterence, that the pulpy substance into which it was converted, projected into the joint, so as nearly to fill its cavity, and adhered to the carti- laginous surfaces. On making a longi- tudinal section of the joint, the cartilage covering the bones was seen, as a white line, about one-tenth of an inch in thick- ness, connected to the bone on one side, and having the pulpy substance adhering to it on the other. It was, therefore, thinner than natural; but otherwise en- tire, except at the posterior part of one ( 8i ) of the condyles of the femur; where it was destroyed hy iilceriition for a small extent. There were no distmct remains of the ligaments external to the joint, and only some small vestiges of the crucial ligaments and semilunar carti- lages. CASEXVIL John Dillemore, thirteen years of age, was admitted into St, George's Hospital, in the summer of 181 2, on account of a disease in one knee. At that time the joint was slightly swollen and stiff, so as to admit of only a very limited degree of motion. He was free from pain. The swelling was elastic, without any percepti- ble fluctuation of fluid. These symptoms had been coming on gradually about two years previous to his admission. At this time he remained in the hospital for up- wards of three months; and a great num- ber of remedies, which it is unnecessary 12 ( 82 ) to enumerate, were employed witliout the smallest benefit. On the 26th of January, 1814, he was re-admitted into the hospital. The af- fected knee was about two inches and a half in circumference more than the other. The swelling was elastic; it ex- tended up the anterior and lower part of the tliigh, as in cases of inflamed synovial membrane, but its form was less regular, being more prominent, and extending higher up on the outside than on the in- side. The leg was kept in the half-bent position, and was perfectly immoveable on tiie thigh. He was subject to occa- sional attacks of violent pain. He said, that the swelling had gradually increased from the period of his quitting the hos- pital in 1812, but that he had not been subject to very severe pain, till about six weeks previous to his re-admission. On the 31st of January the limb was am- putated. ■( 88 ) On examining the diseased joint, the synovial membrane was found converted into a pulpy substance of a light brown colour, with red spots arising from ves- sels ramifying in it, injected with 'their own blood, and intersected by very nu- merous membranous lines. On the out- side of the joint, the diseased membrane was in some places nearly an inch in thickness. The membrane covering the cartilages in some parts was in a natural state; in other parts, it had undergone the same morbid change of structure as elsewhere. The cartilages were ulcerated in spots. TJiere was about half an ounce of pus in the cavity of the joint; and there were two or three abscesses in the substance of the synovial membrane, not communicating with the joint, contain- ing about the same quantity of purulent matter. ( 84 ) CASE XYIII. AYiliiam Hine. twenty-three years of age, was admitted into St. George's Hos- pital on the 12th of December, 1814, on account of a complaint in one of his knees. He said, that in the summer of 1812, he first observed a slight degree of stiffness and swelling of the joint, un- attended by pain. At first the swelling was confined to the inside, but it gradu- ally extended itself over the whole cir- cumference of the joint. The stiffness and swelling slowly, but uniformly, in- creased: about the end of the year 1813, he first began to experience considerable pain. At the time of liis admission, the knee was much swollen; the swelling was irregular and most prominent on the inside: it was soft and elastic, without the fluctuation of fluid. He complained of constant, deep-seated, gnawing pain, which disturbed his sleep. He had a ( 85 ) ^ilight degree of hectic fever. On the 16th of December the hmb was am- putated. On dissecting the amputated joint, the synovial membrcine was found to have underscone the same morbid alteration of structure as in the last case. The car- tilages were slightly ulcerated in a few spots. CASE XIX. James Gould, sixty-five years of age, wa^ admitted into St. George's Hospital, in 3Iay, 1814. One knee was swollen and stiff, admitting of scarcely any motion. The swelling ^ras elastic. He complained of severe pain in the joint, ^ear the liga- ment of the patella was the orifice of a sinus, communicating Avith the articular cavity, and discharging a very small quan- tity of pus. No clear history could be procured of the disease in its earlier stages, but it appeared, that he had been subject ( 86 ) to repeated attacks of inflammation of the synovial membrane. The limb was amputated on the 23d of May. On dissection, the ligaments, bones, cartilages, and that portion of the syno- vial membrane which is reflected over the cartilages, were found to be in a natural state; but the svnovial membrane in other parts had undergone the same mor- bid alteration of structure as in the pre- ceding cases. These cases furnish examples of the same disease in different stages of its pro- gress. The morbid action evidently ori- ginates in the synovial membrane, which loses its natural organization, and be- comes converted into a thick pulpy sub- stance, of a light brown, and sometimes, of a reddish-brown colour, intersected by white membranous lines. As the disease advances it involves all the parts, of which ( 87 ) the joint is composed, producing iilniev" ation of tlie cartilages, caries of the bones, wasting of the ligaments, and abscesses in different places. I have already remarked, that this dis- ease is peculiar to the synovial mem- branes; at least that I have never met with it, in any other part of the body: but it belongs to the same order with tubercles of the lungs, scirrhus of the breast, the medullery sarcoma or fungus hsematodes of the testicle, and numerous others, in which the natural structure of the affected organ is destroyed, and a new and different structure is added in its place. To these also it bears a near resemblance in its progress. Thus, tu- bercles of the lungs in the first instance, occupy the vesicular and interlobular sub- stance; but ultimately, they inflame and ulcerate; abscesses form in them, and then the pleura, the bronchia, and other contiguous parts become affected. Si- milar circumstances mark the progress ( 88 ) of other maladies of tlie same de- scription. The cases, which have heen related are not the only ones, in which I have had the opportunity of tracing the same mor- hid appearances. I have also met with numerous others, in which the similarity of the history and symptoms, and the resemblance in the form and elasticity of the tumor, indicated the disease to be of the same nature, although I was not able to verify the fact by dissection. In every case, in which I have had it in my power to watch its progress, the complaint has been slow, and sometimes has remained in an indolent state, during a very long period: but ultimately it has alv»^ays terminated in the destruction of the joint. It is a remarkable circumstance, that this affection of the synovial membrane IS rarely met with except in the knee. I have never known an instance of it in the hip or shoulder. It is probable that ( 89 ) the influence of the external cold may operate as one of the causes, by which the disease is produced, and this ex- plains, why it occurs frequently in the knee, and seldom in the deep-seated articulations.* It is evident from the history of cases, in which a part of the living body has asr sumed a new and morbid structure, that this alteration seldom takes place except by slow degrees; and it would add much to the interest and utility of researches in morbid anatomy, if it were more fre- quently attempted to ascertain, what is * The account of the fung'us articuh which has been given by some German writers, appears to have been drawn, partly from cases of the disease de- scribed in this chapter, partly, from cases of inflam- mation of the synovial membrane. Mr.Russel seems to have taken his history of the pathology of white Eweliing, in great measure from cases similar to those which have been related; but we must observe, that the term white-swelling has been applied, almost in- discriminately; to all the aftcctions, to which the joints are liable, and by no means confmed to that under our present consideration. 13 ( 90 ) the first change in the organization of the aftected part, which disease produces, and from thence to trace the gradual progress of the other changes, which take place, until the destruction of the natural or- ganization is completed. Whether the following case is to be considered as of the same kind with those already re- corded, but in an earlier stage of the disease, cannot at present be determined; but it appears not improbable that it is so, and I shall venture to relate it in this place, in the expectation, that it may at any rate, be of some service in assisting the investigations of future inquirers. CASE XX. Belton, a boy eleven years of age, was admitted into St. George's Hospital in August, 1810, on account of a disease in one knee. There was but little pain in the joint: ( 91 ) it was slightly enlarged, admitted of some motion, but not of complete flexion and extension. His parents said that the dis- ease had begun about a year and a half before his admission into the hospital: that it had increased very slowly, and that he had never suifered from it any serious distress. Various remedies were employed without benefit; and in a short time his friends took him out of the hos- pital. A few weeks afterwards he died, in consequence of an accumulation of water in the ventricles of the brain. I obtained permission to examine the body. The synovial membrane of the affected knee externally had its natural appear- ance. Internally it was lined by a straw- coloured gelatinous substance, so inti- mately adhering to it, that it could not be detached, except by an artificial sepa- ration. The synovial membrane was encrusted in this manner, every where, except on the cartilaginous surfaces. ( 92 ) The gehitinoiis substance in general ap- peared about one-eightli of an inch in thickness, but in some parts near the borders of the cartilages, it was much thicker, so as to project considerably into the cavity of the joint. In a few places, towards the margin of the articu- lating surfaces, the cartilage had begun to ulcerate: in some of these it Mas en- tirely absorbed; so that the bone was exposed; but, for the most part, there was only an irregular ulcerated surface towards the cavity of the joint: the re- maining portion of the cartilage being entire, and having its natural adhesion to the bone. The synovial membrane itself boi-e no marks of inflammation. In the substance with which it was lined, some vessels were observed i*amifyiug, beautifull}^ in- jected with their own blood, but these were few in number, and only in certain parts. This substance differed in ap- pearance, from the coagulable lymph. ( 9-^ ) wliich is found on the surface of an in^ flamed membrauc; and we may presume, therefore, that the effusion of it was the result, not of inflammation, hut of some other mor])id action. Sect. IT. On the Symptoms of this Disease. This disease generally takes place in persons, who are not much above the age of puberty. I do not recollect more than one instance of it having occurred after the middle period of life. In general it can be traced to no evident cause, but oc- casionally it takes place in consequence of repeated attacks of inflammation. In this respect it resembles other diseases of the same order. Inflammation of the lungs may lay the foundation of tubercles, and inflammation of the breast may occasion the growth of a scirrhous tumor. Where I have had an opportunity of examining ( 94 ) the morbid appearances after aniputatioDj I have always found the whole, or nearly the whole, of the synovial membrane afl'ected by the disease; but it is pro- bable, that if the examinations were made at an earlier period, we should often find the morbid change originating in some one point. At least this is in conformity to what we find in other maladies, which correspond to this in their nature: and in one instance, in a girl who laboured under this affection, and who died of a fever, I found one half of the synovial mem^ brane altered in structure, and the other half retaining its natural appearance. In the origin of this disease, there is a slight degree of stiffness and tume- faction, without pain, and producing only the most trifling inconvenience. These symptoms gradually increase, hi the greater number of cases, the joint at last scarcely admits of the smallest motion, but in a few cases, it always retains a certain degree of mobility. The form of ( 95 ) the swelling bears some resemblance to that in cases of inflammation of the sy- novial membrane, but it is less regular. The swelling is soft and elastic, and gives to the hand a sensation as if it contained fluid. If only one hand be employed in making the examination, the deception may be complete, and the most ex- perienced surgeon may be led to suppose that there is fluid in the joint, when there is none: but if both hands be em- ployed, one on each side, the absence of fluid is distinguished by the want of fluctuation. The patient experiences little or no pain, until abscesses begin to form, and the cartilages ulcerate; and even then the pain is in many instances not so severe, as where the ulceration of the car- tilages occurs as a primary disease: and the abscesses heal more readily, and dis- charge a smaller quantity of pus, than in cases of this last description. At this period the patient becomes affected with ( 96 ) hectic fever; loses his flesh, and gra- dually sinks, unless the limb be removed by an operation. The progress of this disease varies in different cases. In general, one or two years elapse before it reaches its most advanced stage; but sometimes the period is much longer; and occasionally it be- comes indolent, so that it remains during many months without any sensible alter- ation. In like manner tubercles of the lungs, or scirrhus of the breast, in some instances remain in an inactive state for several months, or even for one or two Years. The diagnosis of this disease is seldom difficult. The gradual progress of the enlargement, and stiffness of the joint without pain, and the soft elastic swelling without fluctuation, in the majority of cases enable us to distinguish it readily from all the other morbid affections to which the joints are liable. The cases, with which those of this ( ^^ ) N THE ULCERATION OF THE CARTILAGES OF JOINTS. Sect. I. Pathological Observations. The cartilages of joints differ in some ^^ssential circumstances from those, wliich are employed in other organs. The lat- ter are more vascular, more liahle to be- come inflamed; and inflammation in them usually terminates in the depo- sition of osseous matter. The articular cartilages in the adult possess no vessels capable of carrying red blood- Inflamma- tion is not in them a frequent occurrence; when it does take place, it terminates m ulceration, and not in the formation jfbone. Ulceration of cartilage may be ihe consequence of inflammation of the ( 102 ) fcurtilagc itself, or of the bony surface, to. which it is connected; but in many in- stances there are no evident marks of inflammatory action having preceded it, either in one part or the other, and the in- flammation, Avhicli aftei'wards takes place appears to be rather the attendant on, than the cause of, the ulcerative process. The ulceration of soft parts is usually, and, as far as I know, always attended with the secretion of pus; but it is other- wise with the articular cartilages, in which suppuration seldom takes place, while the ulcer is small, and often the disease proceeds so far, as to cause caries of the bones to a considerable extent, without matter being formed in the joint. This circumstance is deserving of notice. It has been long established that suppur- ation may take place without ulceration; and it appears, that, in this instance, ulcer- ation may take place without the form- ation of pus. In the cases, which have been related, ( *03 ) the ulceration of the cartilages of the clis^ eased joints was a secondary affection, the consequence of a niorl)id action originat- ing in the neighbouring soft parts. There are other cases^ and tliose not of rare occurrence, in which the ulceration of the articular fartilages exists as a primary disease. When the nlceration of the cartilage ■occurs in the snperficial joints, it con^ stitutes one of the diseases, which have been known by tlie name of white-SAvel- lins:. From cases which I have met with, I am led to conclude, that when it takes phice in the hip, it is this disease, which has l)een variously designated by writers, the " Morbus Coxarius," the ^' Disease of the Hip," the " Scrophulons Hip," the " Scroplmlous Caries of the Hip-joint." At least it is to this disease, that these names have been principally applied, though probably, other morbid affections have been occasionally con- founded with it. ( 1^1 ) CASE XXI. In examining a body, brought into tbe dissecting-room in Windmill-street, I found tbe cartilage in a diseased state, in tbe joints of botb bips, of one of tbe knees, and of botb elbows. In some spots, tbe cartilages of tbese joints were altogetber destroyed by ulceration, and carious surfaces of bone were exposed; in otbers, tbe cartilage was not com- pletely absorbed, but it bad tbe appear- ance of fibres, Avbicb w ere connected at one extremity to tbe bone, w bile the otber extremity was loose towards tbe cavity of tbe joint, and baving no lateral connec-' tion witb eacb otber. Tbe intervertebral cartilages connecting tbe bodies of some of tbe dorsal vertebrae were also in a dis-^ eased state* Tbey retained tbe usual appearance of concentric layers towards tbe circumference, but in tbe centre, in- stead of tbe wbite semi-fluid substance, wbicb is met witb under ordinary cir- ( 105 ) rii 111 stances, they were found to be of a brown colour, of a solid and somewhat brittle texture, composed of several por- tions, haying a very slight adhesion to each other. The ligaments, the synovial membranes, and the bones, were all in a natural state, except that the latter were occasionally carious in consequence of the absorption of the cartilage; but the caries was unattended bv the formation ft' of matter. In this case, the original disease appears to have been a morbid state, and subset quent ulceration of the cartilages. It shews that where the disposition to it exists, the destruction of the cartilage may take place in several joints at the same time, and I have observed the same thing in many other instances. The conversion of the cartilage into a soft fibrous structure, I am disposed to believe, is the frequent, though not the constant forerunner of ulceration. In a woman, who died a week after a severe 15 (^ 106 ) contusion of tlie hip, the cartilage of the head of the femur Avas found in some parts entirely absorhed, in others having a fibrous appearance, similar to what has been described, and I have noticed the same cu'cumstance in other cases, some- times connected with, and sometimes in- dependent of local injury. CASE XXII. A boy, ten years of age, was admitted into St. George's Hospital, in April 1809, on account of a disease of the left hip. The nates were wasted, and flattened; there was pain in the hip and knee, and a large abscess had formed which pro- duced a tumor on the outside of the thigh. An issue was made with caustic behind the great trochanter. About a month after his admission, the skin over the abscess having become inflamed, I made an opening in it, with a lancet, and half a pint of pus was evacuated. The ( 107 ) orifice made by the lancet, healed by the first intentian, but in a few days, pus was again collected in the abscess, and the tumor was larger and more tense than ever. The limb became shortened, the abscess burst externally, the boy became affected with hectic symptoms, and died on the 21st of October. On examining the body, the abscess was found communicating with the cayity of the left hip. The capsular ligament and synovial membrane were not distinguish- able from the other soft parts, forming the pariet.es of the abscess. There was no vestige of the round ligament, and no remains of cartilage on either of the bones composing the joint. The head of the femur was reduced by caries, to about one half of its natural size; and from the same cause, the acetabulum was rendered deeper and wider than is natural. At the posterior part, the margin of the acetabulum was more extensively ab- sorbed, and the head of the femur had ( 108 ) been drawn out of its ca\it}, and was lodged on the dorsum of the ilium. "No other disease had been suspected to exist during life. If the boy had ever complained of pain in the right hip, the circumstance had been overlooked, on ac- count of the greater disease in that of the opposite side. Having accidentall}' cut into the joint of the right hip, I found the cartilage covering the head of the femur, absorbed for about one-third of its extent, and the surface of bone, which was in consequence exposed, w^as covered by a thin layer of coagulable lymph. The cartilage lining the acetabulum, and all the soft parts belonging to the joint, were in a perfectly natural state, and the bones wel'e of the ordinary texture and hardness. CASE XXIII. A. girl, seven years of age, was adniitteci into St. George's Hospital, in 3Jay, ( 109 ) 1809, on account of a complaint in thfe left hip. She had pain in the knee, the limb was shorter than is natural, and the nates were wasted and flattened. An issue was made with caustic, behind the gi'eat trochanter. Soon after her admis- sion an abscess burst near the crista of the ilium. The disease in the hip appeared to be considerably relieved, but on the first of August, she died of an accidental attack of erysipelas. On inspecting the body, the glutaei muscles of the left side were found wast- ed and of a dark colour. A sinus extended from the external orifice of the abscess through the soft parts, and communicated with the hip-joint, by an ulcerated open- insf in the margin of the acetabulum. There were no remains of cartilage on the surface of the acetabulum. The ex- posed bone was in a carious state, and of a dark colour, and the cavity of the ai^etabulum was rendered deeper and wider tlian is usual. The greater part of the cartilage was destroyed on the head ( *io > of the femur, and the small portion of it which remained, was readily separated from the hone. This circumstance is often met with, where cartilage is under- going the process of ulceration. The capsular ligament was somewhat thicker than under natural circumstances, and more connected with the surrounding parts. There were no remains of the round ligament. In tlie anterior part of the joint, a quantity of organised soft substance, re- sembling that of adhesions, was interpo- sed between the head of the femur and the acetabulum, and behind this was a collection of dark-coloured pus. From these two causes the head of the femur had been separated from the os innomi- natum, and pushed outwards, and it had afterwards been drawn upwards by the action of the muscles, so that it was lodged on the superior part of the bony margin of the acetabulum. The synovial membrane was of a dark colour, but not otherwise diseased. ( 111 ) On examining the liip of the opposite ^ide, I found the soft parts external to it, the capsular ligament, synovial mem- brane, and fatty substance of the joint, having no appearance of disease. The cavity of the joint contained about a drachm of dark-coloured