Anthrax or Carbuncle maybe considered as a severe form of boils. It occurs in the plague, and is a characteristic symptom. It appears in the same parts, and apparently from the same causes, as the boil. The tumour is of a more flattened form, slightly elevated above the surface, and frequently of great extent; the base is deeply-seated, hard, and unyielding. The integuments are at first of a bright colour, but afterwards assume a dark-red or reddish-brown hue. The pain is violent and burning. The process of suppuration is very tedious, and the matter that is formed is small in quantity. If the tumour is not interfered with, ulceration occurs in its surface, producing various apertures, through which the matter is evacuated, the discharge is thin and unhealthy, excoriating the neighbouring surface; and the mortified cellular tissue, remaining at the base of the swelling, keeps up the irritation. The extent of a carbuncle is frequently great, both as to width and depth; on the back, or buttocks, it not unfrequently attains an immense size. In one instance, the whole posterior part of the neck was involved; the cellular tissue, muscles, and tendons, sloughed; and the vertebræ were ultimately exposed. In another case, the whole occiput, the posterior and lateral parts of the neck, and the space betwixt the shoulders, exhibited one continuous mass of carbuncle. By making free incisions, procuring early separation of the sloughing parts, and supporting the strength of their constitutions, both patients recovered, though considerably advanced in life.

It seldom occurs in the face or head, and when it does, it generally proves fatal. In a male patient in the Edinburgh Royal Infirmary, aged forty-eight, a carbuncle of the size of a very large orange was situated in the centre of the forehead; by active local and constitutional treatment, he soon got well.

The affection is sometimes attended with typhoid symptoms, rigors, profuse perspiration, nausea, vomiting, disordered bowels, loss of appetite, anxiety, restlessness, difficult respiration, palpitations, faintings, pale-white tongue, low pulse, pale or turbid urine, headache, giddiness, drowsiness, and, in severe cases, with delirium. In old or exhausted patients, the prognosis is unfavourable.

An early and free incision must be made into the tumour; if the swelling is large or extensive, the preferable form of incision is the crucial; the ill-formed matter is thus evacuated, the slough exposed, and more readily allowed to escape. If the mortification of the cellular tissue be extensive, and the sloughs prove firmly adherent, the free employment of the caustic potass will be found of much service, the half-dead cellular substance being thereby completely destroyed, and the surrounding parts stimulated to a new and superior degree of action, necessary for the removal of the mortified parts, and reparation of the breach of surface. Poultices and fomentations may afterwards be employed, followed by the warm-water dressing, medicated or not. The stomach and bowels must be put into proper order by the exhibition of suitable medicines; and the vis vitæ may be still farther supported by the administration of tonics and stimulants. If, after the separation of the sloughs, the exposed surface shall assume an indolent or debilitated action, stimulating dressings, such as turpentine liniment, or elemi ointment may be employed.

Such practice will be found sufficient to procure a speedy and favourable termination of the disease, in this country, where we have not to combat any of those malignant diseases with which carbuncle is accompanied in other climates.

OF INFLAMMATION OF THE MUCOUS MEMBRANES.

Mucous Membranes and the skin are analogous in structure, somewhat similar in function, and sympathise closely with each other in health and in disease. Both are endowed with that peculiar degree of sensibility which enables them to bear with impunity the impressions of foreign bodies; and both are protected from the influence of these bodies by an inorganic covering; the cutis and rete mucosum by the epidermis; the corium of mucous membranes by a laminated epithelium. They are the seat of all excretions, and by them all substances are introduced from without into the system. The capillary portion of the vascular system appears to have somewhat the same arrangement in both; the distribution of blood to the mucous membranes being, however, more copious. At the commencement and extremity of the alimentary canal, they insensibly pass into each other by means of an intermediate structure, of which the prolabium may serve as an example. In particular circumstances, they change into each other, both in appearance and in function. Thus, in prolapsus of the gut or of the vagina, the discharge from the protruded mucous surface after a time subsides, the rugæ disappears, the membrane becomes thickened and indurated, and gradually assumes an appearance exactly resembling that of the skin. In natural paraphymosis, the delicate membrane which, in the healthy state of parts, lines the internal surface of the prepuce, becomes converted into a cuticular covering. In neglected and long-continued excoriation of the nates, the raw surface, which was at first tender and irritable, and discharged a serous fluid, becomes villous, less sensible, and discharges a fluid similar to a mucous secretion. In sinuses also of long duration, the secreting surface becomes changed, so as to resemble a mucous membrane, and the discharge, from being purulent or gleety, becomes mucous, or at least resembles a mucous fluid,

A mucous surface, when inflamed, has for a short time, perhaps, at first, its functions suspended; it then furnishes a secretion, increased in quantity, and but little changed in appearance from the healthy fluid; afterwards the discharge resembles purulent matter, and is termed muco-purulent. When, however, the inflammation is violent, the discharge becomes bloody, or is altogether suppressed, and the membrane is thickened. Inflammation of a mucous membrane is very apt to spread with great rapidity, in this respect resembling the corresponding affection of the skin. It is attended with a sense of itching, and a burning pain. This pain is much increased by the muscles surrounding the parts being thrown into action, as in expelling their contents, more especially if these be of an acrid quality. The membrane is thickened, and of a spongy appearance; its surface is red, and sometimes covered with flakes of lymph; occasionally it is much softened, and coated with a viscid adherent mucus; and it would appear, in many instances, that, in acute inflammation, the membrane is generally softened, whilst it becomes indurated from chronic inflammatory action. When the inflammation is violent, and consequently rapid, considerable quantities of lymph are effused either on the surface of the membrane, or into the submucous tissue: and the lymph subsequently becoming organised, the membrane is much thickened, and a contraction is the consequence. The functions of a part lined with mucous membrane are more or less deranged, in consequence of the vitiation of the secreted fluid.

In inflammation of this tissue, metastasis is also apt to occur, from one part of the membrane to another, and from the membrane to the external surface. Cynanche, for instance, often follows upon erysipelas of the face and scalp, and vice versâ.

