ff:MS)iti /ft Via* > TREATISE W DISEASES OF THE JOINTS; BEING THE OBSERVATIONS FOR WHICH THE PRIZE FOR 1806 WAS ADJUDGED BY THE ROYAL COLLEGE OF SURGEONS IN LONDON. .. BY SAMUEL COOPER, MEMBER OF THE ROYAL COLLEGE OF SURGEONS, FELLOW OF THE MEDICAL SOCIETY OF LONDON, AUTHOR OB THE FIRST LINES OF THE PRACTICE OF SURGERY, .&C. , :.'^'"- >> f-'d BOSTON: ry PRINTED FOR F. NICHOLS. 1808. S. G. House, printer. *i ■ ■ i 4 \ CONTENTS. Page Introduction - - - - - 5 PART I. A cursory and gensral Sketch of several principal Diseases of the Joints^ and the Outlines of the Treatment adapted to them. CHAP. I.—Preliminary remarks relative to the pathology of the joints 7 CHAP. II.—Inflammation of joints - 16 CHAP. III.—Treatment of inflamed joints, with two cases illustra- tive of the subject - - - - 23 .CHAP. IV.—Preternatural cartilaginous substances in the joints - - 32 CHAP. V.—Treatment of preternatural cartilaginous substances in the joints ---,.- - - .44 -CHAP. VI.—Of collections of fluid in the capsular ligaments - - 53 * Contents. PART II. Of the White Spelling of the Knee, and the Treatment of the Disease. Page CHAP, f.—Preliminary remarks - - 62 CHAP. II.—An account of the symptoms and progress of white swellings 85 CHAP. Ill—Of the causes of the white swelling, and the grounds on which it is regarded as a scro- phulous disease - - - - 92 CHAP. IV.—Treatment of white swell- ings ----•_. -99 CHAP. V.—Treatment of white swell- ings concluded - - - - 123 PART III, Disease of the Hip Joint. CHAP. I.—Description of the complaint 131 CHAP. II.—Treatment of the disease of the hip joint - - - - - 157 / INTRODUCTION., CLU I w TO enter into a minute account of all the particulars now known, relative to the nu- merous morbid affections of the joints, would form a tedious compilation of circumstances, too well known to need repetition, and too numerous to be comprehended in the ordi- nary limits of a dissertation. An unprofit- able transcript of what almost every system of surgery contains would also form a large proportion of such an undertaking. I shall suppose that the experienced men to whom I address myself, will readily dis- pense with my reviving the consideration of many antiquated opinions, merely for the sake of reducing them by argument to the same obsolete state in which they were pre- viously found. I am confident that these gentlemen will not expect me to dwell on many modern proposals, which are branded with such pal- pable absurdity that they will for ever be exT a2 6 INTRODUCTION. pelled from the field of practice, where alone they might interest mankind and become of real importance. The plan which I have pursued in the fol- lowing pages, is to offer, in the first place, a cursory and general sketch of several prin- cipal diseases of the joints, and the outlines of the treatment adapted to them. Second- ly ; I have entered into a particular consid- eration of the white swelling of the knee, and the treatment of the disease. Lastly; I have made the morbid affection usually denominated the disease of the hip joint, the subject of my reflections. In performing this task my ambition has been to communicate in a simple style, useful practical information. I have made no in- tentional effort to dazzle the judgment of my readers by an ostentatious list of authors in the margin, or by quotations from old works, which are now almost as dead as the men who wrote them. The books which I have quoted in the course of this production, are cited only to illustrate important facts, or to expose erroneous doctrines. A TREATISE. PART I. A CURSORY AND GENERAL SKETCH OF SEV- ERAL PRINCIPAL DISEASES OF THE JOINTS, AND THE OUTLINES OF THE TREATMENT ADAPTED TO THEM. CHAP. I. Preliminary Remarks relative to the Pathology of the Joints. IF we recal to our recollection the anatom- ical structure of the joints, we shall find that the heads of the bones, which are con- cerned in the formation of these parts, are of a spongy texture, and connected together by strong ligaments, while their articular sur- faces are covered with a beautifully polish- ed, elastic substance, called cartilage. The a PRELIMINARY REMARKS. smoothness and elasticity of the cartilages are qualities rendering them peculiarly proper for gliding with ease over one another in the motion of the joints, and for breaking the force of such shocks as the limbs have to sustain in jumping, running, and other ordinary ex- ercises of life. In order that the articular surfaces of the bones may move with still greater ease upon each other, we find that their cartilaginous coverings are constantly lubricated with an albuminous secretion, termed the synovia. It was a valuable observation, made by the late Mr. Hunter, and one upon which he laid much stress, that the characters of