pus. The car- tilao'e was absorbed from about one-third of the surface of the acetabulum. The exposed bone in most parts presented an uniform compact surface, but in two places it was in a state of superficial caries. In some parts of the head of the femur, the cartilage had a fibrous appear- ance, similar to what has been already described; in other parts it was entirely absorbed, and a carious surface of bone was exposed; and elsewhere it was in a natural state. The round ligament was ruptured by a very slight degree of force, which seemed to arise from the cartilage having been destroyed round its insertion into the acetabulum. The bones in the neighbourhood of the carious surfaces of the left hip, were ( H2 ) of a darker colour than usual; but no such appearauce was observed in the bones of the other hip, which were in all respects in a healthy state. CASE XXI\. John Catnack, forty-four years of age, was adniitted into St. George's Hospital on the 29th of September, 1813, with pains in the lower limb of the right side, extending from the hip to the knee, and resembling the pains of rheumatism. He attributed these pains to his having caught cold about a month before his admission. He laboured also under a complaint of his bowels, of which he died on the 4th of December. On dis- section, no preternatural appearances were discovered, except in the right hip. The capsular ligament and synovial membrane were in a natural state. The cartilages co- vering the head of the femur, and lining the bottom of the acetabulum, were de- stroyed by ulceration, for about one-balf of their extent, and wherever the car- tilage was destroyed, an ulcerated surface of bone was exposed. The round liga- ment was readily torn, in consequence of ulceration having extended to it, at the part where it was inserted into the acetabulum. The bones possessed their natural texture and hardness. There was no pus in the joint. It was ob- served, that the ulcerated surface of the acetabulum corresponded to that of the femur, these surfaces being exactly in contact, in the position in which the patient had remained since his admission into the hospital. CASE XXV. William Bridges, twenty-one years of age, was admitted into St. George's Hos- pital, on the 28th of November, 1810. He gave the following account of his complaint. About the middle of the May 16 ( 114 ) preceding, he first experienced a pain in the right knee, wliich was aggravated by walking. At the end of a month, the pain became so severe that he was under the necessity of being confined to his bed. He had slight pain in the hip^ but that in the knee was intense, keeping him awake at night. An abscess formed, which in the September following burst on the inside of the thigh. At the time of his admission, the nates were wasted and flattened; the limb on the affected side, appeared to be an inch and a half louger than the other; there was a large abscess in the posterior part of the thigh. He was emaciated, and laboured under a hectic fever. An issue was made with caustic, behind the great trochanter of the femur, and afterwards a second issue was made in the same manner on the an- terior edge of the tensor vaginae femoris muscle. Under this treatment, he experi- 'cnced for a time great relief, notwithstand- ing several abscesses formed and burst m ( 115 ) different parts of the thigh. He hecame free from pain; regained his flesli; the hectic fever abated; and the discharge from the abscesses was much lessened. The limb now appeared to be shorter than the other. He continued to mend, till the middle of February, 1811. At this period the former bad symptoms began to return. He was affected with a constant diarrhoea, and profuse perspi- rations, and he died on the 26th of March following. On inspecting the body, the glutsei muscles were found wasted and shrunk, and in many parts their texture was destroyed by the abscesses, which com- municated with the cavity of the joint by two ulcerated openings, one on the an- terior and the other on the posterior part. The abscesses formed several sinuses in the neighbourhood of the joint, and the capsular ligament was in consequence connected to, and in some measure blend- ed with the other soft parts. ( 116 ) The joint contained purulent matter. The synovial membrane was darker than natural, but otherwise had the ordinary appearance. There were no remains of the round ligament. The cartilages were every where absorbed, and the exposed surfaces of bone were in a carious state. The head of the femur was reduced to about two-thirds of its original size, and the acetabulum Avas rendered deeper and wider, nearly in the same proportion. At the bottom of the acetabulum, there was an ulcerated opening, just lai'ge enough to admit a common probe, com- municating with an abscess within the pelvis. The carious surfaces of the bones, had the same dark colour and foetid smell, as in other cases of caries, but otherwise they did not differ from healthy bones. CASE XXVI. Jemima HoUoway, about 23 years of age, was admitted into St. George's Hospital ( IIT ) on the 30 til March, 1814, on account of a disease of the right hip. There was a large ahscess in the neighhourhood of the hip, and the nates were wasted, and flat- tened. She said that the disease had been going on for some years. On the 6th of June following her admission, she died. On dissection, the glutsei muscles were found wasted and flabby, and of a pale colour. There was a large abscess of the nates communicating with the hip, by means of an opening in the posterior part of the ♦capsular ligament and synovial membrane. In other respects the synovial membrane and capsular ligament were in a perfectly natural state. The cartilages covering the head of the femur, and lining the bottom of the ace- tabulum were destroyed by ulceration. The ulceration had extended to the bones, so that the head of the femur was not more than half, and the acetabulum was double the usual size. The bones ( 1<8 ) possessed their natural texture and hard- ness. There was an ulcerated opening at the hottom of the acetahulum, com- municating with the inside of the pelvis. I could add to tlie foregoing, an ac- count of the dissection of several other cases, in which the hip was affected with the same disease; but in doing so, I should only occupy the reader's attention unnecessarily. It will he sufficient to observe that: 1. In tlie most advanced stage of the disease, none of the parts entering into the composition of the joint retain theii* natural structure. The soft parts are blended into a confused mass. Some- times the head of the femur is com- pletely destroyed, and there remains only the neck, or a portion of the neck, of that bone. Often the projecting margin of the acetabulum is entirely absorbed, so that instead of a cavity, there is a broad ( 119 ) i^nrlous surface of the os innonuoatum. In a feAV instances a portion of the ca- rious bone is found dead, ancl undergoing the process of exfoliation, or having al- ready exfoliated into the cavity of tliQ joint. 2. In whatever period of the disease, tlie examination is made, the cartilages are found in a state of ulceration, but the morbid affections of the soft parts and bones vary very much, nor are they muck altered from their natural state, except in the most advanced stage of the ma- lady. From these circumstances, and from the appearances in several of the cases v.hicli have been related, in which the disease was found in its incipient stage, and wholly confined to the cartilaginous surfaces, we may be justified in conclud- ing, that, in the ordinary cases of caries of the hip, the cartilage is the part pri- marily aftccted, and the following may be stilted to be the progress of the disease. ( 120 ) 1. Ulceration takes place in the carti- lages: generally in that of the acetahu- lum first, and in that of the head of the femur afterwards; sometimes it begins in both at the same time. 2 The ulceration extends to the bones, which become carious; the head of the femur is diminished in size, and the ace- tabulum is rendered deeper and wider. 3. Abscess forms in the joint, which after some time makes its way, by ulcera- tion, through the synovial membrane and capsular ligament, into the thigh, or nates, or even through the bottom of the aceta- bulum into the pelvis. Mr. Astley Cooper has shewn me two specimens, in each of which the abscess had burst into the rectum. 4. In consequence of the abscess, the synovial membrane and capsular ligament become inflamed and thickened. The muscles are altered in structure; sinuses are formed in various parts; and at last all the soft parts are blended together ( 121 ) into one contused mass.; resembling llic pai'ietes ol* an ordinary al^scess. In giving tliis statement, it cannot be intended to assert, that the hip is not liable to other morbid aftections; and of course, disease having its origin in the bones or soft parts may ultimately occa- sion destruction of the cartilaginous sur- faces in this as well as in other joints; but still the conclusion remains, that ia the ordinary disease of the hip joint, in that disease, which an intelligent surgeon, in a work written expressly on the sub- ject, has denominated " The Scrophulous Caries of the Hip," the ulceration of the cartilages is the primary affection, and the other parts, in, and near the joint, become aftectcd only in a secondary manner. As from the peculiar situation and con- nections of the hip, affections of this part aic attended with particularly serious con- Bcqucnces, I trust that the lurgoing ac- count, will not be considered as given too 17 ( 122 ) . much ill detail, ^specially as it ^vill pre* rent the necessity of entering with much minuteness into the history of the ul- ceration of the cartilages of other joints, in which the progress of the disease, al- lowance being made for the difference of structure and situation, is the same as in the hip. CASE XXVII. David Martin, twenty-six years of age, was admitted into St. George's Hospital, on the 25th of July, 1810, on account of a disease in his right knee. He attributed it to a blow, which he had received some years previous; but he said, that the symptoms had all been much aggravated within the last six months. At the time of his admission into the hospital, the knee had the appearance of being sw oUen; but on examination, this was found to arise from the w asting of the muscles, ra- ther than from actual enlargement. The ( 123 ) lieg was fixed, or nearly so, in the lialf-bent position. The condyles of the femur projected beyond the head of the tibia. He complained of pain, which was parti- cularly severe at night. An issue was made with caustic on each side of the patella; but the symptoms were not re- lieved, and an abscess burst on the out- side of the joint, discharging a large quantity of matter. Soon after his admission, he expe- rienced, for the first time, severe pain in the other knee; but this was unattended by swelling, or any alteration in the form of the joint, and the leg admitted of com- plete extension and flexion on the thigh. The pain continued, but no swelling ever took place. In the beginning of September, he was seized with an accidental attack of ery- sipelas. Abscesses formed in different parts of the leg and thigh; and he gra- dually sunk, and died on the 7th of No- vember. ( 12.1 ) On inspecting the body, tlie right leg was found bent so as to form a right angle Avith the thigh. The head of the tibia had been drawn towards the ham by the action of the flexor muscles, so that the condyles of the femur were unusually protuberant. The lateral ligaments were in a natural state. There were no remains of the crucial ligaments, or semilunar cartilao:es. The cartilages of the tibia, femur, and patella, had been entirely ab- sorbed. The bones were carious on their exposed surfaces, but not otherwise dis- eased. The synovial membrane was free from all morbid appearances, except at the points of its attachment to the bones, where, in a few places, coagulable lymph had been effused on its surface. The left knee, externally, had its natu- ral appearance with respect both to form and size. The leg admitted of complete flexion and extension. On dissection, the lia:aments and synovial membrane were found in a perfectly healthy state; ( 135 ) but about one-third of the cartilaginous surfaces of the tibia and femur was destroyed by ulceration, the ulceration having taken place principally, but not entirely, near the circumference. The cartilage of the patella and the semilunar cartilages were entire, but the latter in some parts were softer than usual. The bones were free from disease. There was no pus or other fluid in the joint. The dissection of this case, in which the ulceration of the cartila«:inous sur- faces was evidently the primary disease, explains well the nature of, at least, many cases of that species of white swelling, which some authors have described, in which there is long continued and severe pain in the joint, before any tumour is observable. CASE XXVIIT. William Bowels, eighteen years of age was admitted into St. George^s Hospital ( 126 ) on the 1st of December 1810. He said that about eleven months previous to his admission, he had been seized with pain in his right knee, which was so severe as to keep him frequently awake at night. Six weeks after the pain attacked him, the joint, for the first time, became swollen. He now applied to a practitioner, under whose treatment, joined with perfect rest, the pain and swelling subsided, so that he was able to walk about. In the Sep- tember following, having returned to his usual occupations, and used the joint a good deal, the pain and swelling re- turned. At the time of his admission, the af- fected knee was about an inch and a half in circumference larger than the other. The swelling had the form of the articu- lating ends of the bones. The leg was half bent, and all attempts to give it mo- tion gave great uneasiness. The pain, which he experienced, was great at all times, but particularly at night, when it very much disturbed his rest. ( 127 ) Soon after his admission, an abscess was discovered on the outside of the knee, which burst in the beginning of February, and discharged a large quanti- ty of matter. On the 18th of March, the limb was removed by amputation. On examining the joint, the greater part of the cartilaginous surfaces of the tibia, femur, and patella, were found de- stroyed by ulceration. IVliere the carti- lage was destroyed the exposed bone was carious, and in some places covered by a thin layer of coagulable lymph; but in other respects, the bone was free from disease. There were scarcely any remains of the semilunar cartilages. The joint contained pus, and the abscess in the joint had made its way into the external parts, through an ulcerated opening in the synovial membrane. The synovial membrane was in a natural state, except that, in a few places, there was a thin layer of coagulable lymph on its surface, which evidently had been recently effused. ( 128 ) The external lateral ligament was de- stroyed by the abscess: the other liga- ments were entire. In this case, the principal disease ob- served in the dissection, was the ulcerated state of the cartilages. There was no affection of the synovial membrane be- yond what might be considered as arising from the formation of pus in the joint, and the bursting of the abscess externally. Where inflammation of this membrane is the primary disease, swelling takes place often in a few hours, always within two or three days, from the beginning of the attack; whereas in this instance, the constant answer, which the patient gave to the repeated enquiries made of liim, was, that he had had violent pain for six weeks before the joint was ob- served to be enlarged. From all these cir- cumstances, Ave may conclude, that in this case as well as in the last, the carti- lasces were the ori the process of exfoliation.. The cartikigos of the joints formed hj the cuneiform bones uith each other, with the os navi- culare, and witli the metatarsal bones, were in like manner destroyed, and the exposed surfaces of bone were carious. The abscess communicated with the carious joints. The ligaments and synovial mem- brane were in a natural state, except in a few spots, where they were destroyed by the abscess. The bones possessed their natural texture and liardness. The cellular membrane of the foot contained coagiilable lymph and serum. It would be needless to add to the foregoing an account of T)tlier cases, in which the disease was in a still more ad- yanced stage. Tlie progress of it, in other joints, corresponds witli that in the hip, and whatever may be the joint af- fected, there is ultimately the same com- plete destruction of the cartilages, and ( l'^5 ) [\e ravages among' the bones and soft parts. he same extensive ravages are committed In some cases the nlceration of the cartilage of a joint begins on that surface, ^vhich is connected to the bone, and from having observed this circumstance, I was k^d, at first, to adopt an opinion, which 1 heard stated to liave been that of Mr, Hunter, and which appeared to be war- ranted by tlie small degree of vascularity which cartilage possesses, that ulceration of ittak€s place, not from the action of -its own vessels, but in consequence of it *^being acted on by the vessels of the bone, 'to which it is connected. I afterwards found, that in many instances, previously to ulceration, the cartilaci'e uudero-oes a remarkable change of texture, becoming soft, and assuming a fibrous appearance, thence I was led to conclude that this opinion is not altogether correct, and I am now able to adduce the two following ( 136 ) cases, which seem to prove that cartilage^ as well as other parts, is capable of ulcer- ating from the action of its own vessels. CASE XXXI. A boy, twelve years of agCj on the 28th of June, 1809, fell from a height, and pitched on one of his knees. When he was brought to the hospital, he was found to have a compound fracture of the femur. For some days he appeared to go on well, but afterwards an abscess formed in the thigh, extending as high as the nates; and he sunk and died on the 2 1st of July. On examining the knee-joint after death, the cartilage covering the condyles of the femur, and that covering the head of the tibia were found, in some parts, entirely absorbed, so that the bone was exposed; and in other parts it was absorbed on the surface towards the cavity of the joint, while the layer of it next to the bone retained its natural adhesion. ( 137 ) and its natural structure. The cartilage, in these parts, was formed into grooves, having an appearance, as if the greater portion of its substance had been removed with a chisel. CASE XXXII. A middle-aged man met with an injury of the knee, which was followed by in- flammation and suppuration, and he died in St. George's Hospital, on the 30th of August, 1809. On examining the joint after death, the cartilage covering the condyles of the femur, and the head of the tibia, was found entirely destroyed towards the cir- cumference, so that the bone was exposed. Elsewhere, only a thin layer of cartilage remained; but this had its ordinary tex- ture, and adhered as firmly as ugiial to the bone. ( 138 ) As ill those cases the cartilage was ah- sorbed on the surface towards the cavity of the joint, while t]ie remainder still adhered to the bone, it is evident that the absorption must have taken place from the vessels of the cartilage itself. In young persons, before the period of growth is over, the articular cartilages possess more vascularity than in others, so that their vessels are distinctly to be seen, and admit of being injected, which is not the case in adults; and this ex- plains why the ulceration of the cartilage takes place more frequently, and makes more rapid progress in the formerthan in the latter. Sect. II. On the Symptoms of this Bisease. The ulceration of the articular carti- lages occurs at any period of life, but principally in children, or in adults under the middle age. Of the whole number ( 139 ) of those, who have come under my own ohservation, lahoiirinj^ under this disease, not more than about one fifth were above thirty years of age; the youngest was an infant of a year ohl; the ohlest was a woman of sixty. As the knee is more liabU^ to inflammation of the synovial membrane, so is the hip more lia])le tlian other joints to ulceration of the cartilaginous surfaces. In general the disease is confined to a single joint; but occasionally two or three joints are affected in the same individual, either at the same time or in succession. Some- times the patient traces the beginning of his symptoms to a local injury; but for the most part no cause can be assigned for the complaint, and often the cause, to which it is attributed, appears to be ima- ginary rather than real. Where the hip is aflccted, the only symptoms met with for some time are pain, and a slight degree of lameness in the lower limb. The pain at first is trifling ( 140 ) and only occasional; afterwards becoming severe and constant. It resembles a good deal the pain of rheumatism, since it often has no certain seat; but is refer- red to different parts of the limb in differ- ent individuals, and even in the same indi- vidual at different periods. As the dis- ease advances, the pain becomes exceed- ingly severe, particularly at night, when the patient is continually roused from his sleep by painful startings of the limb. Sometimes he experiences some degree of relief from the pain in a particular po- sition of the joint, and in no other. A patient in St. George's Hospital never obtained any rest, except when he had placed himself on the edge of the bed- stead, with his feet on the ground, and resting his body on a pillow, in a position between that of Ijing and sitting. As the pain increases in intensity, it is more confined in its situation. In tlie greater number of instances it is referred to the hip and the knee also, and the pain ( 141 ) in the knee is generally the most sever** of the two. At other times there is puin in the knee, and none in the hip. A boy in St. George's Hospital complained of pain in the inside of the thigh, near the middle; and another patient, a little girl, referred the pain to the sole of the foot. Wherever the pain is situated it is aggravated by the motion of the joint; but it is aggravated in a still greater degree b) whatever occasions pressure of the ulcer- ated cartilaginous surfaces against each other. Hence the patient is unable to sup- port the weight of the body on the affected Mmb; and if he be placed on an even sur- face, in a horizontal position; and the hand of the surgeon be applied to the heel sc» as to press the head of the femur against the concavity of the acetabulum, violent pain is the consequence; although this be done in so careful a manner that no I; the smallest degree of motion is given to the hip-joint. This circumstance is weH deserving of attention; and no one .