The passages, the internal surfaces of which are invested by a mucous membrane, are those subservient to respiration, nutrition, generation, and the urinary secretions; in other words, the mucous surfaces are the Pneumogastric and the Genito-urinary. Their particular diseases will be treated of hereafter.

OF INFLAMMATION OF THE SEROUS MEMBRANES.

On such an extensive subject it is unnecessary to enter fully; not that the inquiry is uninteresting, or that a knowledge of the diseases of the internal cavities, and the mode of treating them, is not required of the surgical practitioner before he can enter into practice, with safety to his patients and comfort and satisfaction to himself, but we have a very important class of diseases to bring under review in a limited space, and it is properly the province of others to treat of internal disorders, and to describe the best mode of alleviating or curing them. It is, however, the duty of the surgeon to treat the inflammatory affections of some of the serous membranes, and the consequences of inflammatory action in most of them; and it is therefore highly necessary that he understand the symptoms, progress, and consequences of such actions. The affections of the serous membranes are principally under the management of the physician; but they not unfrequently follow wounds and surgical operations, and the diseases of several of them are purely surgical. Inflammation of a serous membrane is attended with heat and pain, aggravated by motion of the parts and by pressure; the natural secretion is increased in quantity, the process of exhalation being incited, and that of absorption weakened; the serous fluid accumulates. The secretion becomes altered in quality, and assumes a milky appearance; lymph is effused, generally mixed with purulent matter, and floats in the fluid, or adheres to the surface of the membrane, which is rough and flocculent. The adherent lymph becomes organised, being penetrated by numerous bloodvessels; and thus the original membrane is, in many instances, much thickened, chiefly from the addition of new matter, though also from enlargement of its bloodvessels and opening out of the primitive tissues, principally the subserous cellular. When inflamed serous surfaces, which have been altered, both in texture and function, in consequence of inflammatory action, remain for a short time in contact with each other, lymph is effused and penetrated by bloodvessels from each surface; thus the new deposit is organised, and forms a medium of connection. By this process the parts are intimately united to each other, and consolidated into one mass; or are merely approximated, and joined, at one or more points, by portions of lymph, in some cases thin and narrow, in others extensive and of considerable thickness; the adhering bands either extend in a straight direction, from one surface to another, or interlace, forming a sort of network. After adhesions of various kinds have been formed, they are often lengthened and attenuated in consequence of the motion of the parts, as is particularly the case with adhesions between the pleura costalis and pulmonalis. When they have been of considerable duration, they often resemble the original membrane from which they were deposited, becoming thin and transparent, smooth on their external surface, and furnishing a serous secretion. Not unfrequently, inflammatory action in this tissue terminates in suppuration; and the pus, secreted by the membrane, accumulates in the most dependent part of the cavity. By collections of matter, whether serous, sero-purulent, or purulent, within a serous cavity, the functions of the contained viscera are deranged, much impeded, and in many instances morbid actions are excited in them. The inflammation, whether it terminates in resolution, or proceeds to serous effusion, adhesion, or purulent secretion, is attended with constitutional disturbance, and the symptoms are proportioned to the original intensity of the action, and the extent and kind of its termination. The effusion of lymph, and consequent adhesion, is, however, in many circumstances, a highly salutary process, as in wounds and injuries of the hollow viscera: effusion of their contents being thereby prevented, and the patient being saved from the danger attending violent inflammation of those cavities and their coverings, caused by the escape of a greater or less quantity of irritating extraneous matter. Purulent collections also, in the solid internal viscera, are thus allowed to discharge themselves externally. The nature, symptoms, and consequences of inflammation of serous membrane, will be more fully considered under the diseases of particular parts.

OF INFLAMMATION OF TISSUES COMPOSING THE ARTICULATIONS.

Inflammation of the synovial surface occurs in consequence of wounds, bruises, or sprains, and often from exposure to cold; from the latter cause, the knee and elbow joints most frequently suffer, as they are generally more exposed to its influence, and not so well covered with muscular substance as the others. Constitutional diseases, such as certain fevers, are followed sometimes by effusion of serous fluid into joints. Purulent matter is also deposited in joints during certain forms of suppurative fever; and this is attended by rapid change of structure.

There is heat, throbbing, pain, and swelling of the part, sometimes redness of the surface, and great constitutional disturbance; the symptoms and appearances, however, vary much, according to the extent of the joint which is involved. When part of the capsule is affected, the inflammation spreads rapidly over all the surface; the synovial membranes resembling the serous in this respect, as well as in healthy structure and function. Like the serous, too, they are shut sacs, are smooth on their surface, and furnish a secretion, the synovial, for facilitating the motion between opposing surfaces; it is, however, somewhat more glairy than the serous. Neither, in their healthy state, are possessed of much sensibility, nor are ligaments, tendons, tendinous sheaths, and bursæ, which two latter textures resemble in every respect the synovial; when inflamed, they become most exquisitely sensible. The incited action of the bloodvessels is followed by increased discharge, which is less glairy and albuminous, partaking more of the serous character. When the incited action soon terminates, and the activity of the absorbents is diminished, the fluid accumulates within the joint, producing Hydrops Articuli. This accumulation of fluid in joints may take place without being preceded by any apparent inflammation, and may remain a long time without any visible change of structure in the membrane. The knee is more frequently the seat of dropsy than any other joint.

When the action is more violent, and is not actively opposed, lymph is effused on the inner surface of the membrane, or is deposited amongst the ligamentous and cellular tissues external to the joint, in consequence of which, the membrane and external ligaments become thickened, and of an almost cartilaginous consistence. Serum is effused into the more superficial cellular tissue, filling up the hollows around the joint, concealing the protuberances of the bones, and producing a globular swelling. The articulating surfaces become ulcerated, and matter forms within the capsular ligament; or the pus is deposited exteriorly to the joint, and gradually approaches the surface. But although ulceration is so prone to occur in the cartilages, the synovial membranes do not readily take on this action, unless from the progress of matter, formed within the joint, towards the surface. The synovial lining of the bursæ and sheaths of the tendons are extremely indisposed to ulcerate; and it may be remarked, that, while suppuration without ulceration is common in the synovial membranes, the cartilages, on the other hand, afford frequent instances of ulceration without suppuration, of which more particular mention will be made in the sequel. The cartilage is occasionally swelled and softened where the disease has long existed.