local diseases differed very materially, according to the situation, structure, and functions of the morbid part. When diseases are situated in parts which enjoy a vigorous circulation of blood through them, they assume a very dif- ferent aspect from what they would do, were they in a situation, in which the circulation is naturally languid, or in which there are only (comparatively speaking) few vessels. PRELIMINARY REMARKS. $ and those of very small diameter. When the part affected is, what anatomists term, highly organized, and vascular, the disorder ^ is generally more mild and tractable than i the part were only furnished with such small vessels, that it could not be rendered red by anatomical injections. But, besides great vascularity and high organization of structure, a situation near the source of the circulation seems oftentime* to render parts less disposed to become dis- eased, and not only better able to resist the attack of morbid affections, but also more prone to return, when so attacked, to a state of health. However, if the functions of the parts affected be inn nately essential to the continuance of lite, then, as Mr Hunter ob- serves, the natural operations of universal health depend so much upon their sound con- dition, that the local disease has not the same tendency to end well, as if it were situated in a part of similar structure, but of differ- ent functions. When we apply these remarks to the 10 PRELIMINARY REMARKS. joints, we may in some measure account fof the frequency, obstinacy, and peril of their diseases' •, at least we may discover general principles, to which such circumstances may rationally be referred. The cartilages and ligaments, the bones themselves, are parts endued with an inferior degree of vascularity, and the quantity of blood with which they are furnished is, when compared with that of most other parts, ex- ceedingly inconsiderable, This is, perhaps, one principal cause that the joints in general are so backward in recovering from the ef- fects of accidental injuries, and so slow in freeing themselves from a state of disease. It is well known that diseases of the upper extremity are generally more tractable than those of the lower. Every part of the arm may be considered as being nearer to the source of the circulation than the whole of the lower extremity. This circumstance may, per- haps, explain why diseases situated in the arm are much more under the control of sur- gery than when they affect the leg. How much PRELIMINARY REMARKS. 11 more seldom scrophulous elbow-joints require amputation, how much more frequently they are cured, than similar affections of the knee ! We may also deduce another reason for this fact from a comparative consideration of the functions of these two articulations. When a patient has a complaint in the elbow or wrist, he places his arm in a sling, walks about, visits his friends, and takes his usual exercise •, his general health is neither impaired by confine- ment, nor by that dejection of spirits which so frequently attends the long privation of lo- comotion, and the apprehension of losing this enjoyment for ever. The structure of the knee-joint is more complicated than that of any other articulation in the body. Besides the capsular and lateral ligaments, which it has in common with the majority of other joints, it is also furnished with particular ligaments, named the crucial ones, and with interarticular semilunar cartil- ages. The complication of its structure may also seem to the contemplative pathologist a reason why its diseases should not only be more frequent, but, at the same time, more obsti- 12 PRELIMINARY REMARKS. nate, and difficult of cure, than those of other joints. The articular surfaces of the knee, and the cavity of its capsular ligament, are also much larger than those of any other artic- ulation. The hip-joint is greatly protected, by its deep situation, from blows and other species of external violence ; from the bad effects of sudden vicissitudes of temperature ; and from the operation of outward damp. These cir- cumstances, which, undoubtedly, are very fre- quently the primary exciting causes of the worst diseases of the joints, must affect the knee with peculiar force, on account of it sex- posed situation, and the vicinity of its cavity to the surface of the body. Hence it seems a matter of no surprise that the hip-joint should be much less frequently diseased than the lat- ter articulation. No large joint in the human body is so lit- tle strengthened and supported by the confor- mation of the bones, as the knee ; no other important joint derives its strength so entirely from ligaments. The ankle receives lateral support from the two malleoli. In the hip the PRELIMINARY REMARKS. 