^bould ( 142 ) attempt to give an opinion as to the na- ture of a disease connected with the hip, without haviiig made an examination in the manner, which has been just described. Soon after the commencement of the complaint, the hip joint is found to be tender, whenever pressure is made on it either before or behind. The absorbent g'lands become enlarged, and occasionally there is a slight deii;ree of i»'eneral tume- faction in the ^roiii. In this there is no- thing remarkable, since we must suppose that, a, disease going on within the articu- lation must ultimately occasion some de- gree of inflammation in the neighbouring parts. But it is a curious circumstance, that in some cases, there is tenderness of those parts, to which, though not diseased themselves, the pain is referred from sympath}^ with the disease in the hip. I have observed this in tiic knee several times, and a gentleman, in whom the pain was referred to the outside of tht^ ^ 148 ) lieg, complained of great tenderness every where in the course of the peronseal nerve. I have also seen a slight degree of puffy swelling of the knee, where pain was referred to it, in consequence of disease in the hip. These facts corres- pond, to what may he ohserved in some other cases, where pain is referred to a sound part, in consequence of a sym- pathy existing hetween it, and some other part that lahours under disease; for example, I have known the passage of a calculus down the ureter, to occasion not only pain, hut tenderness, swelling, and no trifling inflammation of the testicle. When the disease has existed for some time, the nates undergo a remarkable alteration in their form. They become wasted and less prominent: so that in- stead of their usual convexity, they present the appearance of a flattened surface: they are flaccid to the touch, and hang more loosely towards the lower edge; and they have the appearance of being wider than those of the other side. ( *44 ) In a very few cases, in the abvanced stage of the disease, the nates are really wider, in consequence of the acetabulum being filled with coagulable lymph and matter, and the head of the femur being pushed out of its natural situation. But in general the increased breadth of the nates is only apparent, and on an accu- rate measurement no difference will be found between the nates of one side, and those of the other. The alteration in the figure of the parts in those cases, may arise partly from the position, in which the patient usually places himself, when he stands erect; but the principal cause, to which it is to be attributed, is the wasting of the large fleshy bellies of the glutsei muscles from want of use; and this has been ascertained, by re- peated, and accurate examinations of the living, and numerous dissections of the dead body.* * This alteration in the form of the nates is a- 53'mptom, but is not in itself 10 le considered as at ( 145 ) Another symptom, which occurs in this disease, is an alteration in the length of the limb. 1st, In the early stage of the disease the patient often complains, that the limb on the affected side is longer than the other. This cannot be explained on the supposition of the acetabulum being filled with pus, or solid substance, since it would cause the head of the fe^ mur to be pushed outwards rather than downwards. The fact is that there is only an apparent, and no real elongation of the limb. If the patient be placed on his back in the horizontal position, so certain diagnostic mark of disease in the hip-joint; as it may be observed in other cases, where from any cause, the glutai muscles have been for a con- siderable time in a state of inaction. Thus children arc subject to a paralytic state of the muscles of the lower limb, and in this complaint, if the muscles are affected as high as the pelvis, the nates present to the eye the same appearance. It may be noticed also where there is disease of the thigh-bone, or where from any other cause, the motion of the hip is painful and difRcult. 20 i( 146 ) that both thighs make the same angle with the pelvis, the fbot on the diseased side may at first appear as much as two or three inches lower than the oppo- site foot: but, if the distance be accur- ately measured with a tape, from the anterior superior spinous pi*ocess of the ilium to the patella, no difference is per- ceptible. The apparent elongation is pro- duced by the position of the pelvis being altered, in such a way that the crista of one ilium is visibly depressed below the level of that of the other. It is easy to understand how this effect is produced, by observing the position, in which the patient places himself, when he stands erect. He supports the weight of hi§ body on the sound limb, the hip and knee of which are in consequence main- tained in the state of extension. At the same time the opposite limb is inclined forward, and the foot on the side of the disease is placed on the ground, consider- ably anterier to the other, not for the purpose of supporting the superincum- ( 147 ) bent weight, but for that of keeping the person steady, and preserving the equi- librium. Of course this cannot be done without the pelvis on the same side being depressed. The inclination of the pelvis is necessarily attended with a lateral cur- vature of the spine, and hence it happens that one shoulder is higher than the other, and that the whole figure is in some de- gree distorted. All these symptoms will disappear in the course of a few weeks, if the patient under these circumstances be confined to his bed and the horizontal position^ except in some instances, where, in consequence of their having occurred in ayoungand growing person, and having already been allowed to exist for a con- siderable time, the shape of the parts has become adapted to their new situation, and the alteration of the figure may con- tinue durins: life. 2. In a few cases, where the patient is in the erect position, it may be observed that the foot, which belongs to the affected ( 148 ) limb is not inclined more forward than the other, hut that the toes only are in contact with the ground, and the heel raised; at the same time that the hip and knee are a little bent. This answers to the patient the same purpose of enabling liim to throw the weight of his body on the other footj but it produces an in- clination of the pelvis in the opposite direction. The crista of the ilium is higher than natural, and there is an ap- parent shortening, instead of elongation, of the limb on the side of the disease. 3. In the very advanced stage of the disease, when the head of the femur has been completely destroyed by ulceration, there is nothing to prevent the muscles from pulling the bone upwards. Tliis may be compared to a case of fractured neck of the femur. The limb is not only apparently, but it is really shortened: the foot may he rotated inwards, but, if left to itself, it generally is turned outwards. 4. In other cases, the limb is shortened; the thigh is bent forwards; the toes are ( 149 ) turned iiiAvards, and do not admit of being turned outwards; and there is every symptom of a dislocation of the hip up- wards and outwards. The following case fully explains the cause of those ap- pearances. CASE XXXIII. — — Taylor, a middle-aged man^ was idmitted into St George's Hospital, in the autumn of 1805, on account of a dis- ease in his left hip. He laboured also under other complaints, and he died in the February following. On inspecting the body, the soft parts in the neighbourhood of the joint were found slightly inflamed, and coagulable lymph had been effused into the cellular membrane round the capsular ligament. There were no remains of the round ligament. The cartilages had been destroyed by ulceration, except in a few spots. ( 150 ) The bones on their exposed s^urfacef? Nyere carious; but they retained their na- tural form and size. The acetabulum was almost completely filled with puis and coagulable lymph; the latter adhering to the carious bone, and having become highly vascular. The head of the femur was lodged on the dorsum of the ilium. The capsular ligament and synovial mem- brane were much dilated; and, at tlie superior part, their attachment to the bone was thrust upwards, so that al- though the head of the femur was no longer in the acetabulum, it was still within the cavity of the joint. Since the man did not attribute this disease to any local injury, we may con- clude that the ulceration of the carti- lage was the primary aifection, and that the dislocation had been produced in consequence of the head of the femur having been first pushed outwards by the coagulable lymph and pus, which occu- pied the cavity of the joint, and then ( 1-51 ) ttrawii upwards by the action of the muscles inserted into the great tro- chanter.* The shortening of the limb, which takes place in the advanced stage of the disease is usually, but not always, the precursor of abscess. The formation of matter is also indicated by an aggravation of the pain, by more frequent spasms of the muscles, by a greater wasting of the whole limb, and by the circumstance of the thigh becoming bent forward, and being incapable of extension, without such an increase of the patient's sufferings as he will be unable to endure. At the same time the pulse becomes quick, the tongue furred, and the whole system is in a state of preternatural excitement. The abscess usually shews itself in the * This case affords an example of the dislocation of the hip from an internal cause, which some surgical writers have described, and it is probable that in the majority of such cases, the dislocation is produced in ?:hc same manner. - ( 152 ) form of a large tumor over the vastus ex- ternus muscle; sometimes on the inside of the thigh near the middle; and occa- sionally two or three ahscesses appear in different parts, and burst in succession. The abscesses discharge a large quantity of thin pus, and in the worst cases a copious suppuration continues, until the powers of the patient are exhausted, and enfeebled and emaciated he sinks under the symptoms of a hectic fever. That an adult should recover under these circum- stances is so rare an occurrence, that the surgeon can never be justified in giving any but the most unfavourable prognosis. Children recover more frequently in tliis advanced stage of the disease, but not without a complete anchylosis of the joint. If suppuration has not taken place, I believe it rarely happens that the limb after the cure does not regain its natui*al degree of mobility.* * However difficult the diagnosis of this disease of the hip may be in its early stage, it may be made ( 153 ) AYhen the cartilages of tlic knee arf^ ulcerated, there is pain in the afleclecl with sufficient certainty, when the disease is somewhat advanced. It is to be founded however, not on a single synnptom, but on the combination of symp- toms, and on the history of their progress, so tliat no degree of experience can enable the surgeon to form his judgment correctly, without a careful investiga- tion of the circnmstances of the case before him. The morhid affections most liable to be confound- ed with the ulceration of the cartilage of the hip are the following. 1. Inflammation of the synovial membrane of the hip, of which I have spoken in a former chapter. 2. Chronic inflammation of the soft parts in the neighbourhood of the hip, terminating in the form- ation of a chronic abscess. Here there is pain, but more confined in its situation, than where the carti- lages of the hip are ulcerated: the pain is less severe> less aggravated by the motion of the joint; not re- lieved in the same degree by rest; not attended by a flattening, and very soon followed by a tumtfactiou of the nates. 3. l"he disease which has itr, origin in the cancel- lous structure of the bone?:, of which I shall speak hereafter. 4. I have seen several cases in which I suspected the symptoms to depend on a morbid condition of the 21 ( 154 ) joint; at first it is slig'ht and only occa- sional, and in the early stage of the disease, it is completely relieved by re- maining in a state of rest for a few days, but it returns as soon as the patient re- sumes the exercise of the limb. By degrees the pain becomes constant and very severe, particularly at night, when it disturbs the patient by continually rousing him from his sleep. The pain is referred principally to the inside of the head of the tibia, but sometimes a slighter degree of pain extends down the whole of that bone. The pain is aggravated by motion^ so that the patient keeps the limb con- sciatic nerve; and in which they bore a certain ana- logy to the disease in question. There was pain re- ferred to the parts, to which the sciatic nerve is dis- tributed; but not very severe, nor materially aggra- vated in consequence of the disease being neglectedo There was tenderness in the situation of the nerve on the posterior part of the hip and thigh, the ten.- derness being usually more considerable at one par- ticular point. The symptoms were relieved princi- pally by the application of blisters over the trunk of the nerve, which was suspected to be the seat of the malady. ( 155 ) ^tautly in one position, and generally half bent: and lie neyer attempts to support the weight of the body on the foot of this side. The ulceration of the cartilages of the knee differs with respect to its symptoms, from inflammation of the synovial mem- brane, in this; that the pain in the former is slight in the beginning, and gradually becomes very intense, which is the very reverse of what happens in the latter. But there is another circumstance, which forms a remarkable distinction between the ulceration of the cartilages, and most other diseases, towhich this joint is liable. The pain in tlie first instance is unat- tended by any evident swelling; which comes on, never in less than four or five weeks, and often not until several months have elapsed from tlie commencement of the disease. The reason of this is too unanifest to require explanation,- and it is equall^Mmnecessary to point out the iiii- portance of it, as affordnig tlie means of ( 15t> ) making a more ready diagnosis. Wc must not indeed conclude indiscrimi- nately, whenever tliere is a slight pain in the knee, unattended hy swelling, that the cartilages are in a state of ulceration, since this symptom may equally arise from inflammation of the hones them- selves; of the ligaments; of the fatty substance of the joint, or from simple nervous affection; and instances will occur to every surgeon, where there is reason to believe that the above men- tioned symptom arises from one or other of these causes^ But when the pain con- tinues to increase, and at last becomes very severe; wlien it is aggravated by the motion of the joint, and by the pres- sure of the articulating surf\ices against each other: and when after a time a slight tumefaction takes place, sucli as I shall presently describe; we may con- clude that the disease consists in an ulcer- ation of the cartilages; and in all such prases, which have come under my own ( <5T ) observation their subsequent progress, and the morbid appearances presented by dissection, where an opportunity has occurred of observing them, have fully justified this conclusion. The swelling, which attends this disease in the knee, differs from that, which oc- curs in either of those of the synovial membrane, which I have formerly de- scribed. It arises from a slight degree of inflammation having taken place in the cellular membrane external to the joint, in consequence of the disease within it. The swelling is usually trifling, appearing greater than it really is, in consequence of the wasting of the muscles of the limb. It has the form of the articulating ends of the bones; that is the natural form of the joint. ISo fluctuation is perceptible, as where the synovial membrane is inflamed: nor is there the peculiar elasticity, which exists, where the synovial membrane has under- gone a morbid alteration of structure. But a few cases occur, in which this ( 158 ) disease is attended with a collection (A' fluid in the joint, and in which therefore the tumor has a form different from that which has heen described, and giving to the hand a distinct sense of fluctuation. 1st, Inflammation of the synovial mem- brane may occur as a secondary disease, ulceration of the cartilages having pre- ceded it, and the eifusion of synovia into tlie joint being the consequence of it. This 1 supposed to have happened in the case of John Child, which will be related hereafter. 2dly. In an advanced stage of ulcer- ation of the cartilages, where an abscess is formed, it occasions ulceration of the soft parts, and usually makes its way to the skin; but sometimes the pus is col- lected in the joint; distending the syno- vial membrane, and causing a tumor very similar to that, which would arise fi'om it being distended with synovia. In these cases, the surgeon must form his diagnosis, by attending to the previous ( 159 ) liistory; by observing tbe degree and the kind of pain of ^vhich tbe patient com- plains; and the state of his general health; and by bearing in mind this circumstance, that blisters very seldom fail in procm*ing absorption of the too abundant synovia, and that they never cause the absorption of pus. As the ulceration of the cartilages is sometimes followed by dislocation of the hip; so we find that dislocation of the knee occasionally takes place from the same cause. Where there has been con- siderable distension of the soft parts in consequence of ulceration extending to them, the head of the tibia is gradually •drawn backwards by the action of the flexor muscles and lodged in tile ham; and I have even known this to happen where abscess has never formed, the patient ultimately recovering with a stiff joint and disfigured limb. In such a case, the condyles of the femur make an unusual projection, and the articulating ^ 160 ) surfaces of tlie bones are partially or en- tirely separated from each otlier. The symptoms produced by the ulcer- ation of the cartilages of other joints cor- respond very nearly with those already described. The principal diagnostic mark is the pain, which is experienced in the beginning unattended by swelling. The |)ain is referred to the part, which is the victual seat of the disease: but where th6 elbow is affected, the more violent pain in this joint is accompanied by a slighter degree of pain in the lower part of the fore-arm and wrist; and where the disease is in the shoulder there is often a pain- ful sensation, extending down the whole of the bone of the arm. In all cases the pain is much increased, when the articu- lating surfaces are pressed against each other, and in the first instance it is unat- tended by swelling. In cases of ulceration of the cartilages of the shoulder, the joint is smaller than natural, in consequence of the wasting of the deltoid muscle. ( 161 ) Whatever joint is the seat of the dis- ease, the formation of abscess is always attended with an aggravation of all the symptoms. But the degree, in whicli the general system is disturbed, when suppur- ation is established, depends on various circumstances; on the age and powers of the patient; on the size of the affected joint; and on its situation. An abscess connected with a deep-seated joint occa- sions more extensive mischief of the soft jiarts, before it reaches the surface, and therefore is productive of more serious consequences, than one which is connected with a joint, that is situated superficially. The progress of the ulceration of the cartilages varies, w ith respect to time, in different cases, but it is generally tedious. In one case, where violent pain had ex- isted in the knee, with little or no swel- ling, for two years and a half previous to amputation, I had an opportunity of examining the diseased joint, and found the cartilages destroyed for only a small 22 ( 162 ) extent; a dram and a half of pus in the articular cavity, and no morbid appear- ances of the soft parts, with the excep- tion of a Tcrj slight inflammation, which had been induced in the synovial mem- brane, and the effusion of a minute quantity of coagulable lymph into the cellular texture on its external surface, In another case, the pains in the lower limb had existed for a whole year, be- fore they were sufficient to attract the patient's serious attention. In this case no pus was formed in the joint; and the ultimate recovery was complete, Avith- out the smallest detriment to the motion of the limb. Sometimes, however, the progress of the disease is much more ra- pid. There was a patient in St. George's Hospital, in whom, in the course of four months, the destruction of the head of the femur and acetabulum was such, as to occasion a real shortening of the limb to the extent of an inch. ( 163 ) Sect.III. On the Treatment Where the cartilages of a joint are ul- cerated, it ma}' well be supposed that the motion of their surfaces on each other must he favourable to the progress of the ulceration. I have known some cases, in which rest alone was suilicient to produce a cure. In all cases the symptoms of the disease are aggravated by any consider- able exercise; and we may therefore con- clude that the keeping the limb in a state of perfect quietude, is very important, if not the most important, circumstance to be attended to in the treatment. Issues made with caustic* have been * The immediate relief, which sometimes follows the application of" caustic to the skin, or the surface of an issue, when the limb is under precisely the same circumstances, as before, with respect to rest; and the return of the symptoms, which in many in- stances follows the early healing of an issue, sufii- ( 164 ) recommended by many practitioners for the cure of diseased joints; but as far as I know, no one has attempted to point out the particular class of cases, to which this remedy is applicable. I have em- ployed caustic issues, and seen them employed, in a great number and variety of instances, and have found them to be usually productive of singular benefit, ciently prove the efficacy of this remedy. It maybe difficult to explain the modus operandi; but what happens in these cases seems to bear no distant ana- logy to the suspension of gonorrhoea, by the occur- rence of inflammation of the testicle, or the metastasis of gout from the stomach to the foot. Issues are employed in surgery for the purpose of stopping the morbid action of the animal body: but it is probable that if made of too great an extent, they would inter- fere with its natural actions also. In a guinea-pig, a large abscess took place of one leg and thigh in consequence of a local injury. The formation of the abscess completely stopped the growth of the claws on the foot of this side-. They wore away at the points, without being regenerated at the base, be- came short and dry, and readily cracked and splin- tered; while on the foot of the opposite limb they continued to grow as usual, and possesed their ordi- nary appearance. ( 165 ) where the cartilages are in a state of ulceration, and to be of little or no ser- vice in any of the other morbid affections, to which the joints are liable. Setons and blisters kept open by means of the savine cerate appear to operate nearly in the same manner as caustic issues, and may be used with advantage in the same description of cases.