Along with ulceration of the cartilage, a portion of it may become dead, or either state may occur separately; and in many cases, the substance of the bone also becomes affected, of which two classes of cases may occur, viz., great inflammation on the articular surface of the bone, with separation of the cartilage by the ulcerative process in this situation; and inflammation of the medullary web, leading to atrophy of the cancelli, collections of pus therein, or even death of a portion of the spongy texture of the bone, as will be more particularly treated of in the chapter on diseases of the osseous tissue. These changes often compose the primary disease, and to them the affections of the synovial membrane and other parts succeed.

Such occurrences are attended with alarming disturbance of the constitution, with fever, and even with the most threatening and dangerous symptoms, such as delirium and coma. If the patient survive, and the matter be evacuated from the joints by openings into its cavity, hectic fever is almost certain to supervene.

An opinion has been broached lately by Mr. Key, that the ulceration of cartilage was consequent upon the increased vascularity and thickening of the synovial membrane, that the cartilage, in fact, was removed by the action of the vessels ramifying in the membrane, and the prolongations or fringes from it in its diseased condition. Occasionally these fringes correspond, in a remarkable manner, to the breach of surface in the cartilage; but again, ulceration is frequently met with far removed from the membrane. It is also seen, in cases where an opportunity is afforded of making the examination in the earlier stage of disease, that ulceration exists to some extent whilst the synovial membrane is unaffected. And certain cases, in which the cartilage is affected with hypertrophy, and the common form of atrophy of this part in old people, are altogether adverse to Mr. Key’s views. When ulceration takes place at a point removed from the attachments of the synovial membrane, it appears to proceed more frequently from the attached than from the free surface of the cartilage; then the adventitious membrane occupying the rugged spaces, and which under the microscope appears highly vascular, is connected apparently with the medullary web.

In acute inflammation of the synovial membrane, and in cases where the cartilage is ulcerated, the pain is very intense, and the spasms of the limb most distressing. This happens when the surface is ulcerated, and perhaps to no great extent. We know that in the horse an ulcerated hollow in the cartilaginous covering of the navicular bone, not so large as to contain a grain of barley, will cause such lameness and suffering as to render the animal so affected perfectly useless. If he is not destroyed at this stage, as many valuable animals have been, the mischief extends, and terminates in extensive disease of that and the neighbouring bones and articulations. It is different if the disease commence, as it sometimes does, in the human subject, in the cancelli of the bone, and on the attached surface of the cartilage, the free surface remaining some time entire and smooth. When the synovial membrane is primarily affected by chronic disease, the pain is in general trifling, often not complained of, and swelling of the part, from effusion, into the joint or neighbouring bursæ, first attracts attention, after it has existed, perhaps, in a slight degree, for a considerable time. The joint is stiff, and pain is experienced from extensive motion; on this account the patient is disinclined to use it, and it is soon tired by the slightest exertion. The swelling becomes more solid, though still remaining elastic, and the feeling of fluctuation diminishes. Effusion of lymph follows that of serum, the latter having been absorbed; the motion of the joint is still further impeded, and the articulation is distorted; the patient keeps the limb in the most easy position, generally that of partial flexion, in which it becomes almost immovably fixed. The cause of the flexed position, which is almost pathognomonic of knee disease, being preserved, seems to be that the limb is insensibly brought into it in order to take the pressure off the interarticular apparatus, the ligamenta mucosa and alaria,—these swell—the muscles of the hamstrings get contracted from habit, and a difficulty, even after the disease is completely subdued, is often enough experienced in procuring complete extension. The muscles, from disuse, shrink, the adipose substance is absorbed, the shafts of the bones also are diminished in size, get into an atrophied state, as the phrase is, and thus the whole limb is rendered slender and wasted, so as to make the swelling of the diseased articulation still more conspicuous. The bones are softened, and the muscles are of a white colour, as in the limbs of the paralytic or bedridden, and resemble more cellular than muscular tissue. The wasting of the muscles and loss of power often precede the appearance of disease; this is frequently observed in the shoulder-joint, the deltoid shrinking, and almost disappearing, before any disease in the articulation is suspected by the patient. Not unfrequently, also, this wasting occurs without obvious cause, or any affection of the joint. When the disease is advancing, the patient may feel no acute pain, but merely a reluctance to use the limb; and from this, if long continued, the muscles, and afterwards the bones, become wasted. Wasting of the limbs in children, often of one of the lower, frequently arises from disorder of the bowels, and the irritation and debility attendant on teething. This must be distinguished from the wasting accompanying diseased joint. The history of the case, the period at which the weakness of the limb was observed, and its appearance, will lead to a correct diagnosis.

The swelling is often irregular, being more protuberant at one part than another, from the fluid or the addition of solid matter being accumulated where the least resistance is afforded; but the slighter inequalities are generally filled up by œdema of the cellular texture. As the disease proceeds, matter forms in the joint, and is often attended with great pain and fever; or the pus is effused into the bursæ, into the surrounding cellular tissue, or into the filamentous tissue amongst the tendinous sheaths of the muscles in the neighbourhood; being allowed to remain without an outlet, it at length communicates with the cavity of the joint. Portions of the cartilages are absorbed, though this, as already noticed, may occur at the very commencement of the disease; the subjacent bone becomes affected by ulceration, or perhaps its vitality is partially destroyed. When matter has accumulated, a portion of the capsular ligament generally ulcerates, the pus escapes, and is ultimately discharged externally.