13 head of the os femoris is almost enclosed in a complete bony socket. In the elbow the deep sigmoid cavity of the ulna, formed be- tween the coronoid and olecranon processes, affords a very stable lodgment to the inter nal portion of the articular surface of the os brachii, so that the latter is almost securely fixed in its situation without the assistance of ligaments. The groove also, which is form- ed on t,he lower end of the os brachii, and re- ceives a portion of the ulna, contributes very materially to the stability of the articulation. From the preceding observations it becomes obvious that the ligaments of the knee must be particularly exposed to sprains, which are too frequently the forerunners of the most serious morbid mischief to which the joint is liable. We have every reason to believe that the ligaments are the structure in which most of the worst diseases of this articulation first originate. The strength of the wrist, however, seems to depend chiefly on ligaments; and, as this joint is also much exposed to the effects of external violence, and is more remote than B 14 PRELIMINARY REMARKS. . • { the elbow from the source of the circulation', ^ we cannot wonder that it should be more prone to disease than the latter. But, its not being morbidly affected so often as the ankle must be imputed to situation. Both the an- kle and the wrist, however, are very frequent- ly affected with such serious maladies as waste the vigour of the constitution, and even render amputation indispensable. In these cases the disease often commences in the tar- sus and carpus, and subsequently involves the ankle and wrist in its ravages. The great quantity of cartilaginous and lig- amentous structure surrounding the bones of the tarsus and carpus, and the spongy texture of the bones themselves, are sufficient reasons, without enumerating others, to account for * the frequency of disease in these situations. j| The morbid affections of the carpus are, in. 4 general, much more tractable than those of J the tarsus. The reason of this fact may very rationally be referred to principles which have been already noticed. When we recollect that the diseases, which • form the chief objects of investigation in the PRELIMINARY REMARKS. 15 subsequent pages, are of a scrophulous nature, we cannot be surprised that, situated as they are in a structure peculiarly unfavourable to the amendment of disease in general, they should so frequently baffle all the power of the surgical art. When diseases affect parts which seem to possess, like the joints, very inferior powers of recovery, the effects of the local disorder on the.constitution are proportionally more severe. Hence the mere inflammation of a large joint is often attended with so high a degree of inflammatory fever, and such dis- order of the nervous system, that the preserva- tion of life itself is at stake. Hence also dis- eases of the. joints sooner induce hectic symp- toms than when there is an equal quantity of disease" in almost any other part. Having premised these general pathologic- al observations I next proceed to delineate the outlines of several principal diseases to which the joints are subject. All accidental injuries, such as fractures, luxations, &c. and all subjects not strictly surgical, such as gout, rheumatism, &c. are purposely omitted. 16 CHAP. II. Inflammation of Joints. IDIOPATHIC cases of this kind are not common. The complaint ordinarily origin- ates in consequence of a contusion, sprain, wound, or some other kind of injury, done to the part affected. Phlegmonous inflammation; wheresoever situated, is uniformly attended with certain local symptoms, by which both its presence and degree may be ascertained. Preternat- ural redness, increased heat, a throbbing pain, and a tense swelling, affecting the seat of its attack, are the common marks which denote its existence in all situations. When a joint \\ is inflamed the same local phenomena are present, and the constitution is disturbed by the usual symptoms of inflammatory fever ; but, in these cases, they are apt to be exceed- ingly severe. The inflammation attacks the capsular ligaments, and, not remaining confi- ned to any particular portion of them, it very INFLAMMATION OF JOINTS. 