* In many instances, which occur par- ticularly in hospital-practice, the patient, from too freely exercising the limb, brings on an inflammation of tlie ulcerated sur- faces of the bones, occasioning an aggrava- tion of the pain, and usually some degree * It may be expected that I should in this place offer some remarks on the effects of the application of the cautery, which has been recommended at different times, for the relief of some cases of diseased joints. I do not however feel myself warranted in giving any confident opinion as to the comparative efficacy of issues made by the caustic, and those made by the cautery; my experience of the latter being very limited. The little, which I have had an opportunity of observing, has ce^-tainly not led me to prefer the cautery to the caustic. ( 166 ) of fever; and here bleeding may be em- ployed with advantage. Under other cir- cumstances I have not known the loss of blood to be productive of much benefit. Indeed I know of no analogy, that should lead us to expect much benefit from it, since bleeding is not found to possess the power of stopping tlie progress of ulcers m other parts. In the early stage, the warm bath is sometimes of service. At least it is ca- pable of relieving the symptoms, if not of stopping the progress of the disease. Plasters made of gum ammoniac, and others of a similar nature; embrocations and Mniments of all kinds, are entirely inefficacious. Friction is invariably in- jurious. I have shewn in a former section that ulceration of the articular cartilages may take place to a considerable extent, with- out suppuration being established. This is a circumstance of much importance, not only with respect to pathological science, but also in a practical point of { 167 ) view. The prospect of a cure, which the employment of any remedies affords, is undoubtedly much greater where ab- scess does not exist, than where it does; and the prognosis which the surgeon gives must depend in a great degree on the opinion, which he is led to form on this subject. Haying premised these general observ- ations, I shall proceed to offer a few practical remarks: first, on tlie treatment of this disease in the hip, and afterwards in other joints, without reference to sup- puration having taken place; secondly, on the plan which sliould be adopted, where suppuration is established, and there is a collection of pus communicat- ing with the articulai* cavity. Where the cartilages of the hip are ulcerated, the patient should, in the first instance, be confined to a couch, if not to his bed; and if the disease be far advanced, the limb should be sup- ported by pillows and cushions properly ( 168 ) diiiposed, so as to favour the production of anchylosis, by allowing it to vary as little as possible from one position. In young children, blisters are capable of affording complete relief. They may be applied to the nates, round the great trochanter, and in the groin. A blister kept open by means of the savine cerate is usually more efficacious than a num- ber of blisters applied and healed in suc- cession. In children above the age of eight or ten years, and in adults the same treat- ment is useful in the ^ cry earW stage of the disease; but in the more advanced stage, issues made with caustic appear to be much more efficacious, and to be at- tended on the whole with less inconve- nience to the patient. The hollow behind the great trochanter of the femur, is in many respects the most convenient situation for the applica- tion of the caustic; but in some cases the application of it on the outside of ( 169 ) the hip is attended with better effects. The skin of this part is in fact nearer to the joint, than the skin behind; and there are some grounds for the opinion, that issues are more efficacious, when made near to the seat of the disease, than when made at a distance from it.* The skin in the groin is still nearer to the hip than on the outside, but the large vessels and nerves of the thigh forbid the use of the caustic at this part. A slough may be * " I have for many years applied caustics above " and below the internal condyle of the thigh-bone, " for white swellings of the knee, with various suc- " cessj and I have remarked, that where this plan " disappointed my hopes, and where a suppuration *' took place in the joint, that the inflammation in al- " most every case arose, and that the matter collect- *' ed generally made its way, outwards on the exter- " nal side of the knee. Observing this fact i*epeat- " edly, I was lead to believe that the caustic, in the " manner I used it, checked the progress of the " disease, as far as it had influence; but that the in- " fluence was not sufficient to pervade the whole ca- " vity of the joint." Ford on the Hip- Joint, p. 194; drst edition, 2^ ( I'O ) uiade with the potassa fusa, in the adult, half an inch in breadth and two inches in length behind the great trochanter. If this fails in giving relief, a second slough of a smaller size may be made on the anterior edge of the tensor vaginae femoris muscle; and in some instances, though no relief is afforded by the first issue, there is great relief from the second. The good derived from the issue does not seem to be in proportion to the quantity of pus discharged from its sur- face. It has been observed by others^ that sometimes more abatement of the symptoms is produced in the first few days after the caustic is applied, and before the slough has separated, than in several weeks afterwards. This circum- stance first led me, instead of employing beans for this purpose, to keep the issue open simply by rubbing the surface with the caustic potash, or with the sulphate of copper, twice or three times in the week^ and after an extensiv^e trial of ( *71 ) both methods, the latter has appeared to be decidedly preferable to the former. The pain produced by the caustic is very considerable, but the relief of the symp- toms is such, that I have known patients to be in the habit of making the applica- tion themselves, saying that " they knew they should be better by the next morn- ing." Besides, the issue is more easily dressed than where beans are used; and the inconvenience arising from the beans slipping out under the adhesive plaster, and from any accidental pressure of them against the sore surface, is avoided. The cases, in which complete relief of the symptoms immediately follows the miaking the issue, are not very numerous. In general, there is some degree of abate- ment on the caustic heing applied; and in a few weeks afterwards (provided that suppuration has not taken place), if the patient continues in a state of quietude, the pain entirely leaves him. Where the pain is exceedingly severe (as it sometimes I 172 ) is, so as to prevent sleep during many successive nights), it is very desirable that some method should he adopted, capable of affording more speedy relief, than that, which can usually be obtained from the application of the caustic. If there is reason to believe that the ulcer- ated surfaces are in a state of inflammation, in consequence of the joint having been too much exercised, bleeding may be had recourse to. A blister may be applied to the groin, and repeated if necessary. Blisters applied to the knee, or to the thigh, though there is no actual disease in these parts, will often occasion consider- able or even entire relief of the pain, which is referred to them, from sympathy with the affection of the hip. This is a curious circumstance, but I have known it happen in so many instances, that, however difficult it may be to explain it, I can entertain no doubt of the fact. Sometimes the pain is altogether relieved by the application of the blisterj at ( 173 ) other times, I have known it leave the knee, to whieh the hlister was applied, and attack the hip. The objections, which may be urged against the application of caustic to the skin in the groin, do not hold good with respect to a seton in this situation. I was led to adopt this treatment some years ago, partly from observing that the skin of the groin is nearer to the hip- joint, than the skin elsewhere; partly from an expectation (though not a very confident one), that the making a seton over the trunk of the anterior crural nerv e, might be particularly calculated to relieve the pain referred to those parts, to which the branches of that nerve are distributed. The results of this practice more than realized whatever hopes I had entertained of its success. In many cases the seton occasioned very speedily a complete relief of the pain. In other cases indeed, it failed in producing the like good effects; but these cases have ( 174 ) borne only a small proportion to those in which it has succeeded. On the whole, I am led to conclude, that where the pain is very severe, the seton in the groin is more calculated to afford immediate relief than the caustic issue; but that it is not equally efficacious in checking the pro- gress of the disease, as in lessening the violence of its symptoms, and that the caustic issue can be better depended on for the production of a cure.* The following are extracted from notes, which were taken formerly, when I was making observations on this subject. "November, 1808. " Martha Atkinson, fifteen years of age, laboured under symptoms of ulceration of the cartilages of the hip. She had pain in the hip and knee, but that in the hip was the most severe of the two. Her suiferings were such that she could scarcely venture to make the slightest alteration in her position; and she could scarcely procure any rest at night. " November 20., a seton was made in the groin. " November 22., the pain in the hip was almost completely relieved; and from this time she mended rapidly." ( 175 ) To make the seton in the groin it is convenient to use a curved seton-needle, " John Selly, eleven years of age, was admitted into St. George's Hospital on the 28th of December, 1808, with severe pain in the hip and knee; tender- ness in the region of the hip, and enlargement of the glands in the groin. " December 30., a seton was made in the groin. ** The pains in the hip and knee were almost com- pletely relieved within a few hours after the seton was introduced. The relief was permanent, and on the 24th of May following he left the hospital as cured." *' Susan Dean, about twelve years of age, was admitted into St. George's Hospital, in November 1808, with very severe pains in the hip and knee, in consequence of disease in the former joint. A large abscess presented itself on the upper aiKl outer part •of the ^igh. *' On the 4th of December a seton was made in the groin. The pains were relieved on the same afternoon. She had no return of pain, while she continued in the hospital, but as her friends took her away in a few weeks after the seton was made, I had no opportunity of observing the termination of the case," " James Craven, a young man, was admitted ap. out-patient of St. George's Hospital on the 15th of March 19P9, with the usjual symptoms of ulceration ( 176 ) 111 the majority of cases, the patient keeps the thigh considerably bent on the pel- vis; and this position of the limb makes it difficult to employ a needle of the usual form. The seton may be intro- duced obliquely on the anterior part of the joint; including from one inch and a half to two inches of integuments. After some time the skin over it usually inflames and ulcerates, and the seton drops out; but this does not happen before it has produced all the benefit which may be expected from it. of the cartilages of the hip. There was a large abscess on the outside of the thigh, and intense pain in the knee preventing his rest at night. " March 16., a seton was made in the groin. Being unable to become an in-patient of the hospi- tal, he walked home afterwards. Nevertheless the pain was completely relieved in a few hours: and he slept soundly at night, the pain not at all disturbing him. " After this the abscess burst, and collected again several times; and he became affected with hectic symptoms. I did not see the termination of the case, but I make no doubtof it having ended fatally/' ( 177 ) Of the above observations on tbe uU eeration of the cartilages of tlie hip, many arc applicable to the disease in other joints. In all cases, a state of the most perfect quietude is indispensable. If the disease be in the lower extre- mity, the patient should be confined to the horizontal position; if in the upper, the arm should be supported in a sling. Where the knee or elbow is affected, we may employ the caustic issue, or the blister kept open by means of the savine cerate, but the former appears to be the most efficacious of the two. In the knee, a narrow slough may be made by rubbing the skin with the potassa fiisa on each side of the patella; and, in the elboAV, the caustic nvAj be applied in the same manner on the in- side, and on the outside of the joint. When I have met with this disease in the shoulder, I have sometimes employed a large blister, and kept it open by means of the savine cerate; and in other cases J 24 ( 178 ) have made two caustic issues, one on the anterior, the other on the posterior part of the joint; and, on the whole, the caustic issues have appeared to be pro- ductive of better effects than the blister. Where the disease has its seat in those joints, which are surrounded by numerous tendons, as the wrist and ankle, it may be more prudent to employ the blister, lest injury should be done to the superficial tendons by the application of the caustic. I have, however, in a few cases, made a caustic issue below the internal or exter- nal malleolus. It has produced the best effects with respect to the disease in the ankle, but has been attended Avith unusual irritation and distress to the patient, so that it was with difficulty that he could be induced to allow it to be kept open for a sufficient length of time. I have seen scAcral cases, which the cr^Qstic issue has in the first instance re- moved all symptoms of the disease, and yet after some time, notwithstand- ( 179 ) ing the patient has remained in a state of perfect quietude, and there has heen no evident cause of aggravation, they have returned nearly in the same form as hefore, and with their original severity. In some of these cases, their recurrence is to he attrihuted to the issue itself; which from some cause, that the present state of our knowledge does not enable us to explain, prqduces an effect, appa- rentl}^ the opposite to that, which is pro- duced when it was first made. The issue being allowed to heal, the symptoms again subside, and perhaps the patient may find himself entirely and permanently re- lieved before the sore is completely cica- trized. 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 a large size, the recurrence of the pain is usually attended with a quick pulse, and a furred tongue, and much constitutionj^l irritation, of all which the patient is re- ( 180 ) iicvcd, when the hlistered surface is al- lowed to skin over. It is evident that it is of much importance, and also that it may require considerable discrimination on the part of the surgeon, to distinguish when the issue or the blister begins to be injurious, and ought therefore to be per- severed in no Ion O'er. In other instances, where the symp- toms have returned under the use of the caustic issue, it has appeared to me that this was to be explained in a different manner. A very small quantity of matter has been formed by the ulcerated sur- faces of the joint, but not suificient to prevent the iipplication of the caustic from producing in the first instance Acry considerable benefit. But having once begun, the suppuration has continued, luitil a sufficient quantity of pus has been collected to occasion distention of the joint, and the reproduction of the former symptoms, in spite of the remedy, which before relieved them. Such cases are ( 181 ) ^lot of very im frequent occurrence, and they shew tliat the surgeon should not incautiously give a very favourable pro- gnosis in the iirst instance, because the immediate effects of the issue have been beneficial; but that he should wait and ob- serve, whether these good effects continue, before he ventures positively to predict his patient's recovery. The treatment of the abscess, which arises from this disease in a joint, makes a question of very serious importance, but more so as it regards children, than adults; since the former may, and do frequently, recover, even after an exten- sive suppuration has taken place; whereas. this is a very rare occurrence in a grow n- n p person * -* It is to be observed that I speak here only of the abscess in a joint, v^hich is the consequence of ulcer- ation of the cartilage occurring as a primary disease. ( i«2 ) 1 have not found that the method of evacuating the matter, which has heen recommended by Mr. Abernethy, in his treatise on the lumbar abscess, is attended with any particular advantage in a case of carious joint. Indeed this corresponds with what a little consideration might lead us to expect. If an abscess takes place as a primary aftection, the disease being confined to the soft parts, there may be nothing to prevent the contraction of tlie cyst, and gradual diminution of the quantity of pus evacuated at each punc- ture. But where an abscess occurs, in consequence of an ulcerated state of the articular cartilages and bones, as the cause of the abscess exists equally after, as before the puncture, the suppuration will necessarily be kept up, and the con- traction of the cyst, and the obliteration of its cavity, will be prevented. In some instances I have been led to believe, that, after the application of the caustic, the tumor formed b} the abscess ( ^S3 ) lias diminislied in size, as if from an ab- sorption of a portion of its contents. I have however seen no instance of com- plete absorption haying taken place, though I have made vai'ious attempts to produce so desirable an effect. Emetics, whether they were given to excite vomit- ing, or only in nauseating doses, were, in my experiments, of no service. Electricity was never useful; appearing rather to occasion a more rapid accumulation of matter. Knowing that pressure, under certain circumstances, causes an increased action of the absorbent vessels, in tv>o cases I applied stripes of adhesive plaster round the limb, with the view of trying the effects of pressure on the contents of the abscess. The consequence was a speedy diminution of the external tumor; but 1 afterwards found that this arose, not from any absorption having taken place, but simply from the increased re- sistance on the surface causing the abscess ( 184 ) to occupy a larger space in the interioi* of the Jimb. The earl}' puncture ot* an abscess con- nected with a diseased joint is certainly not to be recommended. I have always observed that such an abscess has healed more readily, and that the opening of it, (whether by a natural process, or by the lancet,) has been attended with fewer ill consecjuences, where the patient has been kept for some time in a state of perfect quietude, and the other methods of treatment, formerly mentioned, have been previously resorted to, than where it has taken place immediately on the patient comins: under the care of the sursceon. Nor is this difficult to explain: in the latter case, at the bottom of the abscess there is a carious oi* ulcerated surface of bone; in the former, it is highly probable that the process of cure has already be- gun, and that where there was diseased bone before, there is now a granulating surface. At any rate it cannot be sup. ( 185 ) posed, that when, in consequence of the neglect of the disease, the ulcerated bones as well as the other parts, are in a state of inflammation, the abscess can be under such favourable circumstances for beina: opened, as when such inflammation has been previously allowed to subside, under rest, and the employment of proper re- medies. An abscess connected with any joint, but particularly one connected with the hip, does not form a regular cavity, but usually makes numerous and circuitous sinuses, in the interstices of the muscles, tendons, and fascise, before it presents itself under the integuments. It is there- fore less easy to evacuate its contents, than those of an ordinary lumbar abscess; and indeed it can seldom be emptied, without handling and compressing the limb, in order to press the matter out of the sinuses, in which it lodges. But this is often attended with very ill conse- 4j[uences. Inflammation takes place of 25 ( 186 ) the cyst of the abscess, and pus is again very rapidly accumulated. Small blood- vessels give way on its inner surface, the bloody discharge of wliich, mixed with the newly-secreted pus, goes into putre- faction, and exceedingly irritates the ge- neral system. I have seen cases, where, after a great deal of pains having been taken to obtain the complete evacuation of the contents of the abscess, and the puncture having healed, in a few days the tumor has become as large as ever, at- tended with pain in the limb, and a fever resembling typhus in its character, and threatening the life of the patient. A second puncture having been made, a quantity of putrid foetid ,pus, of a reddish brown colour, has escaped; the confine- ment of which had produced all the bad sym2)toms, which have been immediately relieved by its evacuation. The practice, which has 4appeared to me to be, on the whole, the best, is the following. An opening having been made ( 187 ) witli an abscess lancet, the limb may be wrapped up in a flannel wrung out of hot water, and this may be continued, as long as the matter continues to flow of itself. In general, when a certain quantity has escaped the discharge ceases; the orifice heals, and the puncture may then be re- peated some time afterwards; but where the puncture has not become closed, I have seldom found any ill consequences to arise from it remaining open. I have already observed that the pro- gnosis, which the surgeon is led to form, must depend very much on the circum- stance of suppuration having, or not hav- ing taken place. The formation of even the smallest quantity of pus in the joint, in cases of this disease, in the young per- son considerably diminishes, and in the adult very nearly precludes, the possibility of any ultimate good being derived, except from amputation. On the other hand, where abscess has not bescun to form. I 188 ) there is perhaps no disease, anjoiig those which come tinder the care of the surgeon, in which he can eniploy his art, with a better prospect of success than this. It is to he observed however that the symp- toms may be relieved, while there are still some remains of the disease: or, at any rate, while there is still a disposition to relapse; and in order that the cure should be permanent, it is necessary that the treatment should be employed for some tim^ after the patient is apparently recovered. xV gentleman who had long laboured under ulceration of the cartilages of the hip, finding himself to be free from all uneasiness, allowed the issue to be healed. This was attended with no immediate ill consequences; but in the course of two or three months he began to experience the well-known symptoms of his former complaint. A caustic issue was again made, and he was again re- lieved. The issue was kept open for ( 1«9 ) twelve months longer and then liealed. When I last saw him, two or tliree years after the healing of the issue, he continued perfectly well. This however is only one of many cases, which might be quoted in proof of the above observation. When the ulceration of the cartilages has made very considerable progress, if the patient recovers, so as to preserve the limb, he seldom has the use of the joint afterwards, the bones composing it being united by anchylosis; but if it has been checked in a less advanced stage, even though , there is reason to believe that the cartilages have been extensively de- stroyed, the patient may retain the na- tural motion of the joint. I have not Iiitherto examined any cases, in which it appeared, that there had been an attempt at tlie regeneration of the absorbed car- tilages: and I have occasionally been ( 190 ) 'able bo til to feel and to hear the hard surfaces of the bones grating against each other in the motion of the joint, in such a manner that it was evident that they had no cartilaginous coverings. In some instances a compact layer of bone is formed on the carious surface, nearly similar to what is seen in the healthy bone, after the cartilage has been de- stroyed by maceration. I have many times, in dissection, observed a portion of the cartilage of a joint wanting, and in its place, a thin layer of hard, semi-transparent substance, of a grey colour, and presenting an irregular gra- nulated surface. It is probable that in these cases, the original disease had been ulceration of the cartilages. In a subject in the dissecting room, I found no re- mains of cartilage on the bones of one hip; but in its place, a crust of bony matter was formed, of a compact texture, of a white colour, smooth, and having an appearance