When the disease begins with swelling, which is of a chronic character, and produces but little inconvenience, and when the more urgent symptoms supervene after the swelling has continued for a considerable time, there is every reason to suppose that the disease has originated in the synovial membrane, or perhaps in the osseous cancelli, and this is generally met with in poorly fed and strumous subjects. But when the first symptoms have been pain and stiffness of the joint, without change of its appearance, and when the swelling has occurred after these symptoms have been of some duration, then it is probable that the cartilages are the primary seat of mischief. For the most part, however, the symptoms have a general resemblance in most chronic affections of the joints, and all the apparatus is sooner or later involved. When the cartilage has been extensively absorbed, a grating sensation is felt in moving the articular surfaces of the bones upon each other. In consequence, also, of the softening and disorganisation of the lateral and other ligaments, the affected articulation at length becomes unnaturally loose, which is owing in some measure, also, to the muscles being wasted and paralysed from pain and disuse. At an earlier stage of the disease, the joint may be rigid from deposition of lymph into the contiguous cellular tissue, and contraction of the muscles.

Purulent matter not unfrequently collects in the substance of the bones, which in all cases ultimately become softened in a remarkable manner. In many subjects, without actual disease of the osseous tissue, the heads of the bones are so altered in consistence, are so deficient of earthy matter, as to be easily cut with a knife. It has been a matter of dispute, whether, in this affection, the articulating extremities of the bones are enlarged or not; and the supposition that they are always more or less increased in size, or hypertrophied, has arisen from the extensive effusion and indurated state of the soft parts being mistaken for this enlargement. In the first stages of the disease, they are seldom, if ever, enlarged; but when ulceration of the bone has occurred, new osseous matter is deposited to a greater or less degree in the neighbourhood of the ulcer,—an attempt by nature towards a cure, but too often an ineffectual one. The bones, in strumous subjects, are often much enlarged, from collection of purulent matter in their substance giving rise to a sort of spina ventosa. I removed the upper extremity of a boy lately on account of extensive disease about the elbow. The ulna to near the wrist was swollen enormously by purulent collections in its medullary canal. In cases when the whole of the articulating extremity of the bone is not enlarged, still that portion which is more immediately concerned in the articulation is often considerably expanded.

Frequently when the knee is the seat of the disease, the lymphatic glands in the groin are enlarged; and when the elbow or wrist joints are affected, there is often a similar enlargement of the glands in the axilla: such glandular tumours have not rarely been confounded with those accompanying malignant disease, and measures which were absolutely necessary for the salvation of the patient, have thus been delayed or neglected.

When the disease is extensive, and has endured for a considerable period, hectic fever supervenes, and is aggravated after the abscesses give way. The patient becomes much weakened and emaciated, and loses his appetite; the pulse is rapid, with night sweats, diarrhœa, &c.; and from a continuation of the hectic cause, the life is endangered. In some cases, however, the health is restored, and the disease abates spontaneously; in others, the disease is arrested, and a complete cure accomplished, by the careful employment of such means as will be afterwards mentioned.

The appearances produced by inflammation and consequent disease of the synovial membrane, are the following. In the first stage, the internal surface of the capsular ligament, and the rest of the synovial membrane, is found of a red hue, its formerly colourless vessels being now made apparent, from enlargement and consequent injection with a greater quantity of red blood; and the serum within the cavity of the joint is more abundant than in the natural state. When the disease has been of longer continuance, the membrane is found considerably thickened, its usual smooth glossy surface is destroyed, it is irregularly flocculent, and frequently of a light yellow colour.

The interarticular adipose tissue also seems to be increased in volume, from being infiltrated with a serous fluid, by the discharge of which the diseased bloodvessels may have attempted to relieve themselves. When the inflammation has been intense, or of long duration, lymph is secreted, and deposited on the external surface of the membrane, forming an intimate union between it and the ligaments, and producing thickening of the external apparatus. Or the lymph is also effused on the inner surface of the membrane, to which it adheres and becomes organised; this is generally accompanied by the formation of purulent matter; the organised effusion is often so extensive as to conceal almost the whole of the synovial membrane, excepting portions of its delicate reflexions which invest the articulating cartilages. By the lymphatic deposit, to a less degree, the folds also of the synovial membrane adhere to each other, whereby the motion is still farther impeded, and the pain, when attempted, increased. Occasionally the synovial membrane is found enormously thickened, much softened in texture, and of a brown hue, when the disease has been of a very chronic character. Along with these appearances, serum is generally found effused, in a greater or less quantity, into the cellular tissue exterior to the ligamentous covering. In cases in which the matter has formed and remained long within the cavity of the articulation, the synovial membrane and the ligaments become blended into one soft mass, the internal surface of which is lined with a thick coating of lymph, as in the case of common abscess. If purulent matter is effused externally, and communicate with the joint, the capsular ligament will be found to have ulcerated and given way at certain points, forming apertures, usually of small size, and with ragged margins.

All these appearances may exist without disease of the cartilages or extremities of the bones; but generally they are also affected at the same time. At first the surface of the cartilage is slightly irregular and rough, and the change is not observed, unless on minute inspection. Afterwards the surface is marked with small depressions, which may be numerous, and are surrounded with irregular and somewhat serrated margins. They gradually increase in depth and extent, and the subjacent bone is ultimately exposed at one or more points, as here shown. Often the greater part of the cartilage is removed by absorption; the bone is exposed, opened out in its texture, softened, of an irregular surface, and in some places excavated, containing a thin ichorous fluid; the process of ulceration has also extended to the osseous tissue. Sometimes scales of cartilage of considerable size are either completely detached, having become dead, and been thrown off by the natural process, and are found lying loose in the cavity of the articulation; or they are all but separated, adhering by one or more very slender attachments.

The incipient stage of such disease may exist without the synovial membrane being much, if at all, affected; but when the ulceration has made farther progress, all the articulating apparatus is more or less diseased. It may be here remarked, that the synovial membrane may be affected for a long period, thickened portions may extend over the cartilages, and these may have lymph upon them and yet remain intact.