17 quickly diffuses itself universally over their whole extent, as is commonly the case in all inflammations of smooth membranes. That there is this peculiarity in inflammation of membranes, is often strikingly proved in the instance of peritonitis, arising after the ope- ration of lithotomy. Here we know that the inflammation commences in the bladder, is communicated to the portion of the peritone- um, which covers the fundus and posterior surface of this viscus, and thence rapidly spreads over the whole extent of the abdo- men. The capsules of the joints are naturally en- dued with little sensibility •, but, like many other parts similarly circumstanced, they be- come acutely painful when inflamed. The complaint is accompanied by an increased se- cretion of the synovia, which becomes of a more aqueous, and of a less albuminous qual- ity, than it is in the healthy state. Hence this fluid is not so well calculated for lubri- cating the articular surfaces, and preventing the effects of friction, as it is in the natural condition of the joint. This circumstance b 2 18 INFLAMMATION may explain why a grating sensation is often perceived on moving the patella, when the knee is inflamed. The increased quantity of synovia, in cases of inflamed joints, has often appeared to me an argument against the ex- istence of a spasmodic constriction of the minute vessels in inflammation. The capsules of the joints may, like other membranes, be thickened by inflammation. At other times an exudation of coagulating lymph, or an effusion of a gelatinous fluid, may take place upon their internal surfaces. According to a general law of the animal e- conomy the contiguous vessels always have a tendency to shoot into coagulating lymph, when thus extravasated, and the result.is, that organized substances, such as cartilaginous and osseous bodies, &c. are formed in the in- terior of the joint. Jf the inflammation be more vehement, sup- puration may happen within the capsular liga- ment. Indeed this is by no means an un- frequent occurrence. At length the capsular ligament ulcerates, and purulent matter is ef- fused beneath the integuments. The skin OF JOINTS. 19 may next ulcerate, so that the abscess is dis- charged, and the case seems to be somewhat benefited. The openings through which such collections of matter are discharged, will be found, upon examination with a probe, to be the terminations of sinuses leading into the cavity of the joint. A large joint seldom falls into a state of suppuration in consequence of acute inflam- mation, without the constitution being, at the same time, sd disturbed that life itself is great- ly endangered. In the most vehement st»e of the inflammation, or that which is the im- mediate forerunner of suppuration, the pulse is exceedingly frequent; but not quite so full and strong as it would be, if the part affected were of a structure better adapted to resist the ravages of disease. The patient's skin is dry and hot; he is restless and vigilant; and, I have known persons, under these circum- stances, become affected with delirium and coma, and ultimately perish. But the rapidity with which the common inflammatory fever assumes, in such cases, the hectic type, is a circumstance which it 20 INFLAMMATION would be inexcusable to pass over in silence. When suppuration has occurred in a large joint, in consequence of a severe attack of common inflammation, the patient immedi- ately begins to be affected with hectic symp- toms, and the strong action, attendant on the inflammatory fever, suddenly ceases. Local consequences, even worse than those which I have described, may follow inflam- mation of a joint. As the layer of the cap- sular ligament, reflected over the cartilages of the articulation, is often inflamed, the car- tilages themselves are very apt to have the inflammation communicated to them. Parts partaking of a cartilaginous structure, being very incapable of bearing the irritation of disease, often ulcerate, or, in other words, are absorbed, so as to leave a portion, or the whole, of the articular surface of the bones, completely denuded of its natural covering. At length the heads of the bones, entering into the formation of the affected joint, in- flame and become carious. Sometimes only such parts as are exterior to the cavity of the joint are inflamed, and, in OF JOINTS. 21 this case, the symptoms are never so severe,* nor so obstinate, as when the complaint inter- ests the capsular ligament, and parts contained in it. Even when suppuration takes place on the outside of the capsule, the case is not dan- gerous, provided the cavity of the joint be not involved in the inflammatory attack. Every inflammation of a large joint may, upon the whole, be deemed a case of considerable im- portance. I do not mean to assert that cases, in which the inflammation is mild in degree, and simple in its nature, are dangerous : no,; I only wish to inculcate that, though the in- flammation be originally genuine, yet it is al- ways very likely to be converted into one of a specific nature, whenever there is a tenden- cy in the system to scrophulous disorder. A person, whose constitution is scrophulous, may sometimes continue, during life, exempt from any local diseases of this specific nature, pro- vided he be fortunate' enough to avoid all irri- tation of parts on which scrophula is most particularly disposed to make its attack. A- • Treatise on the Morbid Affections of the Knee Joint, by James Russell, p. 60. 