not very unlike that of ( 191 ) marble. I suspected tins also to have been a case, in which the patient had re- covered, after ulceration of the cartilage; and this opinion was rendered more pro- bable, by the following case, which after- wards occurred. CASE XXXIV* A woman, thirty-six years of age, was admitted into St. George's Hospital, with pain in the hip and knee on one side. The nates were wasted and flattened, and a large abscess had burst, leaving a sinus communicating with the hip-joint. She was affected with hectic fever, and gradually sunk and died. On inspecting the body, various sinuses were found in the neighbourhood of the hip and communicating with it. The synovial membrane and capsular ligament had undergone no alteration in their appearance, beyond what evidently ( 192 ) depended on the abscess. The cartilage was every where absorbed from the arti- culating surfaces, and in its place there was a white polished surface, similar to that, which has been just described. Sect. IV. Cases of this Disease. The following cases, which are taken from many similar, of which I have pre- served notes, are intended to illustrate the observations, contained in the two last sections. There seems to be no doubt that the disease was ulceration of the articular cartilages, since the symp- toms exactly corresponded with those, which have been observed in cases of this description, in which an opportunity occurred of examining the morbid ap- pearances after death, or after ampu- tation. It will be observed that I have not selected cases, in which the disease was ( 193 ) situated in the liip: nor, in which it liad reached its most advanced stages: my reasons for which have heen, that a suffi- cient number of examples of this affec- tion of the hip, may he found among the cases already published by Mr. Ford, and other writers: and that it is in the early stage of the disease that it principally deserves to be studied, and that the diagnosis is of the most importance. CASE XXXV. Mary Jenkins, twenty-one years of age, in May, 1809, received a blow on one of her knees. Soon afterwards she was seized with pain in the joint, which gra- dually became more severe. In Septem- ber of the same year, she was admitted into St. George's Hospital, on account of this, and of some other complaints, which required medical treatment. At first she was under the care of Dr. Ban- croft. On the 9th of November, she 26 ( 1^4 ) came under the care of the surgeons. At this time, the knee was somewhat swollen; the swelling having the form of the articulating ends of the bones, and appearing greater than it really was, on account of the wasting of the muscles of the limb. No fluid was perceptible in the joint. She complained of violent pain, which she referred chiefly to the inside of the bead of the tibia, and which was extremely aggravated by motion. There was no redness of the skin. She was emaciated, and laboured under a slight degree of hectic fever. An issue was made with caustic on each side of the ligament of the patella. The issues were kept open by means of peas: their surfaces being also rubbed with caustic every fourth day. At the expiration of a fortnight the pain was very much abated: she was able to give some motion to the joint without much uneasiness. The swelling had nearly disappeared. ( 195 ) In a short time the pain was com- pletely relieved; however she did not quit the hospital until the September of the following year. At this time she was free from all had symptoms, and had re- covered the perfect use of the joint. CASE XXXVI. John Reade, twenty-eiglit years of age, applied for relief as an out-patient of St. George's Hospital on the 4th of October, 1811. He said, that for two years preceding he had been subject to pains in the elbow, which were occasionally severe, but at- tended with little or no swelling. At the time of his coming to the hospital, the pain in the joint was very violent, particularly at night, when it continually roused him from his sleep. There was also pain in the shoulder and wrist, but trifling, Avhen compared to that in the elbow, and only occasional. The elbow ( 196 ) was slightly swollen, the swelling hav- ing the fornn of the articulating ends of the hones, and arising, not from fluid within the joint, but from inflam- mation having extended to the cellular membrane external to it. The fore-arm was kept bent, and all attempts to move it from this position caused a severe ag- gravation of the symptoms. There was some degree of symptomatic fever. Eight ounces of blood were taken from the other arm, whicli occasioned some, but not considerable relief. October 8th. A caustic issue was made on each side of the joint. October 11th. He was free from the symptomatic fever; the pain in tlie shoul- der and wrist had entirely left him; that in ^he elbow was much diminished. October 19th. The sloughs were se- parated. The issues were afterwards kept open by the occasional application of caustic. He now made very little com- plaint of pain, and slept well at night. ( 197 ) From tliis time be experienced very little uneasiness. He gradually recovered the use of the elbow; and in a few weeks, findins: no inconvenience from tbe com- plaint, be ceased to attend at tbe bospital. CASE XXXVIT. Anne Wbite, twenty-one years of age, was admitted into St. George's Hospital, on tbe 8tb of January, 1814. Sbe said, tbat tbree montbs before lier admission sbe was seized witb pain of tbe left knee. Tbe pain was sligbt at first, but gradually increased in violence. In less tbaii a montb after tbe pain first at- tacked ber, tbe joint became sligbtly swollen. About a fortniacbt before ber admission, slie was seized with a pain in ber left elbow unattended by swelling. At tbe time of ber applying at tbe hospital, tbe knee was swollen, but only in a sligbt degree. Tbe swelling had tbe form of the bones of tbe joint. C 198 ) arising from an effusion into the cellular texture, and not from fluid within the synovial memhrane. During the day she had violent, but not constant pain in the kneej the pain attack- ing her by fits, which lasted a few minutes. During the night, the pain was more con- stant, and very severe, so as to disturb her rest exceedingly. The pain, when most violent, extended up the thigh and down the leg. The joint was capable of motion, but all motion aggravated the pain There was great tenderness on the in- side of the knee. The skin was somewhat redder than natural, but the redness was greater at one period than at another. She complained also of pain in the el- bow, extending up the arm and down the fore-arm. This joint was not at all swol- len. She had lost flesh: had a white tongue, quick small pulse, and was occa- sionally flushed. Immediately on her admission leeches were applied to the knee, which some- ; ( 199 ) what relieved the pain in this joint. On the nth of January a caustic issue was made on each side of the elhow: and on the 13th of January an issue was made on each side of the knee. On the 17th of January the pain in the elbow was almost completely relieved: that in the knee was somewhat less. The issues were kept open hy the occa- sional application of caustic. The pain and swelling of the knee gradually sub- sided, and she recovered her health. The issues were not healed until the end of May, at which time the swelling of the knee had subsided, and there was no pain either of the knee or elbow. CASE XXXVIII. A gentleman, twenty-four years of age, about the end of the year 1816, became affected with a slight pain in the left ankle; and he observed also that this pain was particularly aggravated, whenever any ( 200 ) thing occurred to press the articulating surfaces of the joint against each other; for example, when he happened to tread with his heel on any projecting stone in the street. He also observed a very slight degree of puffy swelling on the anterior and outer part of the joint, before the external malleolus. On the 6th of January, 1817, he went to a ball and danced; and on the follow- ing day the pain was very much aggra- vated. The exercise also brought on some degree of general tumefaction about the joint, which however subsided with rest, in the course of twenty-four hours. But the pain continued and increased; so that he could not support the weight of his body on that foot, and he was com- pelled to walk with the assistance of one, and afterwards of two sticks. In May fol- lowing, a general puffy swelling took place round the whole joint, which did not subside. ( 201 ) On the SOtliof June, 1817, he consulted me, being then in the following condition. There was some degree of general cedematous tumefaction of the whole joint, in consequence of slight inflamma- tion of the cellular membrane external to it. There was a constant and severe pain referred to the ankle, which was rendered more violent, when he attempted to stand, and when the cartilaginous sur- faces were pressed against each other, by the hand placed on the lower part of the heel. His rest was disturbed at night, by painful startings of the limb. He had come to consult me at my own house, and in going home, he fell from his horse, and wrenched his ankle, which brought on inflammation, and rendered all the symptoms still more severe. He was directed to remain at home, in a state of perfect quietude, and never to place the foot on the ground. Leeches and cold lotions were ap^^lied, and the leeches were repeated. Under this treat- 27 ( 202 ) ment the additional inflammation induced by the accident subsided; and the pain became much less severe. At the end of August, a blister was applied on each side of the ankle, and kept open by means of the saline cerate. After the first blisters were healed, others were applied, and kept open in the same manner, and in the intervals between the applications of the blisters the joint was bound up in stripes of linen spread with soap cerate plaster. About the end of September he was so much relieved that (having some con- cerns which it wa^ of much importance to himself to attend to,) he was allowed to go out occasionally in a chaise. On the 20th of December, a caustic issue was made behind the inner ankle. This occasioned exceeding irritation and uneasiness, and the issue was in conse- quence allowed to begin to heal, about a fortnight after the separation of the slough. He was how^jver much benefited ( 203 ) hy the issue; and after it was healed, he was free from pain, and the swelling had subsided. On the 23d of May, 1818, he was in the following condition. He was free from all pain; could bear the joint to be moved, and could support the weight of the body on that foot without inconveni- ence. There were still some slight re- mains of the external swelling. When the joint was moved, a grating sound could be heard; and if at this time the fingers were applied to the joint, a sen- sation was communicated to them, as if two hard and rough surfaces were rubbed one against the other. CASE XXXIX. Mary Taylor, fifty years of age, was ad- mitted into St. George's Hospital, on the 3d of December, 1809. She said, that in the preceding July she had a violent wrench of the right ( 204 ) shoulder, in consequence of her husband having pulled her by the arm. Soon afterwards she was attacked with pain in this joint, which gradually became very severe. At the time of her admission into the hospital, there was no alteration in the external appearance of the shoulder. There was not the smallest evident swell- ing; but she complained of constant and violent pain, which was much aggravated by every attempt to move the arm. The pain w as most severe at night, so as very much to disturb her rest. She was unable to lie on the side, on which the disease was situated. The arm was supported by a sling, and a blister was applied to the shoulder, and afterwards kept open by means of savine cerate. In less than a fortnight the symptoms were much relieved. In the beginning of January, 1810, she had very little pain, and slept well at night. About the middle of February she was dismissed from the ( 205 ) hospital, being free from all her former symptoms. She was directed to attend as an out-patient, that the blister might be kept open for some time longer; how- ever she never made her appearance at the hospital again, probably in conse- quence of her finding no inconvenience from the complaint, and of her not being convinced of the necessity of continuing the treatment after the symptoms were relieved. I have before observed that ulceration of the articular cartilages is not unfre- quently complicated Avith inflammation of the synovial membrane. Sometimes the one, and sometimes the other is the original disease, in like manner as we find ulcer of the cornea of the eye in some cases the cause, and in others the con- sequence, of inflammation of the tunica conjunctiva. In the very advanced stage, when the organization of the joint is ( 206 ) completely destroyed, this complication must always exist: and it is unnecessary to adduce evidence of this fact. But occasionally the two diseases are com- bined together in a more early stage, and previous to the establishment of suppuration. In the following case, which is related for the purpose of illustrating this sub- ject, ulceration of the cartilage appears to have been the primary, and inflam- mation of the synovial membrane the secondary affection: at least the symp- toms which occurred are better expli- cable on this supposition than on any other. CASE XL. John Child, thirty-three years of age, in April, 1814, was seized with a pain in one knee, the pain at first was slight, but gradually became very severe. It was referred principally to the head of the ( 207 ) tibia on each side of the ligament of the patella. At the end of five months, the joint for the first time became swollen, and the swelling soon attained a considerable size. He was now un- der the necessity of confining himself to his room. Five blisters were applied in succession, and the swelling and pain subsided, so that at the end of three weeks he returned to his usual occu- pations. In five or six days however the pain and the swelling returned, and he was in consequence admitted into St. George's Hospital on the 26th of October. At this time he complained of pain in the joint, referred to the head of the tibia, on each side of the ligament of the patella. The pain was excruciating, so as often to keep him awake during the whole night. The knee was much swollen: the swelling arising from an eff^usion of fluid into its cavity, and having the same form as in ordinary cases of inflammation of the synovial membrane. ( 208 ) October 29. A blister was applied in- cluding tbe greater part of tbe circumfer- ence of the joint. IN^ovember 6. The swelling and pain were relieved. Another blister was ap- plied, which was kept open with the savine cerate until the end of the month. It was then healed, and a thii'd blister was applied and kept open in the same manner. On the 21st of December he left the hospital of his own accord. The pain at this time was very nearly, but not com- pletely relieved: the knee was swollen only in a very slight degree, and the tri- fling swelling, which remained, appeared to arise not from fluid within the articu- lation, but from thickening of the soft parts in consequence of their having been previously inflamed. CHAP. y. ON A SCROPHULOUS DISEASE OF THE JOINTS HAVING ITS ORIGIN IN THE CANCELLOUS STRUCTURE OF THE BONES. Sect. I. Patholomcal Observations. '3' The term scrophula is often employed without much precision; and indeed it is not always easy to determine, what symp- toms ought, and what ought not, to he referred to this disease. It has been usual to regard nearly all the affections of the joints as scrophulous; and I believe it may be found that persons having a pre- disposition to scrophula are on the whole more liable than others, to those af- fections, which form the subject of the 28 ( 210 ) preceding chapters. As however they occur very frequently, where no such predisposition exists, there seem to he no sufficient grounds for considering them as having any necessary connection with it: and it can be no more proper to designate these as scrophulous, than it would he to denominate inflammation of the synovial membrane a mercurial disease, because it occasionally arises from the use of mercury. But there is another maladv, which affects the joints, having all the characters of scrophula: generally occurring in persons who have a scrophulous appearance, and usually preceded by, or continued with, other scrophulous symptoms. In this disease of the joints, the can- cellous structure of the bones is the part primarily aflected; in consequence of which, ulceration takes place in the carti- lages covering their articulating surfaces. The cartilages being ulcerated, the subse- quent progress of the disease is in many respects the same, as where this ulceration takes place in the first instance. ( 198 ) CASE XLI. Thomas Scales, aged 18, liavinga scro- phuloiis appearance, was admitted into St. George's Hospital on the 18th of Oc- toher, 1815. He complained of pain, which he re- ferred to the inside of one foot. The pain was constant, hut slight, and not suf- ficient to prevent his walking as usual. There was very little, if an} , tumefaction, and the parts were not tender to the touch. He was also in a general ill state of health: there were symptoms of derangement of the functions of the liver, and the urine was turbid and deposited a quantity of sediment, which stained the vessel that contained it of a pink colour. He was heavy and stupid, and scarcely able to give any consistent account of his ailments. There were some small ulcerations at the edges of his e^ elids. While he was under a course of reme- dies for these complaints, he was seized, ( 212 ) iu the beginning of February, 1816, with a fever, of which he died on the first of March. On dissection, the foot, which had been the seat of the pain, was particularly ex-^ amined. Tiie bones of the tarsus, and metatarsus, w ere found to contain an un- usually small quantity of earthy matter, so that they were preternaturally soft, and admitted of being cut in any di- rection with a scalpel, without turning its edge. The cut surfaces of these bones v. ere of a deep red colour, in consequence of increased vascularity; and vessels injected with their own blood could be distinctly traced extending from the bones into the cartilages covering them, and renderhig the latter, in a few spots, of a red colour. The cartilage covering the internal cunei- form bone, where it forms the joint w ith j the metatarsal bone of the great toe, was ulcerated to a small extent. The ulcer- ation had begun on that side of the car- tilage which was connected to the bone; the surface towards the joint remaining ( 218 ) entire. The bones of the tarsus were more diseased than those of the metatarsus; and those on the inside of the tarsus were affected in a greater degree than those on the outside. The bones of the other foot were affected in the same manner, but in a much less degree. Some of the other bones y»^ere examined, and were found nearly in a natural condition. CASE XLLT. December 21st, 1814. In a boy appar- ently about ten years of age, whose body I had the opportunity of examining after death, I observed the following appear- ances. Both elbows were slightly swollen. On the fore-part of the right arm, imme- diately above the elbow, there was the orifice of a sinus, which extended down- wards obliquely into the cancellous struc- ture of the bone, where it terminated, without communicating with the cavity ( 214 ) of the joint. The cancellous structure, of the articulating extremities of the os brachii, radius, and ulna, was so soft, that it might be crushed by a very slight de- gree offeree when squeezed between the fingers: it was of a dark red colour; pre- ternaturally yascular, and there was a reddish fluid, mixed with medulla, in the cancelli. The cartilages covering the ra- dius and ulna were in a natural state; that belonging to the os brachii was ul- cerated in a few spots on the surface to- wards the bone, w hile the surface towards the cavity of the joint was entire. There were no morbid appearances of the liga- ments or synovial membrane. The bones of the left elbow were in a similar state of disease; the cartilages were entirely destroyed by ulceration; and carious surfaces of bone were ex- posed. A small portion of dead bone had exfoliated into the cavity of the joint, where it lay, surrounded by matter. The synovial membrane and ligaments were extensively destroyed, and there ^ 215 ) were several sinuses communicating ^vitli the joint and opening externally. On examining' the right knee, which externally had not the slightest marks of disease, and admitted of perfect motion, the cancellous structure of all the bones, which enter into its composition, was found in the same morbid condition with the bones of the elbows, being preter- naturally red and vascular, with a much less proportion than is usual of earthy matter, so that they admitted of being crushed by a vexy slight force. In the interior of the lower extremity of the fe- mur, between the two condyles, there was one part, where the earthy matter seemed to have entirely disappeared, and there was in consequence an irregular space, in which there was little else than medulla and reddish fluid mixed together; near this part, tlic cartilage had only a very slight adhesion to the bone, and ulceration had begun on its inner surface. ( 216 ) In several other joints, which were examined, there were marks of the same disease, but in a less advanced stage. CASE XLIII. John King, twenty-six years of age, hav- ing blue eyes, thick lips, and a florid com- plexion, was admitted into St. George's Hospital, on the 1st of June, 1811, on account of a complaint in his right ankle and foot. I receiAcd the following ac- count of his case, partly from himself, and partly from a medical gentleman, who ^as in the habit of seeing him before he came into the hospital. About the end of May, 1810, he wrenched his foot. The instep and ankle became swollen and painful, but in a few days these symptoms subsided. During the summer he experienced slight pain and weakness of these parts, whenever he took more than his usual quantity of exercise; but in October a slight tume- ( 217 ) faction was observed on each side of the ankle, and the pain was more severe, but still not snfiicicnt to prevent his going about his usual occupations. About the middle of December the pain became more violent, and he was confined to the house for a fortnight; after this the pain abated, so that he was able to go about with the assistance of a crutch. In March, 1811, an abscess burst on the outside of the foot. The formation of the abscess was not attended with any considerable degree of pain. He formerly had been supposed to la- bour under incipient phthisis pulmonalis; but from the time of tlie disease havino^ begun in his foot, he suffered no inconve- nience from the complaint in his lungs. At the time of his admission into the hospital, there was a diffused cedematous swelling of the soft parts over the whole foot and ankle. On the outside there were tlie orifices of three or four sinuses, 29 ( 218 ) which had biirst at different periods. He had very little pain, even on motion or pressure. Soon after his admission, an- other abscess broke on the inside of the heel. On the 11th of July, the leg was ampu- tated. On examining the foot, the cells of the cellular membrane were found distended with serum and coagnlable lymph. All the bones had undergone a morbid change, similar to what was observed in the last case, except that they were still softer and more vascular. The cartilages of the ankle were com- pletely destroyed by ulceration, and