The cure, resorted to by nature, and in which she may be much assisted by the surgeon, is Anchylosis, ligamentous or osseous. New bone is deposited in the neighbourhood of the disease, and the ulcers become, as it were, cicatrised; the articulating extremities of the bones are joined to each other by a firm osseous matter, either universally disposed or consisting of processes extended between the bones at various points: or again, in consequence of the effusion of lymph into the cellular tissue, and the consequent thickening and induration of that and of the fibrous tissue exterior to the joint, this connecting medium is so strengthened and concentrated as to retain the articulating surfaces in exact apposition; from one, and usually from both, of these changes, the joint is securely fixed and rendered immovable, or nearly so. In complete anchylosis, the cancellous texture of the two bones, after some time, becomes perfectly continuous, so that they in fact constitute but one bone, as seen in cut, p. 84. A very perfect specimen of anchylosed knee joint is also delineated in the cut above. But even after this happens, the disease is still apt to recur from slight causes, the bony or ligamentous union being disturbed or destroyed, and the original disease attacking the parts with fresh activity; abscesses form,—may be extensive both in size and number,—and thereby the health is again undermined. So that the patient, after undergoing much suffering and risk, preserves, perhaps only for a few years, a limb which is almost useless to him, and which must be removed at last. In other cases, the union is permanent, the disease does not return; by care and time the limb is brought into the most convenient position, and proves of considerable service.

The joints are often affected by rheumatic and gouty inflammation; and there are three species of disease, tolerably distinct in their pathological characters, generally attributed to these causes. In one there is a deposit of chalky-looking matter, composed chiefly of super-lithate of soda, on the articular surfaces of the synovial membrane and cartilage, but most abundantly in the cellular tissue outside the joint, an affection in which the cartilage is seldom known to ulcerate. In the second, the cartilages are atrophied, as if worn away by attrition, the articular surfaces of the bone being much modified in shape, more or less denuded of cartilage, and remarkably polished and hard, so as to have been compared to porcelain, as will be described in another section. In the third, the fibrous tissue in the neighbourhood of a joint is primarily affected, the synovial membrane and cartilages not becoming involved till the disease is much advanced. It is not uncommon in the elbow of middle-aged persons who have been much exposed to the atmospherical vicissitudes, and is sometimes attributed to the effect of mercury or syphilis. The periosteum around the articular ends of the bones becomes swelled and painful; the affection is very slow in its progress; abundant deposition of adventitious bone takes place, often in short spiculæ, gradually encroaching around the joint, which ultimately becomes involved. A good specimen is here given. The disease was of twelve months’ duration, and was attributable to rheumatic inflammation supervening upon sprain. The affection involves extensively all the bones composing the articulation.

Although wounds penetrating the larger joints are attended with danger, the synovial membranes are possessed of considerable powers of reparation, and often heal readily after severe injuries. An occasional result of inflammation is adhesion between the layers of the membrane, but this is by no means so frequent as in the serous tissues. The reparative power of cartilage is so low that the best termination that can be expected from the ordinary forms of ulceration, is union between the abraded surfaces. In experiments which have been made on the lower animals, portions of cartilage which had been removed from their joints were never reproduced, but the functions of the part were soon restored by the cut surface becoming smooth. In like manner there is occasionally to be seen in museums a circumscribed indentation in human articular cartilage, as if it had been destroyed by a small ulcer in this situation, which had cicatrized without any reproduction of the destroyed tissue.

ON HYPERTROPHY AND ATROPHY OF THE ARTICULAR CARTILAGES, WITH EBURNATION OF THE SURFACES OF THE BONES.

It has been already observed (at page 68), that the cartilages are occasionally swelled and softened in cases of chronic inflammation; and it now remains to notice instances in which they become hypertrophied or atrophied, apparently without inflammatory action. Although these affections are not likely to come often under the treatment of the surgeon in civil life, yet they are of much importance to the naval or military practitioner, since an accurate knowledge of them will lead him to institute a careful inquiry when a man complains of inability to sustain the fatigue of marching with the burden of a heavy knapsack; and they are of considerable interest in a physiological point of view, because they tend to show the inherent vitality of cartilage, and that it is liable to serious organic changes quite independently of diseased action in the surrounding tissues.

Some examples of hypertrophy of cartilage, principally affecting that of the patella, have been described by Mr. Gulliver, and figured in the third fasciculus of drawings from the Army Anatomical Museum. In these the cartilage is swelled so as to form a ridge across the articular surface of the bone, the hypertrophied part being perfectly smooth, except where its continuity is interrupted by irregular fissures, as if the perpendicular cartilaginous fibres were split into bundles of variable size and shape. These cases occurred in young and middle-aged men who died of pulmonary consumption; and it is probable that the disease would be more frequently found, if it were more frequently looked for, since it does not seem to have been accompanied by any change in the surrounding parts, and would perhaps only be indicated by weakness of a joint rendering it unfit for severe work.

The atrophy, or absorption of cartilage, is so frequently seen in the joints of old subjects, that some authors have been disposed to regard it rather as a physiological than a pathological condition. It is, however, unquestionably a disease; and in the drawings above mentioned, are some specimens of it from a soldier under the middle age. The cartilage seems in the first instance to be opened out in its texture, and numerous little villous processes appear on its surface, often as if its fibres were enlarged after absorption of the substance which connected them. The thinning sometimes takes place in patches, occasionally in grooves, corresponding to the motions of the articular surfaces; the subjacent bone becomes at length completely denuded, and soon presents a polished porcelain-like surface, which is so remarkable that it is commonly known under the name of porcellaneous deposit. It is obvious that, when the disease has proceeded thus far, the joint must become more or less deformed, and its motions considerably impeded. Accordingly, old men are often seen at work with much rigidity of the joints, particularly of the knee, which is frequently projected inwards, from absorption of the cartilage from the outer condyle of the femur and corresponding part of the tibia, with a thinning and degeneration of the inner-articular cartilage into a tissue resembling the cellular.