22 INFLAMMATION OF JOINTS. mong such parts we must class the joints, es- pecially the knee; hip, elbow, and ankle. Hence, when a joint is inflamed, however mild the affection may be, we ought never to forget that, when there is a tendency to scrophula in the system, the original case of simple inflam- mation is very apt to be the exciting cause of 1 the white swelling, one of the most severe and intractable diseases which increase the cata- , f logue of human miseries. , After what has been said it must be obvious that, whatever may be the curative means in- dicated, they ought to be most rigorously-a- dopted, not merely on account of an abstract view of the present state of the case, but also on account of the opportunity which is now af- forded for a terrible disease to arise, which of- ten remains previously in a dormant state. . 23 CHAP. III. Treatment of inflamed Joints ; and two Cases illustrative of the Subject. IT will considerably shorten this part of my observations to state, that the antiphlogis- tic plan of treatment, in the full sense of the expression, is to be strictly adopted. But, as there is a variety of means, often adapted to the same purpose, it seems necessary to of- fer a few remarks on those which lay tb^e greatest claim to our commendations. Also, as the treatment of inflammation of the knee will illustrate that of all other large joints, I shall select this case as an example. From what I have seen of this affection I have no hesitation in asserting that there are few other surgical cases, in which general, and, especially, topical bleeding, is more strong- ly indicated. The violence of the inflamma- tion, and the strength, age, and pulse of the patient, must determine with regard to the use of the lancet; but the topical application of leeches may be said to be invariably prop- 24 TREATMENT OF per. When the leeches fall off, the bleeding is to be promoted; by fomenting the part. The surgeon should daily persist in this prac- tice, until the acute stage of the inflammation has entirely subsided. But, in conjunction with this treatment, we are to keep the joint continually surrounded with linen wet with ^ the saturnine lotion. In no case of local in- flammation are the application of cold lotions, and the maintenance of a constant evaporation from the surface of the part affected, more strikingly advantageous. In a few instances, however, the patient seems to derive more ease and benefit from the employment of fomentations and emol- lient poultices. I would always recommend the feelings of the patient to be consulted , for, if the pain be materially alleviated by this, or that application, the employment of it will hardly ever be wrong. I shall say nothing more concerning the rest of the treatment proper during the ve- hemence of inflammation, as the duty of the surgeon is not materially different from what it is in other inflammatory cases. INFLAMED JOINTS. 25 When the acute stage of the inflammation has abated, the plan of treatment may be a little altered. The grand object now is to re- move the effects, which have been left by the preceding affection. These are a thickened state of the capsular ligament, and parts sur- rounding the articulation ; a stiffness of the joint, and pain when it is moved ; a collec- tion of fluid in the capsule, &c. This state of the complaint, when neglected, and there is a tendency to scrophula, may prove exceed- ingly obstinate, and even terminate in an ir- remediable, specific distemper of the joint. Common inflammation of an articulation, like the same affection of the eye, is peculiarly apt to end in a chronic species of the affection, even more difficult of cure than the acute stage of the complaint. When, therefore, the redness, tension, throbbing, and symp- toms of inflammatory fever subside, the activ- ity of the practitioner ought not to be relaxed. The application of a blister is what I have found particularly efficacious in the second stage of the inflammation, and a discharge c 26 TREATMENT OF should be kept up from the blistered surface, for a few days, by means of the savin cerate. I have often seen exceedingly large collec- tions of fluid in the capsular ligament, the thickening about the joint, and other remain- ing effects of the inflammation, totally dis- persed, under such treatment, in the short space of ten days from the period when the blister was first applied. In other cases, in which the inflammation has been more trivial, and the effects which it jbas left are slight, lotions, composed of vin- egar and sal ammoniac, suffice for the remov- al of the chronic complaints, continuing after the abatement of the acute stage of the disorder. My own experience enables me to confirm the reputation which such appli- cations have most justly acquired. To illustrate the present subject I shall se- lect the two following cases from several oth- ers, which have fallen under my own observa- tion. CASE I. A young man, about twenty-three years of age, fell from the top of a coach, August 20th, CASES. 