the exposed surfaces of bone were in a state of caries. The cartilages of the tarsus were entire, but, in some places, of a red colour, and this was found to arise from vessels loaded with red blood, extending into them from the bone. The ligaments and synovial membranes of the tarsal joints were in a natural state, as were alsc? ( 219 ) those of the ankle, except Avhere they had heeii destroyed hy the abscesses. CASE XLIV. This patient was a soldier in the Cold- stream Guards. I once had an opportu- nity of seeing him before amputation was performed, and through the kindness of the medical officers of the regiment, I was favoured with the previous history of the coniplaint, and with the opportunity of examining the amputated joint. William Miles, twenty years of age, of a delicate complexion, jyith red Iiair and dilated pupils, was attacked with a slight pain and swelling of the left knee, about the middle of January, 1808. On keep- ing quiet for a few days the swelling subsided; but it returned about the end of March, though still attended with very little pain. He was received into the hospital of the battalion at Chatham, and on the ( 220 ) Otli of June following, lie was sent Lo Uio regimental hospital in London. At this time, the diseased knee measured in circumference three inches more than the other. -Fluid was felt external to the joint, and in the cavity of the joint itself. The leg was kept extended, and all at- tempts to hend it gave considerable pain; but otherwise, the pain which he endured was trifling, amounting only to a slight degree of uneasiness, deep-seated in the Joint. On the 8th of July, an abscess burst near the inner edge of the patella, and discharsced about eisjjht ounces of thin pus. On the 27th of July, the limb was amputated. On examining the knee, the articulating extremities of the tibia and fibula were found so soft, that they w ere readily cut by a common knife: they contained mucli less earthy matter tlian is usual, and their cancelli w^erc filled by a yellow cheesy substance. The cartilage covering the head of the ( 221 ) tibia, was destroyed by ulceration in a a few spots at the margin. Tliat of the femur, was eroded for a very small extent behind the crucial ligaments. The pa- tella, and the cartilage covering it, were in a natural state. Coagulable lymph, having a gelatinous appearance, had been effused into the cellular texture, on the outside of the synovial membrane. Pns was found external to the joint, and in the joint itself. CASE XXXYII. Charles Miller, tv.enty years of age, hav- ing blue eyes, light hair, and a fair com- jdexion, was admitted into St. George's Hospital, in April, 1808, on account of a disease of one foot. The whole foot was swollen and oede- niatous, with two fistulous sinuses, one on the inside and the other on the out- side, through which a small quantity of scrophulous matter was discharged. V ( 222 ) probe having been introduced into either of these sinuses, some exposed pieces of bone might be distinguished. On the 16th of May, the limh was am- putated below the knee.. On examining the amputated foot, the muscles were found pale and wasted from want of use, and the cellular membrane was distended with coagulable lymph. The extremities of the tibia and fibula, all the bones of the tarsus, and extrcr mities of the bones of the metatarsus, con- tained much less earthy matter than is usual. They were so soft, that they might be cut with a scalpel without the edge of it being turned. They were preternaturally red and vascular, and a yellow cheesy sub- stance was deposited in the cancelli. The cartilage at the base of the fifth -jietatarsal bone was destroyed by ulceration. Those at the bases of the three middle metatar- sal bones were also destroyed, aud the exposed surfaces of bone were undergo- ( 223 ) ing the process of exfoliation. The carti- lages of all the other bones were in a natu- ral state. Pus and coagulafjle lymph had been effused in the neighbourhood of the dead and carious bones, and the sinuses communicated with them. The synovial membranes and ligaments were in a natural state, except where destroyed by the abscesses. CASE XL VI. James Miller, twenty-one ^ears of age, was admitted into St. George's Hospital on the 21st of May, 1817, on account of inflammation of the iris of one eye, and Some eruptions, which had followed a sore on the prepuce: and for these complaints he was put through a course of mercury. About the end of July, soon after the ftiercurial course had terminated, he com- plained of a slight degree of pain of the left ankle. A swelling took place, and an abscess formed on the outside of the ( 224 ) ankle, whick was opened on the 26tli of September. Another abscess afterwards formed, and was opened on the inside. It was observed, that there was pain while the abscesses were coming forward, but little or no pain after they were opened. The abscesses continued open, and dis- charging matter, but the quantity of the matter gradually diminished. About the beginning of October, he became affected with cough, and it soon became evident that he laboured under tubercles of tbe lungs. In the beginning of December, he complained, for the first time, of pain of the left elbow; and on examination, it Avas found that an abscess had already presented itself underneath the skin. This abscess burst in the beginning of January, 1818, and he scarcely complained of any pain in the elbow afterwards. The disease in the lungs continued to make progress, lie expectorated purulent matter, and died in March following. ( 225 ) On dissection, the lungs were found extensively tuberculated, and containing numerous abscesses. The bones com- posing the left ankle, were preternaturally vascular and soft, so that they might be cut with a scalpel, and in some parts a small quantity of yellow cheesy substance was found in the cancelJi. The abscess on the outside of the ankle seemed to have originated in the lower extremity of the fibula, and there was a cavity (large enough to receive the end of the little finger), in that boncj made by the process of ulceration, and forming the bottom of the abscess. Both abscesses however communicated with the joint itsdif. The cartilages of the ankle were nearly de- stroyed; and the tibia and astragalus were united, partly by coagulable lymph, and partly by bony anchylosis. The abscess in the outside of the left elbow, was found communicating with that joint by a large opening. The bones were in the same morbid condition as those of . 30 ( 226 ) the ankle; the cartilages were entirely destroyed hy ulceration. The patient had never comjdained of the right elbow; but after death, a small abscess was discovered on the inside, which however did not communicate with the cavity of the joint, but appeared to have originated in the substance of the bone, and to have made its way through the periosteum. The cant^ellous structure of the articu- lating extremities of the bones, which composed the joints of the knees, wrists, and the right ankle, were preter naturally soft and vascular; but there were no abscesses connected with them, and the cartilages were entire. The bones of the hip and shoulder were in a natural state. There was an enlarged absorbent gland in the groin, converted into a cheesy substance. ( 227 ) The preceding cases sufficiently illus- trate the nature and progress of this dis- ease. The morhid affection appears to have its origin in the hones, which become preternaturally vascular, and containing a less than usual quanity of earthy matter; while, at first, a transparent fluid, and afterwards a yellow cheesy substance is deposited in their cancelli. From the diseased boncy^ vessels carry- ing red blood extend into the cartilage, which afterwards ulcerates in spots, the ulceration beginning on that surface, which is connected to the bone. The ulceration of the cartilage often proceeds very slowly. I have known a knee amputated on ac- count of this disease, in Avhich the carti- lage was absorbed, for not move than the extent of a sixpence. Occasionally a portion of the carious bone dies and exfoliates. As the caries of the bones advances, pus is collected in the joint. At last the abscess bursts externally, having; formed ^ (^ 228 ) numerous and circuitous sinuses. Inllam- matioii takes place iu the cellular mem- brane external to the joint. Serum, and afterwards coagulahie Ijmph is efiused, and hence arises a puflj and elastic swelling in the early, and an cedeniatous swelling in the advanced stage of the disease. The scropliulous aiTection attacks only those bones, or portions of bones, which have a spongy texture, as the extremities of the cylindrical bones, and the bones of the carpus and tarsus: and hence the joints become affected from their conti- guity to the parts, which are the original seat of the disease. I have never met with an instance of the alteration of structure, which has been just described, in the cranium, nor in the middle of the cylindrical bones.* * It should be observed, that in some other cases, besides those of scrophulous affection, the bones are found to be more or less altered from their natural ( 229 ) Sect. II. On the Symptoms of this Disease. The scropliiiloiis affection of the joints occurs frequently in cliiklren: it is rare after thirty years of age. Examples of it occur in almost every joint of the body, but the hip and shoulder appear on the texture. When a bone is extensively carious, it seems as if the absorption of the earthy part sometimes takes place more rapidly than that of the animal matter, and hence it becomes preternaturally soft in the neighbourhood of the carious surface, at the same time that It assumes a dark colour, and has a fcetid smell, from the lodgment of putrid matter in the can- celli. Occasionally a bone loses some of its natural hardness, in consequence (as it would appear) of it having been for a long time inflamed. This hap- pened in two cases, which came under my observation, where the cranium had been in a state of slow inflam- mation, induced in one case by the use of mercury, and in the other by a mechanical injury. But here the softened condition of the bones does not exist in the same degree, as in the scrophulous disease, which has been described above, nor is there the same red appearance of the cancellous structure, nor the same deposition of yellow cheesy substance. ( 2;:J0 ) Avliole to be less liable to it than any of the other articulations.* As it depends on a certain morbid con- dition of the general system, it is not surprising that we should sometimes find it affecting several joints at the same time; nor, that it should shew itself in different joints in succession; attacking a second joint after it has been cured in the first, or after the first has been re- moved by amputation. It is seldom met with, except in persons who have the marks of what is called a scrophulous diathesis: and in many cases it is either preceded, attended, or followed, by some other scrophulous symptoms; such as * Perhaps this arises from the circumstance of the hip and shoulder being less exposed to the influence of the external cold, which in most instances pro- motes the developement of scrophulous diseases. So Are find, the scrophulous enlargement of the lympha- tic glands, to occur more frequently in the neck' than in the groin or axilla, which are generally defended by a warmer clothing. ( 231 ) tBniargement of the scropliulous glands of the neck and mesentary; or tubercles of the kings. I liave often been led to believe, that the occurrence of this dis- ease in the joint, has suspended the pro- gress of some other, and perhaps more serious disease elsewhere. The scrophulous disease is more likely to be confounded with that, which formed tile subject of the last chapter, than with any other. There is in many respects a correspondence in their symptoms. There are how^ever certain points of difference, and I believe that this difference will be found sufficient to enable the practitioner, w ho is careful and minute in his observa- tions, to make a correct diagnosis; at least in those cases, in which the local disease is not so far advanced, and in which it has not so much affected the general con- stitution, as to make the diagnosis of no importance. While the disease is going on in the soancellous structure of the bones, before ( 232 ) it has extended to the other textures, and while there is still no evident swelling, the patient experiences some degree of pain, Avliich however is never so severe as to occasion serious distress, and often is so sliglit, and takes place so gradually that it is scarcely noticed. After a time (which may vary from a few weeks to several months) the parts external to the joint hegin to sympathise with those within it; and serum and co- agulable h mph being effused into the cel- lular membrane, the joint appears swollen. The swelling is puffy and elastic, and though usually more in degree than it is, at the same period, in those cases, in which the ulceration of the cartilages oc- curs as a primary disease, it is not great- er in appearance, because the muscles of the limb are not equally wasted from want of exercise. I have observed that in children, the swelling is in the first in- stance usually less diffused, and somewhat firmer to the touch than in the adult. ( 233 ) if a supicion of some disease of tlie Joint has not existed previously, it is al- ^vays awakened as soon as the swelling has taken place. Should the patient be a child, it not uncommonly happens that the swelling is the first thing, which the nurse or the parents discover. This leads to a more accurate enquiry, and the child is observed to limp in walking, if the dis- ease be in the lower limb, and to com- plain of pain on certain occassions. I have said, that the swelling is puffy and elastic, and after what has been re- marked in the former chapters, it is needless to point out more particularly the difference between it, and the swelling which takes place in cases of inflamed synovial membrane. The swelling in- creases, but not uniformly^ and it is greater after the limb has been miich exercised, than it is, when it has been allowed to remain for some time in a state of quietude. As the cartilages continue to ulcerate/ 31 ( 234 ) the puiu becomes somewhat, but not materially aggravated. It is not severe, until abscess has formed and the parts over the abscess have become distended and inflamed. The skin under these circumstances assumes a dark red or purple colour. The abscess is slow in its progress; when it bursts or is opened^ it discharges a thin pus, with portions of curdly substance floating in it. After- wards the discharge becomes smaller in quantity, and thicker in consistence, and at last it nearly resembles the cheesy matter, which is found in scrophulous absorbent glands. In most instances several abscesses take place in succesion, but at various intervals; some of which heal, while others remain open in the form of fis- tulous sinuses, at the bottom of which carious bone may be distinguished by means of a probe. The disease not unfrequently remains in this state for several months, or even ( 235 ) for a mucli loger period, without tlie con- stitution being materially disturbed. In the less fortunate cases, the patient at last becomes affected with a hectic fever, un- der which he gradually sinks, unless the cause of it be removed by amputation. At other times, a curative process begins; the sinuses close; the cedema subsides; and the patient ultimately recovers, either with or without an anchylosis; accord- ingly as more or less destruction of the articulating surfaces has taken place. But the cure is always tedious, unless the disease has been arrested at a very early period. It is not uncommon to see a patient with a scrophulous joint, in a state of imperfect anchylosis, with a single sinus remaining open, and waiting for many years, before even such a cure as anchylosis affords, can be said to be com- pleted. The chance of ultimate recovery is not the same in every articulation; and I have observed, that it is much less, where the disease attacks the complicated ( 23b ; joints of tlie foot and liund, than when u is situated in those, Avliicli, tliougL of a larger size, are of a more simple struc- ture. The principal difference wliich is to he observed, hetweeij tlie symptoms, which have been just described, and those, which are met with, where ulceration of the car- tilages occurs as a primary affection, is in the degree of pain, which the patient en- dures, and which is much less in the cases of the former than in those of the latter descriptioi]. It may indeed be a matter of surprise, that in cases of this scrophulous affection, the sufferings of the patient should be so little as they are found to be, in propor- tion to the quantity of local mischief. For the most part, the pain, which he ex- periences, is not a subject of serious com- plaint, except at the time when an ab- scess is just presenting itself underneath the skin, and then it is immediately re- Jieved by the abscess bursting. There is ( 237 ) 4iever that severe pain,Avhich exhausts the powers and the spirits of the patient, in cases of ulceration of the cartihi<^'e, except in a very few instances, and in the most advanced stage of the disease, when a por- tion of the ulcerated bone has died, and having exfoliated so as to lie loose in the cavity of the joint, irritates the parts, with which it is in contact, and thus becomes a source of constant torment. There are other circumstances, besides the less degree of pain, which although not in themselves sufficient, it is useful to take into the account in forming our diagnosis; such as the general aspect and constitution of the patient, and his having manifested a disposition toother scrophu- lous symptoms; the very tedious progress of the disease; and the circumstance of the suppui'ation not behigin general con- fined to a single collection of matter; but producing a succession of abscesses. Perhaps it is on the whole more diffi- cult to distinguish this disease in the hip, ( 238 ) than in any other joint; since the ap- pearance of the nates as well as the position, and the alteration in the length of the limb, give it in great measure the same character with the disease, which formed the subject of the last chapter. Yet even here, attention to the circumstances which have been enumerated, will usually enable us to distinguish the real nature of the case. A girl laboured under an affection of the hip-joint, in which the nates were flattened, the limb had become shortened, and an abscess had broken on the outside of the thigh; but it was ob- served that she had suffered comparatively little distress, and that she had complained of very much less pain, than is usual with the same combination of symptoms. Under these circumstances she died, and when I was about to examine the body, I observed to those who were present, that there was little doubt, but that the origin of the disease would be found to have been, not in the cartilaginous surface, ( 239 ) but in the cancellous structure ot* tlie bone^ The appearances which were ob- served verified this remark. The car- tilages were ulcerated, and the bones themselves destroyed to some extent. The latter were soft, so that they might he cut with a scapel, without turning its edge; and on dividing the articulat- ing extremity of the femnr longitudinally, a considerable collection of thick pus was found in the neck of that bone, below the head, which either had noL escaped at all, or had escaped in very small quantity, hy oozing through the cancelli, which were interposed between it^ and the cavity of the hip-joint. Sect. III. On the Treatment. In atempting the cure of the scro- phulous disease of the joints, it is neces« ( 2J4o ; ' sary to bear in mind, tliat it depends on a certain morbid condition of tbe general system. It seems reasonable to expect, tbat when the local affection has once begun to exist, local remedies may be of service in checking its progress; but that with a view to the ultimate result, such remedies as operate on the constitution of the patient, may be of as much, if hot of more importance, than any local treatment. I cannot say, that the abstraction of blood froni the neighbourhood of the diseased joint is never useful, but it cer- tainly is not necessary in ordinary cases. The state of the cancellous structure of the bones approaches to that of inflam- mation, and the cartilages have the ap- pearance of being inflamed, before they begin to ulcerate; but the inflammation is of a specific kind, and like scrophulous inflammation in other parts, is not likely to be relieved by the loss of blood, ift ( 211 ) the same degree as common inflamma- tion. I have seldom known any benefit to be derived from the use of blisters oi* stimulating liniments: nor in the cases, in which I have tried them, have I observed caustic issues to be productive of those good effects, which are so distinct in ano' ther variety of disease. Cold evaporating lotions seem to check, in some degree, the extension of the dis- ease from the hones to the other textures, and to retard the occurrence of suppura- tion, and they may be employed with ad- vantage, in the early stage of the com- plaint- But neither at this, nor at any other period, is any thing of so much import- ance, as that the joint should be kept in a state of quietude. All motion, and pres- sure of the articulating surfaces against each other is likely to promote the ulcer- ation of the cartilages, and hasten the formation of abscess. We cannot sup- pose that rest will contribute to the 32 ( 242 ) amendment of the scrophuloiis state of the bones themselves; but it may da much towards preventing the disease from aftecting the other parts. I do not mean to assert, that in every case, the patient should be kept in a state of ab- solute rest for a long period, but cer- tainly all motion and exercise of the limb should be avoided, as much as pos- sible, consistently with due attention to the state of the patient's health, and the impi'ovement of his constitution. If the disease be in the lower extremity, he should never rest the weight of the body on the foot belonging to it; he should never walk, except with the assistance of a ei'Utch; and he should, if possible, be exposed to the fresh air, by means of some kind of open carriage, rather than in any other way. If it be in the upper extremity, the hand and fore-arm should be supported by means of a sling. In many cases, it will be useful to keep the diseased joint steady by means of a light paste-boait splint and a bandage. ( 243 ) During the formation of abscesses, fomentations and poultices may be em- ployed, with a view to hasten their pro- gress, and relieve pain; and they may be continued for some time after the abscess has burst; or simple dressings maybe ap- plied accorduig to circumstances. When, after several abscesses have taken place, the disposition to suppuration ap- pears at length to have ceased, and the swollen joint has become diminished in size, it may be expected that a curative process by means of tyichylosis, is about to commence. At this period, pressure by means of stripes of linen, spread with soap cerate, or some other moderately adhesive plaister, and applied in a cir- cular manner round the limb, will be productive of benefit. This will promote the healing of the sinuses, and by more completely preventing the motion of the joint, will lessen the chance of fresh sup- puration, and favour the union of the ulcerated bony surfaces. (^ 244 ) If a portion of the bone has lost its living principle, and has exfoliated into the cavity of the joint, the chance of ultimate recovery is very much dimi- nished. For the most part, the dead bone is so entangled in the living