The hard, polished, and ivory-like appearance of the articular surface, would lead us to suppose that it contained an unusual quantity of earthy matter, yet an analysis by Dr. Davy, here given, shows the contrary.

In many instances where the disease is of long standing, a deposit of adventitious bone takes place around the articular surfaces, and this may occur to such an extent as to produce anchylosis of the joint, the articular extremities of the bone often presenting several irregular depressions, and becoming variously altered in shapes, as shown in the cuts, p. 86.

It is curious that the atrophy of cartilage is generally seen in its early stage to attack the joints in pairs, and to occur also in corresponding parts of the articular surfaces; a fact which coincides with the disposition of caries to appear simultaneously or successively in corresponding molar teeth.

Of the causes of the disease but little is known, although it is generally attributed, like some other obscure affections, to the effect of rheumatism. It often follows in old people upon long disuse and confinement of a limb to one position, as during the cure of fractures. A very valuable specimen was presented to me lately by my friend Mr. Busk, of the Dreadnought hospital ship. The elbow had been apparently subjected to great injury. The radius and ulna had been fractured: the former had united, whilst a false joint had been formed betwixt the portions of the ulna. There is profuse deposit of bone around the elbow-joint, which must have been quite stiff, or nearly so, as regarded flexion and extension; but the end of the radius and corresponding articulation of the humerus are beautifully polished. This polish is not unfrequently seen also upon disunited fractures, as in the neck of the femur. Atrophy of the cartilages has been seen where no rheumatism was ever known to have troubled the patients; and they are more generally disposed to ascribe it to the effect of incessant hard work. At all events it is comparatively rare among women, and in the upper ranks of society; and the wasting often presents very much the appearance which would result from the effects of attrition, as if the wear of the cartilage had not been supplied by a corresponding reproduction. It is probable, therefore, that the affection is attributable to defective nutrition, somewhat allied to certain changes in the cornea, which are known to proceed from this cause, and which are also unattended by inflammation or the formation of pus.

The symptoms of the disease are generally obvious enough in the more advanced stages by the crackling which may be heard when the joint is moved; and in the early stage a grating may be felt by a careful manipulation.

SCROFULOUS DISEASE OF JOINTS.

Affections of the membranes, ligaments, and bones, often occur in persons of weak constitutions, and proceed very gradually. They have been all classed under the general term of white swelling. They most frequently present themselves without any assignable cause, or are attributed to the slightest injuries. The disease generally commences in the cancellated texture of the bones: these are soft and light, and contain in their cells a quantity of caseous or tubercular matter. The softness is attributable to an interstitial atrophy of the bony tissue, as well as to an alteration in the proportion of its constituents; the animal matter being in excess, with a corresponding deficiency of the phosphate of lime. There is an increased vascularity of the medullary membrane, and the cancellated texture contains thin brownish-looking fluid instead of marrow. In cases of disease which has commenced in the cancellated texture, there is hardly any pain at first, and the progress of the disease is remarkably insidious. When the lower extremity is affected, the child is observed to limp; the limb wastes; it appears to be longer, partly from atrophy of the muscles, partly from relaxation of the ligaments and effusion into the joint.

The term white-swelling, which ought to be discarded from surgery, was at one time made to include all the different affections to which joints are liable in weak constitutions—thickening of the parts, with an external colourless swelling—collections of matter about articulations, with or without an external aperture—effusion of fluids into the cavities of joints, or into the bursæ—destruction of cartilage by ulceration, or in consequence of portions becoming dead—absorption, ulceration, caries, or intractable ulceration of the bone adjoining the articulation.

Those under twenty years of age are most liable to chronic affections of the joints, and they occur very frequently in children. Great anxiety is often shown by friends of patients to account for chronic disease of a joint, so as to save their whole generation from the imputation of being tainted with scrofula. It is attributed, sometimes correctly enough, to some injury perhaps trifling; to a sprain, or twist, or squeeze from a tight shoe, or to a bruise from falling; and it is no doubt true, that young or old people of the most healthy constitutions, if thrown out of health from one cause, will present all the appearances of scrofula, and become affected with chronic diseases of the mucous membranes, glands, joints, or bones, from very slight existing causes.

Such affections advance slowly; all the articulations are liable to them; but those which are most subject to the disease are the hip, knee, ankle, and elbow. Of these, the knee-joint is most frequently affected, probably from the greater extent of cancellated and articulating surface. In young persons of unhealthy constitutions, the joints not unfrequently become affected one after another, and superficial abscesses form, terminating in open sores. I was obliged to amputate the upper extremity of a young lady a few days ago, in which a metacarpal bone and its articulation, the entire chain of carpal bones, the wrist and elbow joints, were all thoroughly involved in disease.

NEURALGIC AFFECTIONS OF JOINTS.

The joints, like other parts of the body, are very often the seat of painful affections, without organic disease existing. These neuralgic affections are often connected with, or followed by, hysterical symptoms. They frequently also depend upon derangement of the digestive organs,—upon the lodgement of irritating matters, sordes, or worms in the intestinal tube; and when we reflect upon the extent of the lining membrane, the expansion of nervous filaments, and upon the sympathy which they hold with the whole system, we cannot be astonished at the circumstance. Many cases of supposed hip-disease in children, with the symptoms and some of the signs of it, have come under my notice, which have yielded at once to the expulsion of offending matters or worms. Some affections of joints seem to depend upon gouty diathesis; others are intermittent: at one time the joint complained of is hot, and somewhat swollen; at another cold, and bluish on the surface. In these affections of joints the pain, indeed, is seldom constant: the patient’s rest is not broken; there are none of the violent spasms during sleep, which attend upon certain alterations of structure. The pain is equally complained of when the part is touched with the utmost gentleness, or when a thorough and searching examination is made, when the joint is freely moved, and the articulating surfaces of the bones are forcibly squeezed against each other. The pinching of the skin causes pain. There is seldom throbbing, or heat, or swelling; though, after long continuance of the diseased state, these may supervene to a slight extent. The pain complained of is seldom referred to one point, but to a large extent of the limb; and if the attention is diverted, the examination may be carried to any extent, without complaint being made.