parts, that it is incapable of separation by a natural process, and every attempt to remove it by artificial means will occa- sion a fresh attack of inflammation and abscess. It is to be observed, however, that bone, which is found exposed at the bottom of a sinus, is not necessarily doomed to exfoliate. It may be simply ulcerated, and may possibly granulate, and recover; and tlie surgeon, therefore, is not warranted in giving a prognosis, which is decidedly unfa voui able, merely because he discovers apiece of exposed bone, when he makes an examination with a probe. With respect to the constitutional treat- ment; — it is to be supposed, that the air of a crowded city, must be more or less unfavourable; and that a residence on ( 245 ) the sea-coast is likely to be more be- neficial tlian a residence in tlie country elsewhere. The patient should live on a nourishing but plain diet; he should be in the open air in summer, as niuch as he can be, without exercising the joint. His mode of life should, in all respects, be regular and uniform. It is more difficult to appreciate the value of medicines in a disease, which is so completely chronic, than in acute dis- eases; but of those, which I have tried, it lias appeared to me, that preparations of iron are much more useful than any others. They must, however, be con- tinued for a considerable length of time, aud in order that this may be effected, it is generally necessary that diiferent pre- parations should be given in succession, a change being made, wlienever the pa- tient begins to loathe that, which he is already taking. Of course the steel me- dicine should be suspended if it excites any febrile action in the system, or if a ( 246 ) febrile action be excited in consequence of the formation of abscess. Under these circumstances the mineral acids may be substituted for it with advantage. In children, it will be generally found use- ful to combine the plan of treatment, which has been just described, with the occasional exhibition of mercurial pur- gatives* When the organization of the joint is completely destroyed, and the consti- tution has become aftected, so that the patient's health is evidently failing, there can be no doubt of the necessity of the local disease being removed by ampu- tation. But a question concerning the expediency of this operation will often arise under other circumstances. The patient has hitherto not suffered with re- spect to liis general health, or has suffered in a very slight degree; the condition of the diseased joint is such that ultimate recovery is very doubtful; and it is cer- tain that no better cure is to be expected ( 247 ) than that by means of anchylosis; and even this cannot be looked for except after the lapse of a considerable length of time. Is the chance of the ultimate preseryation of an imperfect limb suffi- cient to repay the patient for all the trouble, and pain, and anxiety, which he must go through, in order to attain this object? Perhaps it is not: particularly with persons belonging to the lower orders of society, who have to support themselves by their bodily labour. There are however some other points to be taken into consideration, before this question can be properly decided. A girl was admitted into St. George's Hos- pital, who laboured under this disease in the bones and joints of the tarsus. Her foot was amputated by Mr. Griffiths. In about three weeks the stump was per- fectly healedj but now she was seized with symptoms, which indicated an af- fection of the mesenteric glands, which had not shewn itself previously, and she ( 248 ) died. On dissection, numerous glands of the mesentery were found enlarged, and containing a cheesy matter. Another girl, whose arm I amputated on account of a scrophulous disease of the elbow, became affected in the same manner, im- mediately after the stump was healed. She also died, and similar appearances presented themselves on dissection. A man, whose leg was amputated on ac- count of a scrophulous disease of the tarsus, in a short time after the operation, began to experience symptoms, which indicated the incipient state of some pul- monic complaint: and soon afterwards the other foot became affected in the same manner as the first. These are a few of many cases, which might be ad- duced, as leading to this conclusion, that the occurrence of this scrophulous disease in a particular joint may be the means of preventing the scrophulous dis- position from shewing itself in some other organ, and that if the affected joint be ( 249 ) removed by an operation there is more danger of disease breakini^ out else- where, than if the operation had not been resorted to. I do not say that these considerations are sufficient to war- rant the surgeon in forbidding an oper- ation altogether, in all cases, where it is not actually and indisputably necessary to save the patient's life; but they are cer- tainly sufficient to make him cautious not to recommend and urge it too strongly. They shew the prudence of delay in cer- tain cases. Perhaps after the lapse of one, or two, or more years, by means of proper medicines, and a judicious at- tention to diet, and mode of life, and still more in consequence of that change, which the mere lapse of time may produce in the constitution of a young person, the patient's general health may be so far im- proved, that the diseased joint may be re- moved, without the risk of subsequent mischief, which would have been incurred at a former period. 33 ( 250 ) Sect.1V. Cases of this Disease. Several of the cases related in the first section, will serve to explain the prin- cipal circumstances of this scrophulous affection of the joints, in its most aggrava- ted form. The following exhihit it in its less ad- vanced stages, where it is still capable of a cure. It may be presumed that in these cases, the original disease was that mor- bid condition of the cancellous structure of the boneSj which has been just de- scribed, since the symptoms exactly cor- responded to those, which have occurred in other cases, which have been proved by dissection to be of this nature. CASB XLYII. William Moulds, six years of age, hav- ing a scrophulous aspect, was admitted ( 251 ) into St. George's Hospital, on the 23d of February, 1814. His left knee was an inch and a half in circumference larger than the other. The swelling was puffy and elastic; with- out fluctuation, having nearly the form of the articulating extremities of the bones; but filling up the space on each side of the ligament of the patella. The joint admitted of considerable motion, but not of complete flexion and extension. He complained of pain, which was worst at night, but never very severe. It was somewhat aggravated by pressure. His parents attributed the complaint to some trifling hurt, which he had met with a year ago; soon after which, a slight degree of pain' and tumefaction was first observed, which had continued ever since, and had increased, particularly within the last month. On his admission, with a view to the relief of the external inflammation, blood was taken from the knee by means of ( 252 ) leeches and ciippijig. A cold lotion wab applied; and he was directed to take 3) of the vinum ferri, with a few drops of the tinctura ferri muriatis three times in the day. On the 3d of March, the knee was bound up in stripes of linen spread with soap cerate, chiefly with a view^ to restram the motion of the diseased joint, without interfering with the patient's bo- dily exercise. March 20. The swelling was somewhat diminished; and he did not complain of pain. April 1 . He ^^ as in all respects better. As the former preparations of iron had begun to disagree with him, they were chan2:ed for ten trains of the carbonate of iron, three times in the day. April 20. Scarcely any swelling of the joint remained: and there was no pain or stiffness. He quitted the hospital ( 253 ) CASE XLVIII A. B., a handsome boy, having bhie eyes, and light hair, in the year 1806 had a scrophuloiis enlargement of some of the glands of his neck, which suppurated and burst. In the month of June, 1810, being then eight years . of age, he was observed to limp in walking; but he did not com- plain of pain, and little notice was taken of this circumstance. In the beginning of December, 1810, some degree of tumefaction was observed of the left instep and ankle. About the end of this month he received a trifling hurt of these parts; and now the pain of the ankle, which before had been so slight, that he scarcely spoke of it, became more considerable, and he was unable to walk. A gentleman who was consulted directed the application of blisters, but they were productive of no relief. In the middle of January, 1811, when ( 254 ) 1 was first consulted, there was a pufiV elastic swelling on each side of the ankle and instep; there w^as scarcely any pain when the joint was perfectly quiet; but on attempting to use it, the pain was more considerable, and it was particularly aggravated, when the heel was pressed upwards against the bones of the leg. In other respects he was in perfect health. I directed him to take the sulphate of iron internally, and to avoid all exercise of the joint, walking only on crutches, and so as never to place his foot in contact with the ground. Stripes of linen spread with soap cerate, were applied for the purpose of more effectually restraining motion. I did not see him again until the be- ginning of March, when the pain and swelling were found to be somewhat di- minished. As the stripes of soap cerate did not seem sufficiently to answer the intended purpose, a light pasteboard splint was applied on each side of the leg ( 255 ) and foot, and secured by means of a bandage. April 12th. The puffy swelling was evi- dently diminished, and there was no pain, even when the heel was pressed upwards against the tibia. The same treatment was continued. May 26th. The swelling was further diminished; and, on the 29th of June, the affected foot and ankle scarcely dijffered in appearance from the other. He was free from pain even on motion. The splints were left off, hut it was directed that he should continue to wear the bandage. He was allowed occasionally to put his foot on the ground. July 20th. He continued well. He went to the sea-side, with directions to continue the steel medicine, and to bathe in the sea twice in the week. CASE XLIX. George Lavel, nine years of age, and having a scrophulous appearance, in ( 256 ) January, 1817, complained of an aching in his leh elbow, and in about two or three months it was observed that the elbow was swollen. In May, 1817, he became an out-patient of St George's Hospital. At this time, the elbow was swollen, and painful, but the pain arose chiefly from an abscess which presented itself underneath the skin on the inside. After the abscess had burst, it was ob- served that the swelling, which was in- dependent of it, was not considerable, and that it seemed to arise entirely from an effusion of serum and coagulablc lymph into the cellular membrane ex- ternal to the joint. From this time he suffered very little pain, until the be- ginning of January 1818, when another abscess began to shew itself on the out- side of the elbow. On the 28th of Januar}'^ he was admitted as an in-patient of the hospital. The joint now admitted of very limited motion. Whenever it was moved, or when the articulating surfaces were pressed against each other, he com- ( 257 ) plained of some but not of severe pain. He kept the fore-arm in the half-bent position, and walked about, supportinj^ the hand in a sling, with very little inconvenience. In the beginning of February, he was directed to take six grains of carbonate of iron three times in the day; and a purge of calomel and rhubarb was ad- ministered occasionally. The abscess was opened, and a poultice was applied. March 1st. The joint was smaller, but he was feverish, and suffered pain at night. March 21st. The swelling was much diminished, the pain had abated; he slept well at night, and was free from fever. In the middle of May there was a re- currence of pain in the joint, and another abscess presented itself on the outside, which was opened on the 19th of May. After this a fourth abscess formed on the fore-part of the elbow, and broke on the 23d of June. 34 ( 258 ) July 4th. There was little or no swelling. He was free from pain; the abscesses continued open, discharging a very small quantity of matter. The poultices and fomentations, which had been hitherto employed during the formation of the abscesses, were now left off; and some simple dressings, and a bandage, were applied in their stead. The swelling continued to subside; he had no return of pain or abscess. On the 4th of September, the joint was not larger than the other; it admitted of much more motion than formerly; there was no pain; there was still one sinus, which was not completely closed, an4 which discharged a minute and almost imperceptible quantity of matter; all the other abscesses were completely healed. CHAP. VI. ©N CARIES OF THE SPINE, Sect. I.. Pathological Observations,. It is obvious from the structure of the vertebral joints, that they can be liable to no diseases bearing any resemblance to the affections of the synovial membrane, which occur in other articulations. But analogy would lead us to expect, what experience demonstrates, that those dis- eases, which commence in the harder textures may occur here as elsewhere, and that an extensive caries of the spine may have its origin, sometimes in an ul- ceration of the intervertebral cartilages, and at other times in a morbid con- dition of the cancellous structure of the bodies of the vertebrae. ( 260 ) In one of tlie cases, wliich have been related in a former chapter, where ulcer- ation of the articular cartilages had begun in several other parts, tliose between the bodies of some of the dorsal vertebrfe were found to have been very much al- tered from their natural structure. I had an opportunity of noticing a similar morbid condition of two of the inter- vertebral cartilages in a patient, who, some time after having recei^ ed a blow on the loins, was affected with such symptoms, as induced Mr. Keate to con- sider his case, as one of incipient caries of the spine, and to treat it accordingly with caustic issues; and who, under these circumstances, died of another complaint. In various other instances, in which the patients had died in the advanced stage of caries of the spine, and in which the appearances were examined after death, I observed that the destruction of the intervertebral cartilages was much greater than that of the bones themselves, the lat- ( 261 ) ter having retained their ordinary struc- ture and hardness, and the caries of them heing either entirely confined to, or most extensive on, those surfaces, to which the cartilage had been connected. The above circumstances seem to ren- der it probable that this affection of the spine frequently originates in the inter- vertebral cartilages. The following cases afford a more direct evidence in favour of this opinion. CASE L. Christiana Clear, a girl eight years of age, was admitted into the Infirmary of the parish of St. Greorge, Hanover-square, in the year 1808, on account of a disease of the spine. At this time, the upper part of the spine was bent forward, and the spinous processes of some of the dorsal vertebrse formed a preternatural projection at the posterior part; but still she was able to walk without assistance. ( 2&2 ) Soon after her admissioD, an abscess presented itself, and burst in the groin; and this was followed by a second ab- scess, which burst near the former. The child was now under the necessity of being confined entirely to her bed. The abscesses continued to discharge pus. She became affected with hectic fever; never- theless more than two years elapsed from the time of her having been first admit- ted into the infirmary', before she died. The body was examined by Mr. How- ship, to whom I am indebted for this account of the case. It was universally anasarcous. The abdominal muscles were so wasted that scarcely any vestige of them was perceptible. This probably arose from the circumstance of the child having remained in bed for so long a time previous to her death, and having scarcely ever varied her position. At the posterior part of the abdomen, there was a confused mass of soft sub- stance, which proved to be the parietes ( 263 ) ol'an abscess communicating with the orifices in the groin. The bodies of the lowest dorsal, and three superior lumbar vertebrse were found at the posterior part of the abscess, nearly consumed by caries. There were no re- mains of the intervertebral cartilages be- tween the tenth and eleventh dorsal, nor between the third and fourth lumbar, ver- tebrae. These intervertebral spaces were filled with pus, and the opposite surfaces of the vertebrse were carious, but only to a small extent. The central part of the intervertebral cartilage between the ninth and tenth dorsal vertebrae had been com- pletely absorbed, and pus was found in its place. Externally to this, the concentric layers of elastic cartilage were entire, though somewhat altered from their na- tural appearance. CASE LI. Mr. M., a yonng man, in the suUi- mer of 1816, became affected with pain ( 264 ) in liis back, and general debility, wliicli he attributed to bis having lain on damp ground, while in the island of Ascension, in the preceding March. In the begin- ning of September he sailed for England, being compelled to return home, on ac- count of the state of his health. In February, 1817, he arrived in Lon- don; complaining of pain in the back, and numbness of the thighs. Soon after- wards, on examining the spine it was ob- served that that part of it, which is formed by the dorsal vertebrae, was in- curvated forward, and that in addition to this these was an evident lateral incurv- ation also. After this, an abscess burst in one groin, and continued open, dis- charging a large quantity of matter. The lower extremities became imperfectly pa- ralysed; he lay constantly on one side, with the thighs drawn forwards, so that his knees nearly touched his chin, and never varied from this position. He lingered until the lOtli of August, 1818, when he died. ( 205 ) On inspecting the body, 1 lound an abscess, which occupied nearly the whole of the anterior surface of the spine, from the upper part of the posterior medias- tinum as low as the pelvis, and which communicated with each groin, extending downwards in the direction of the psoce muscles. In many parts, in consequence of the contact of the matter of the abscess, tlie bodies of the vertebrie, and even the heads of the ribs, were affected with a superficial paries. There were no remains of the inters vertebral cartilage between the fourth and fifth dorsal vertebrae, and the opposite surfaces of these two vertebrae were con- siumed by caries to some extent, and hence arose the curvature of the spine forward; and they were consumed to a greater extent towards the left side, than towards the rigbt, and hence arose the Lateral curvature. The intervertebral cartilage between the eleventh and twelfth dorsal vertebrae had 35 ( 2b6 ) also entirely disappeared, and the oppo- site surfaces of these bones were in a state of caries; but this had not extended itself sufficiently to occasion any sensible loss of bony substance. The intervertebral cartilages between the third and fourth, fifth and sixth, se- venth and eighth, tenth and eleventh dor- sal Vertebrse; and also that between the twelfth dorsal and first lumbar vertebra*, were all found in a perfectly natural state towards the circumference; but in the centre, they were of a dark colour; and on the surfaces towards the bones they, as well as the bones themselves^ were in a state of incipient ulceration, but with- out any appearance of pus having been secreted. All the other intervertebral cartilages were, throughout their whole substance, in a natural conditioni and the bones of the vertebrse every where had their na- tural texture and hardness. On laying open the theca vertebralis, the membranes ( 267 ) of the spinal marrow were found adhering together, behind the space between the fo.urth and fifth dorsal vertebrae. The above cases, and the circumstances before mentioned, seem to warrant the conclusion, that, in many instances, caries of the spine has its origin in an ulcer- ation of the intervertebral cartilages be- ginning in their centre, and extending to their circumference, and afterwards aflect- ins; the bodies of the contiguous vertebrae. But there is no doubt, that there are other cases, in which caries of the spine has its origin in the bones themselves. The bodies of the yertebrse are liable to that peculiar disease of the cancellous structure, which occurs in the articulating extremities of other bones, and there in no reason, why it should not produce the same results here, as elsewhere. The fol- lowing cases, the first of which occurred in St. George's Hospital, and for the se- cond of which I am indebted to my friend Mr. Henry Earle, of St. Bartholomew's Hospital, aiford examples of this disease, and of the extensive mischief to which it may give rise. CASiE Lli. Edward Griffiths, forty-live years of age, was admitted into St. George's Hos^ pital on the 15th of April, 1818, on account of an abscess, which presented itself in the left groin. He said, that about four months before his admission, he had been seized Avith pain in the loins and that the tumor in the groin had shewn itself about six weeks after the commencement of the pain. He was directed to remain constantly in tbe horizontal position; and in a short time the tumor formed by the abscess ( 269 ) in the groin disappeared, and another shewed itself over the left os innomi- natum. On the 15th of May, this ab- scess was opened, and about forty ounces of pus were discharged. After this, he gradually sunk; and died worn out by a profuse suppuration on the 19th of August following. On dissection, it Avas found that the cancellous structure of all the dorsal and lumbar vertebrae was of a dark red colour, and softer than natural, so that they might be cut with a common scalpel, or even crushed by the pressure of the thumb and fingers. Tlie opposite surfaces of the bodies of the second and third lumbar vertebrre, and of the cartilage betwen them, at the posterior part, were extensively destroyed by ulceration. Anteriorly, the bones and the intervertebral cartilage were entire, and the latter was in a perfectly natural state, but the bones throughout were of a dark and ahuost black colour. ( 270 ) On one side of the body of the twelfth dorsal vertebra, there was a small ulcer- ated spot, forming an opening which ex- tended itself into a small cavity in the centre of the bone. This bone was also of a black colour; but the intervertebral cartilages belonging to it, as well as the intervertebral cartilages connected with the other vertebrae, were in a perfectly natural state. The abscess had originated in the ca- rious surfaces of the second and third lumbar vertebrEe, and had extended itself ibehind the left psoas muscle, as low as the upper and anterior part of the left thigh, where it made a turn backwards on the inside of the tendon, and thus made its way to the place where it was opened on the posterior part. The ribs were throughout unusually vascular and brittle, so that they might be broken by the slightest force. There were vomicae in the lungs, and tubercles in the liver. ( 271 ) CASE LIII. Henry Shaw, seventeen years of age, eonsulted Mr. Earle in N^ovember, 1816, on account of a complaint, which had begun about three months before, and of which the following were the most re- markable symptoms. He had frequent attacks of pain in the head, attended with giddiness. Occa- sionally he had fits, in which he was for a short time insensible, with a spasmodic action of some of the muscles of the neck. The right eye was amaurotic, and there was constant tinnitus aurium. His mental faculties were for the most part unimpaired. By Mr. Earle's directions, he was cup- ped; purgatives were administered, and he was kept under the influence of mer- cury during six weeks, at the end of which time his symptoms had nearly disappeared. About the end of May, 1817, he went ( 272 ) oa a visit into the country, and while there he one day tripped and fell in crossing the room. Another set of symp- toms now sliewed themselves, for which he was brought to London. At this time he had pain in the back and in the right side, shooting in the direction of the costal nerves. He was subject to severe cramps in the stomach, his bowels were irregular; and he breathed with difficulty. He had cramps in his lower limbs, and his locomotive powers were impaired, though there was no actual pa- ralysis of the muscles. His general health was much deranged. On examin- ing the spine, Mr, Earle discovered a curvature, of which the convexity was turned backwards, occupying about the three middle dorsal vcrtebra3, and this was attended with a considerable alter-» ation in the form of the chest. He was now removed into St. Bartholomew's Hospital, where Mr. Earle directed him to remain constantly in the horizontal ( 273 ) position, and an issue was made with caustic on each side ot* the spine. In a short time lie lost the cramps of his lower extremities, hut his general health continued to fail, and the difficulty of breathing increased. In the middle of December he quitted the hospital. The exertion of being moved seemed to aggravate the disease. He was seized with numbness of the left leg and thigh; the dyspnoea became worse; and he sunk and died in con- vulsions on the 23d of December, 1817. On dissection, the arachnoid mem- brane was found opaque and thickened. A large tumor, of almost cartilaginous hardness, occupied the anterior lobe, and a similar one the posterior lobe, of the right hemisphere of the cerebrum; and a third tumor occupied the greater part of the right lobe of the cerebellum. The ventricles were distended with water. The riglit lung Avas studded with tuber- cles, and adhered universally to the pleura 36 ( 274 ) costalis. A large abscess occupied the posterior mediastinum, at the bottom of which, tlie bodies of two of the vertebrae, together with the intervertebral cartilage between them, were found nearly de- stroyed by ulceration. The other inter- vertebral cartilages were in a natural state, but the bodies of the vertebrae were soft, and many of them were beginning to ulcerate. The ribs were porous, and their cancelli were filled with a curdly matter; and they were soft, so that they might be easily divided with a common scalpel. Four of the ribs were separated from their attachment to the sjiine, and were ulcerated as far as their tubercles. There is no reason to doubt, that in these cases, the bones were the parts primarily affected. Other cases occa- sionally are met with, which at first ap- pear to be of a similar, but which are, in reality, of a different nature. Where an ( 275 ) abscess has formed in the neighbouring soft imparts; or, where there has been a large aneurysm of the descending aortaj and wliere a tumor produced by one or other of these causes, or in any other way, has long pressed on the bodies of the vertebrae, the bones become ulcerated, but not the cartilages between them, and the former are ultimately in a greater or less degree consumed, while the latter remain projecting almost of their natural size. In such cases, where the spine is carious, in consequence of disease begin- ning external to it, the symptoms are not the same as where it has begun in the spine itself. For the most part, the affection of the spine is not suspected during the patient's lifetime. After death, the bones are found of their natural texture and hardness; and it is easy to trace the ori- gin of the disease in the neighbouiing soft parts. K 276 ) Sect. II. On the Stjmptoins of Carles of the Spine. As these two diseases of the spine correspond in this respect, that they ter- minate in a more or less extensive caries, it may be expected that there must be a certain degree of resemblance in the symptoms which tliey produce. Tliis re- semblance is indeed greater than where the same morbid affections take place in other joints. I suspect, that that disease, "which has its origin in the cancellous structure of the bones, is more imme- diately followed by suppuration, than that which commences in the form of ulceration of the intervertebral cartilages; and that the former seldom occasions a destruction of the vertebra to so great an extent as the latter. But farther tlian this, nothing, which I have hitherto ob- served enables me to point out any cir- cumstances, in which the symptoms of ( 277 ) these different diseases differ; nor do I believe (however desirable it may be to do so), that it is possible, in the present state of our knowledge, to distinguish them from each other, with any degree of accuracy, in the living person. Perhaps future observations may tlirow light on this important subject. In the mean time, when I speak of the symptoms of caries of the spine, it is to be understood, that the observations which I make, are (as far as I know) applicable to either one or other of those diseases, in which the caries originates. It is evident, that two orders of symp- toms may be the result of caries of the spine: — Ist, Those, Avhich are the imme- diate consequence of the morbid condition of the vertebrae themselves, and of the intervertebral cartilages. 2dly, Those, which arise from pressure on the spinal marrow, or from irritation propagated in some way, or another, to this important part of the nervous system. I believe, it ( 278 ) will be found, that, wlien the disease is situated above tlie lumbar region, it almost constantly happens, that these two gets of symptoms are combined, whereas when the vertebi-ai of the loins are alone affected, the latter set of symptoms are generally w anting. Perhaps, this may be accounted for, partly from the greater magnitude of the bodies of the lumbar vertebrsej in consequence of which, a much more extensive caries is necessary to produce the same quantity of incur- vation here, than elsewhere; and partly, from the circumstance of the spinal mar- row here terminating in the bundle of nerves belonging to the lower extremi- ties; which possess a different structure, exercise different functions, and are pro- bably of a less susceptible nature than the spinal marrow^ itself. Caries of the lumbar vertebrse usually occasions a pain in the loins, which, after a longer or shorter period of time, is followed by an external abscess, shewing ( 279 ) itself in the groin, or in some other situa- tion, and it constitutes one of the diseases, which are confounded with each other, under tiie name of Psoas or Lumbar ab- scess. The symptoms, which are produced in those other cases, where caries is followed by curvature of the spine, and affection of the spinal marrow; have been described at length in the works of former writers, (more especially in the able and eloquent dissertations of Mr. Pott,) and it is unne- cessary for me to repeat what has been al- ready given to the world by others. I shall therefore only advert to certain points in the history of the disease, which some of my own observations may tend to illustrate. The curvature of the spine, which this disease produces, cannot take place until the caries has made considerable pro- gress; and hence, although it furnishes an excellent diagnostic mark of the disease in its most advanced stage, it affords the ( 280 ) surgeon no assistance whatever at tliat early period, when the diagnosis is of the most importance. Previous to the ap- pearance of the curvature, the symptoms are not unfrequently very equivocal; so that the real nature may often be over- looked by a careless practitioner; and sometimes even by the most accurate and minute observer. A pain, and some de- gree of tenderness in that part of the spine, where the disease has begun; a sense of constriction of the chest; an uneasy feeling at tlie pit of the stomach, and of the whole abdomen; a disturbed state of the functions of the alimentary canal, and of the urinary bladder; a sense of weakness and aching, and occasional cramps of the muscles of the extremities; one or more of these symptoms, accord- ing to the part of the spine, which is af- fected, and other circumstances, are in most instances met with before the form of the back has undergone any alteration. But it is obvious, that symptoms very ( 281 ; similar to tliese may arise from other causes; and hence practitioners are liable to be led into error. Many cases also occur, in which these symptoms have been so slight, that, although the patient has recollected them afterwards, he did not experience sufficient inconvenience at the time to be induced to notice them, •and I have even known some instances, in which they are altogether wanting, so that there has been no suspicion of any complaint existing previous to the actual discovery of the curvature. In the greater number of cases, which have come under my observation, the curvature of the spine has been first no- ticed about six months after the com- mencement of the other symptoms. In one case only the interval was as long as two years. In general, the curvature is at first only just perceptible; and by degrees it becomes more distinct. In one instance, ike patientj who had made no previous 87 ( 282 ) complaint, immediately after some sliglit exertion, experienced a sudden pain, as if something had given Tvay in the back, and immediately afterwards lost the use of her lower limbs, and observed that the spinous process of one of the lower dorsal vertebrse made an angular projection. In another patient a similar circumstance occasioned the same sensation, and was followed by numbness of the legs and thighs, and paralysis of the bladder; but not by any evident curvature. Of course, we must suppose, that the disease had been making progress, before the occur- rence of the trifling accident, which first induced its symptoms. The distortion of the spine in these cases is usually of a peculiar kind, and such as nothing can produce except the destruction of the bodies of one or more vertebrte. The spine is bent forward, so as to form an angle posteriorly; and although the destruction of the vertebra may be the sam^, it is more obvious in ( 283 ) isome parts of the spine, than it is in others. For example, the spinous pro- cesses in the middle of the back being long, and projecting downwards, the ele- vation of one of these must occasion a greater prominence, than that of one of the spinous processes of the neck, which are short, and stand directly backwards. Curvature of the spine in the direction forwards, may arise from other causes, as a weak condition of the muscles, or a rickety afl^ection of the bones. In ge- neral, in such caseSj the curvature occu- pies the whole spine, which assumes the form of the sescment of a circle. At other times, however, it occupies only a portion of the spine, usually that, which is formed by the superior lumbar, and inferior dorsal vertebrae; as I have ascer- tained, not only by examinations during life, but by dissection after death. Here the curvature is always gradual; never angular; and thus it may be distin- ( 284 ) guislied from the curvature arising from caries. Nevertlieless, I am satisfied, that those different kinds of curvature, arising from different causes, have frequently been confounded with each other; and that some of the cases, which have been pubUshed as examples of caries of the spine, and in which, it may at first be a matter of surprize, that so complete and so speedy a cure has been effected, have in reality been cases of an entirely differ* ent malady.* I believe it is generally supposed, that the lateral distortion of the spine arises from causes, which are independent of caries. This rule however must not be admitted without some exceptions. A slight degree of lateral curvature is, in some instances, the consequence of caries. * Some excellent observations on this subject are published by Mr. Earle in the Edinburgh Medical Journal for January, 1815. I 285 ) Iriiis was observed in one of the casei related in tlie last section, and the ex- amination of the morbid appearances explained in what manner the lateral curvature was produced; that is, by the bodies of the vertebrae having been de- stroyed on one side, to a greater extent than on the other. Mr. Copeland* has observed that the symptoms, which take place in this dis- ease in consequence of the affection of the spinal marrow, are not always con- fined to the parts below, as might be expected, but that tliey take place also in those parts, which are above the ulcer- ated vertebrae* This is an important ob- servation, and I have had opportunities of ascertaining it to be correct. When the disease has been situated in the mid- dle or lower part of the back, I have not indeed known the muscles of the upper * " Observatioivs on the Symptoms and Treatment of Diseased Spine,'' he. by Thomas Copeliuid. ( 286 ) extremities to be paralytic, but it is not uncommon under these circumstances, for pains in the arms to be connected ^vith a 'paralytic affection of the legs and thighs. I haye already observed, that there is reason to believe, that suppuration takes place at an earlier period, in those cases, where the disease has its origin in the cancellous structure of the bone, than where it begins in the intervertebral car- tilages. It is remarkable in some cases of this last description, to how great an extent ulceration will sometimes proceed, without the formation of abscess. I have known as many as three bodies of yerte- brse completely destroyed, and the disease to have lasted many years, and yet matter has not been formed; a fortunate circum- stance for the patient, as the chance of his recovery is much greater under these, than it would have been under the oppo- site circumstances. In whatever part of the spine the disease is situated, the ab- ( 287 ) ^cess is likely to present itself in tlio upper and anterior part of the thi^li; but it may make its way in various other di- rections. Sometimes it takes the course of the spermatic cord, and forms a tu- mor projecting through the abdominal ring; such as a superficial observer might readily mistake for a hernia. In one case, which I had an opportunity of examining after death, the abscess had penetrated into the theca vertebralis, and the whole of the, spinal marrow, from its origin to jts termination, was bathed in pus. Sect. III. On the Treatment, For reasons similar to those, which pre- vented my entering at length into the his- tory of the symptoms, which occur in cases of caries of the spine, I shall make but few observations on the methods of treat- ment, which may be employed for its re° ( 288 ) lief. Those, which have heen principally recommended, are, first, a state of perfect quietude in the horizontal position, con- tinued for a long period of time; and, se- condly, the establisment of issues made with caustic in the neighbourhood of the affected vertehrse. I should imagine that no one will be bold enough to deny the prudence, and that but few will deny the absolute neces- sity, of the first of these remedies. While the patient is in the erect position, and the weight of the head and other superincumbent parts is pressing the ul- cerated surfaces one against the other, it is not likely that the progress of the ul» Deration can be checked, and it is highly probable that suppuration will be induced. Concerning the advantage to be derived from issues, there may perhaps be a greater difference of opinion: and I am well aware, that some of the most ex- pej'ienced practitioners of the present day, estimate their value at a low rate, ( 289 ) It is not, however, very easy to suppose that 3Ii'. Pott, and others, whose opinion carries with it mucli authority, should have been mistaken so Car as to persevere during a series of years, in the employ- ment of a remedy, which was wholly in- efficacious. If issues are of service, uhere the cartilages of the hip or knee are ul- cerated, analogy would lead us to expect, that they may be useful also, where a cor- responding disease has taken place in the joints of the vertebrre, and my own ex- perience has certainly tended to confirm this expectation. I have known instances of patients, who have been under precisely the same circumstances with respect to rest, and whose symptoms have been manifestly and considerably relieved either immediately, or in a short time, after the issues had been made: and where the caustic has been occasionally applied to the surface of the issue for the purpose of keeping it open, other patients have in- formed me that " they have uniformly 38 ( 290 ) found themselves better in a few hours after eueli application." At the saiue time it must be acknowledged, tiiat some cnses occur, in which the caustic issues st'nitude. that the patient was inducted to consent to the removal of tbe limb. Mr. Thomas, un- der whose care this lady was, performed the operation, and allowed me afterwards to examine the amputated joint. ( 302 ) The tumor occupied the upper part of the knee, beginning at the edge of the cartilaginous surface, and extending about three or four inches up the lower part of the thigh. It was interposed between the muscles and the bone of the thigh, so that the former were seen expanded over it. It wa& of a greyish white colour; composed of fibres of a gristly semitransparent substance, with osseous matter intermixed w ith it, and about two inches in thickness on each side of the femur. At the upper part it was seen distinctly originating in the periosteum; at the lower part, the periosteum could not be traced, and the structure of the bone was continued into that of the tu- mor. The cartilages and ligaments of the joint were free from disease. On the external surface of the synovial mem- brane, unconnected with the diseased structure above, there were three or four flattened bodies, each of about the size of a kidney bean, of a white colour, and ( 303 ) of a texture somewhat softer than that of cartilage. The synovial membrane itself was free from disease. There can be no doubt that in this case, the original disease was the osteo- sarcomatous tumor, originating in the periosteum of the femur. The circum- stance of the other tumors being found connected with the synovial membrane, although the intermediate parts were, to all appearance, in a healthy state, is re- markable, but something corresponding to this may be observed in other diseases. For example, when a scirrhus has formed in the gland of the breast, it is not un- usual to find small tubercles of a similar structure in the skin over it, at various distances from each other, although the intermediate adipose substance, as well as the portions of skin between the tu- bercles themselves, exhibit no marks of disease, I met with another case, in which the patient appeared to labour under an enormous tumor of the hip. It was as- ( 304 ) certained by dissection, that the hip itselfi was free from disease, and that the en- largement was formed by an osteo- sareomatous growth from the periosteum of the upper extremity of the femur.* 6. The effects pf gout on the joints are very remarkable. The cartilages ai'e ab- sorbed; the exposed surfaces of bone are partly, or entirely, encrusted with a white earth^^ matter, which 1 conclude to be urate of soda; and sometimes they have the appearance of being formed into grooves, as if they had been worn by their friction on each other. In some cases repeated, and long-continued attacks of gout occasion complete ancliylosis. * Mr. Russel in his " Treatise on n Sc. EXPLANATION OF THE PLATEB. Plate I. Fig. 1. A part of the synovial mem- brane of tbe Einee in a state of inflam- mation, and lined with coagnlable Ijmph. This is introduced, piincipally, with a view to the appearances being contrasted with those in Fig. 2. and Jig. 3. which represent the cut siiriaces o(* two small portions of a synovial membrane, which had nnder- gone the peculiar morbid alteration of structure, which has been described in the third chapter. Plate II. A knee-joint, the synovial membrane of which had undergone the same alter- ation of structure. In order to make the drawing, the joint was cut into at its ( 326 ) upper and lateral parts, and the anterior portion of the synovial membrane was turned downwards, so as to expose the in- ternal surface. A, The cartilage covering the condyles of the femur. B, The cartilage lining the patella. C C C, The inner surface of the dis- eased synovial membrane. D D, The cut surfaces of the skin and adipose substance. Plate III. The joint of the hip, affected with ul- ceration of the cartilage, from a child seven years old. The greater part of the synovial membrane and capsular liga- ment have been removed, so as to ex- pose more completely the interior of the joint. The round ligament, (which was partly destroyed by ulceratioa, where it was connected to the acetabulum) has been torn through, so as to allow of the head of the femur being dislocated. Ila/. ( 327 ) A, A portion of the os innominatum. B, The head of the femur. C, The acetahulum. D, The inner surface of the synovial membrane in a natural state. E, Portions of the hone of the ace- tabulum exposed, inconsequence of the cartilage having been ulcerated. F, A portion of the cartilage covering the head of the femur converted into a fibrous substance. G, The great trochanter. Plate IV. The knee-joint affected with ulceration of the cartilages. The interior of it is exposed in the same manner as in Plate II. A, The femur. B, The tibia. C, The inner surface of the patella, the cartilage of which has been in great measure destroyed by ulceration. J3, The surface of the external con- ( 328 ) dyle of the femur, the cartilage of >yhich is partly ulcerated also. E, The inner surface of the synovial membrane in a natural state. F, The inner Condyle of the femur covered by a substance resembling that of adhesions. Plate V. A portion of the carious spine of a child, to shew the disease originating in the intervertehral cartilages. A, The seat of the curvature, where the bodies of two vertebrse have been destroyed. B, C, The spaces formed by the ab- sorption of the intervertebral cartilages, while the bones have been left entire. Plate VI. The preparation, from which this drawing was taken, is in Mr. Ileavi- side's collection. The history of the case is not known, but the appearances arc P/(if^e, 3. m f^"?^- 'tV<' 7///'^"<• o\ r:?, '^S -, -- . - JM :'""!!# ( 329 ) precisely similar to those, wliich I liave observed in other cases, in whicli caries of the spine has been induced by the pressure of a tumor situated externally to it. Tliis figure is introduced, chiefly, for the purpose of it being contrasted with the figure in the last plate. A, C, The bodies of the vertebrse de~ »lroyed to a considerable extent, while the intervertebral cartilage between them B. remains entire. For the greater number of the draw- ings from which these plates were taken, I am indebted to the kindness of Mr. Howship and Mr. Gaskoin, whose ana- tomical knowledge have enabled them to express the various morbid appearances with peculiar accuracy. THE END, 1 ^Bm>^;.lA«lM»t«P COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the library rules or by special arrangement with the Librarian in charge. =^===== DATE BORROWED DATE DUE DATE BORROWED DATE DUE 1 1 1 1 C28(946)M100 3 RD686 (Brodie Pathol( Ivations Ijoints APR 2 B78^g^ cop. 2 obser- the ^y '9' - mm .