Sir B. Brodie, who has done a great service to the profession by directing attention to these nervous affections in his excellent work, and in his lectures, notices that the knee, when the seat of pain, is generally kept in the extended position, and this is very different from what has been stated to be the position of one affected by organic disease. The tumefaction following upon local treatment, and especially when leeching and counter-irritants have been employed, is sometimes, as he remarks, very perplexing.

This class of diseases generally affects females of delicate organisation about the age of puberty, and in whom the menstruation is irregular. Males in delicate health are also subject to similar affections.

ON GROWTHS FROM THE SYNOVIAL MEMBRANE, AND LOOSE SUBSTANCES IN THE JOINTS.

The synovial membrane is sometimes studded on its inner aspect with loose fleshy or semicartilaginous substances projecting into the cavity of the joint. The entire surface of the membrane is occasionally covered with these bodies, which are of a white or yellowish colour, and very variable in size and shape; the smallest presenting the form of villi not much larger than those of the jejunum, the largest having somewhat the magnitude and appearance of the appendices epiploicæ of the large intestine, while many of an intermediate size approach in appearance to a lemon-seed. In some instances the membrane is only partially pervaded by them, and they are not unfrequently arranged like a fringe around the edge of the articular surfaces. They are generally very smooth on the surface, which appears to be perfectly continuous, if not identical, with the synovial membrane. Their attachment is frequently broad, and occasionally very narrow and pedunculated, often merely filamentous, so that a little further thinning of the part, or slight force acting on the body, would remove it from the capsule, and throw it loose into the cavity of the articulation. The disease has been most frequently seen in the knee, and sometimes in the elbow.

The affection is obscure in its nature; it is slow in its progress; the joint is the seat of pain after and during exercise, probably from the morbid processes interfering with the motions of the articular surfaces. As the disease advances, the joint becomes swelled and elastic, unattended generally by ulceration of the tissues within or around it. In examining the part, when the articular surfaces are moved on each other, it will be found that their motion is more or less interfered with; and considerable irregularity in their action may be felt by the hand placed firmly on the joint during the procedure.

Loose bodies may be found in the articulations, particularly in the knee and elbow, under the circumstances just described; but we often find others of a different structure loose within the capsule, which may be throughout smooth and apparently healthy. These bodies are extremely variable in size, generally rounded or oval, with a polished surface; many of the smallest present the character of fibro-cartilage or cartilage; the larger are often more or less modulated, very firm and gristly, and sometimes contain a considerable nucleus of bony matter. The articular ends of the bones are occasionally more or less misshapen by the formation around them of knobs of adventitious osseous substance.

The disease is common in the knee; and patients frequently go about for years, who will tell you that they have something rolling within the joint, which will often be found on examination to be actually the case. It is obvious that loose bodies in the joint must prove an obstacle to easy progression; and the smaller ones seem to be particularly so, probably from becoming easily entangled by different parts of the articular apparatus.

However difficult it may be to account for the cause of these formations, the means by which they may get within the articulation seems obvious enough. If a small knob of coagulated lymph should form on the inner aspect of the membrane, the point of attachment, as has already been noticed, might gradually become narrower, from the motions of the joint or other causes, till the connection were severed. But there is reason to believe that many of the substances found loose in the joints are formed altogether in the cellular tissue without the capsule; for it is difficult to conceive that they can increase in size, or take on the ossific action in their centre, by an act of independent vitality, after they have been separated from the surrounding parts. Accordingly, dissection has occasionally disclosed loose bodies within the knee-joint, and others of just the same structure outside the synovial membrane, which was however protruded by their pressure, and appeared to connect some of them by a pedicle only, ready to break and allow the foreign body, with its covering of the membrane, to fall into the cavity of the articulation.

AFFECTIONS OF SYNOVIAL POUCHES OR BURSÆ.

Bursæ are lined by a membrane, greatly resembling the synovial in appearance, function, and disease. They are frequently the seat of inflammation of an acute character; but in most instances the action is of short duration, and generally terminates in an increase and accumulation of the secreted fluid. The attendant pain is very severe, and much increased by any motion of the neighbouring parts.

Occasionally a portion of the cellular substance, which is exposed to pressure of motion, as over a prominent portion of bone, assumes the appearance of a bursa, secretes a similar fluid, and is similarly affected in consequence of inflammation. These adventitious bursæ are met with in various situations. Bunion is a good example of such a bursa thickened from long-continued pressure. They are seen on the outer ankles of tailors, on the shins of boot-closers, on the forehead, point of the elbow, &c.

Disease of the bursæ may occur from external injury, and they often become affected subsequently to disease of the neighbouring joint. If the action is violent, lymph is effused on the inner surface, or external to its cavity, causing considerable thickening. The sac is thus sometimes all but obliterated. Tumours, originally housemaid’s knee, aggravated by continued pressure, are met with over the ligament of the patella in almost a solid state. Occasionally the action terminates in suppuration, pus being effused to a greater or less extent into the cavity; and if allowed to remain or accumulate, the abscess extends, and frequently communicates with the neighbouring joint, which may not have been previously diseased. In chronic cases of enlarged bursæ, especially of the bursal thecæ of the tendons of the wrist or ankle, we not unfrequently meet with loose cartilaginous bodies of various sizes, and of a flattened oval form, floating in the accumulated fluid. These have been also supposed to be formed by portions of lymph which have been deposited on the surface, condensed in structure, and afterwards become detached.

When inflammatory action has commenced in a bursa, it must be subdued by copious topical bleeding, along with the exhibition of purgatives; in most cases general bloodletting will not be required. After the inflammation has subsided, the parts remain swollen, from the effusion either of serum or lymph; stimulating applications may then be employed with advantage. In general, the ammoniacal plaster, or the brushing over the surface with tincture of iodine will answer. Blisters are sometimes employed with the same view. In obstinate cases, when the tumour is of no large size, a seton may be passed, retained till suppuration has taken place, and gradually withdrawn. Great risk attends interference with bursæ of large size near joints or cysts containing serous or glairy fluid in any situation. Even trifling punctures into such have been sometimes followed by inflammation of the inner secreting surface and violent constitutional disturbance. When suppuration has occurred, it will in many instances be prudent to evacuate the matter by one or more incisions, in order to prevent farther mischief, especially if the bursa, a superficial one, is in the neighbourhood of a joint. After the matter has been evacuated, the cavity gradually contracts, and ultimately the bursa is completely obliterated. Diseased bursæ, near the surface, and unconnected with important parts, have been dissected out. The operation is not often necessary, and in some situations attended with considerable risk. Tumours, solid or nearly so, arising from diseased bursa of long standing, may sometimes require to be so treated.

OF COXALGIA, MORBUS COXARIUS, OR HIP-JOINT DISEASE.

This disease has been supposed to commence in the cartilages; it appears, however, to originate indiscriminately in the cartilage and the bone, as well as in the membrane lining the capsule and investing the cartilage and the ligaments; but whether it begins in one or other of these tissues, it soon, if neglected, involves them all. It affects patients of all ages, though children under twelve are most generally its victims; and in these it often makes considerable progress without its existence being suspected. The patient is observed to be a little lame, and to be awkward in the use of the affected limb, but he experiences little or no pain in the first instance; and if he does, it is of a dull kind, and generally referred to other parts. Thus, pain in the knee is generally the prominent symptom of this affection, and occasionally pain is also referred to the ankle, or to the sole of the foot: careful study and considerable experience are here required, to guard the young practitioner from error in diagnosis. Parts remote from the seat of morbid action have often been made the subject of treatment in this and other affections; the knee, in morbus coxarius, has been leeched, poulticed, blistered, and burnt, and that, too, when this joint was not at all altered in appearance, and showed no symptom of disease.

Again, and particularly in adults, the limb is easy only in certain positions, and cannot be moved without great suffering; pain is also complained of in the groin, and often immediately behind the trochanter major. If an examination is made when the patient is thus halting, and even though he complains of no pain, the limb is found shrunk, wasted, and lengthened. The elongation of the limb occurs mainly in consequence of the inclination of the pelvis towards that side. When the disease has made progress, it has been supposed that swelling of the apparatus of the joint, and effusion into its cavity, might separate the head of the bone from the acetabulum, when pressure from the trunk was not applied. The lengthening is often great, and its extent and cause are ascertained by accurate comparison of the two limbs, laid in contact when the patient is in the recumbent posture.

The degree of lengthening is here carefully represented from a recent case. But occasionally, even in the first stage, before destructive ulceration has set in, in consequence of the pain and spasms, the limb becomes remarkably shortened and retracted. This also will be found, on careful examination, to depend upon the relative positions of the two ossa innominata.

When the patient stands, the affected limb is considerably advanced before the other, on which the weight of the trunk is chiefly, or entirely, supported; the knee is generally bent, and the toes only rest on the ground. In the advanced stages of the disease, and when there is reason to suppose that ulceration of the cartilages has set in, the patient, during progression, moves the affected limb with the hands grasped round the thigh, and in bed it is moved by the aid of the sound one. The spine is frequently affected, becoming bent in different directions, to preserve the equilibrium of the body; and a deformity of the trunk to a certain degree occurs, which, however, may be in general easily remedied. The nates are much altered; they become flattened, and those parts which are naturally most prominent are reduced to the level of the others; the usual niche between the buttock and thigh, in the erect position, is effaced, and the upper part of the thigh is often considerably swollen. The alteration is at once manifest on contrasting the healthy with the diseased side. Even from the first, locomotion is difficult: in the morning, the movements of the joint are constrained and stiff; afterwards, however, the patient walks with more ease, though still by very slight exertion the limb is speedily tired, and he is unwilling to use it. Pain is produced by pressing on the groin, or by tapping on the trochanter, and by pushing the head of the femur forcibly against the acetabulum. The inguinal glands occasionally become enlarged. As the disease advances, the lameness is more apparent; pain is produced and increased by motion, and by any attempt to stretch, and more especially to abduct the limb whilst in the recumbent posture. The emaciation of the member becomes more and more visible. The muscles, as it were, are paralysed from inaction and pain, abscesses form, and the constitution then sympathises remarkably; hectic fever supervenes, with its usual train of symptoms.

The circumstances attending the first stage of the disease in childhood, in which the limb is lengthened, and there is no decrease, but rather an enlargement of the parts composing the joint, have been already described and illustrated. When, however, absorption occurs, and the articulation begins to be destroyed, the second stage of the disease commences, and the limb becomes then sensibly shortened; the toes are turned inwards or outwards; in many cases there is every appearance of dislocation of the thigh upward and backward; and in others the limb is much bent, the toes only reaching the ground. The ultimate position of the limb and degree of shortening will depend much upon the extent to which the head and neck of the femur is destroyed, upon the inclination of the pelvis, and also upon the portion of the acetabulum which is most diseased. The joint becomes tender, the slightest motion causing much pain, and the parts around appear swollen. The patient retains the limb in the most comfortable position, and it is generally bent upon the pelvis and inverted. This may arise from relief being afforded when the psoas is relaxed, and the pressure thus removed from the fore part of the joint. In many cases matter forms behind, or rather below, the trochanter major, and the collection often attains a large size. When the presence of matter has been ascertained in this situation, it has been recommended that an early opening should be made, on the supposition that the disease arises from an acrimonious discharge into and round the joint, and that, by the matter being allowed to escape, the cause of the disease may be removed. The synovia has been compared by one old author to bland oil, the vitiated secretion to oil of vitriol. Though the principle is incorrect, still the rule of practice is important; for in consequence of the long-continued presence of matter, accumulating in a cavity which is not dilatable in proportion to the increase of purulent secretion, the original affection will be much aggravated, and disease induced in the neighbouring parts. But the existence of matter in the joint could only be ascertained to exist in a very emaciated person.