27 1799, and bruised his knee against the back part of the carriage. As soon as I was called to the patient I applied the saturnine lotion to his injured knee, and gave him some purga- tive medicine, consisting of the infusum sennie, and natron vitriolatum. Notwithstanding these measures I found the joint, on the fol- lowing day, very considerably swollen j the pain in the part very acute ; and all motion of the articulation utterly insupportable. The patient's pulse was accelerated, and his skin dry. Ten leeches were put on the joint, &pd full ten ounces of blood were taken from the arm. As the severity of the pain was much complained of in the evening, a grain of opium was administered. August 22. The patient had slept but in- differently, and a good deal of pain was still experienced in the injured part. As the red- ness, swelling, and tension were considerable, I ordered eight more leeches to be applied, and the purgative draught to be repeated. At night the patient took twenty drops of the tinctura opii. August 23. The man had enjoyed some 28 CASES. refreshing sleep. This morning his pulse was eighty, and the redness, swelling, tension, and heat about the joint, were somewhat diminish- ed. August 30. All the acute symptoms were now removed. The treatment since the last date merely consisted in applying continually the saturnine lotion. However, the patient still complained of a degree of pain in the articu- lation, and there was obviously a preternatu- ral quantity of fluid in the capsular ligament. Though the tumefaction of the integuments had subsided, yet this accumulation of fluid, and some thickening of the capsule, caused the joint to seem still somewhat enlarged. I now applied a blister immediately over the patella and front of the joint. August 31. The blister had raised the cuticle in the most desirable manner. The patient found infinite relief, and said that the part was less painful than it had been ever since the first occurrence of the accident. The cuticle was removed, and the blistered surface was dressed with the ceratum sabinae. September 3. The blister discharged co- CASES. 29 piously, and the pain and swelling of the joint were daily diminishing. ; September 17. The blister was healed, and the knee was not larger than the other. REMARKS. This case places in a very strong light the utility of employing active measures for the removal of such effects as frequently remain after the acute stage of the inflammation has subsided. Had nothing been done to reduce the thickened state of the capsular ligament, and to disperse the fluid in the cavity of the joint } had the patient imprudently attempt- ed t6 walk about, instead of remaining^ quiet- ly in his bed ; I really believe, from the de- gree of pain which he continually experienced in the articulation until the blister was appli- ed, that the affection might have been con- verted into a very serious disease. Had the patient been of a scrophulous habit the haz- 2rd would have been still greater. CASE II. The following case is mentioned to show how violent the constitutional symptoms some- c2 30 CASES. times are, when the knee joint is vehemently inflamed in consequence of a wound. In June 1800, a lad, about sixteen years of age, accidentally wounded his knee with a penknife, in attempting to stop the instrument as it was falling. The point had penetrated the capsular ligament on the inside of the right knee. The wound of the skin was not more than half an inch in length, and was closed very accurately with sticking plaster soon after the accident. The lotio aq. litharg. acet. was applied round the injured joint. The day after the accident the joint was pro- digiously swollen, and the patient in a very feverish state. Notwithstanding general and local bleeding was extensively and repeatedly practised, while other evacuations were not neglected, the tumefaction of jhe part contin- ued to increase, and a most violent symptom- atic fever supervened. In short, the lad be- came delirious on the fifth day, and died on the seventh. When the first dressings were removed on the fourth day, the wound, how- ever, had shown a disposition to unite in a favourable manner. 31 REMARKS. I believe the severity of the constitutional symptoms is always greater, when the inflam- mation of a joint arises from a wound, than when it is the consequence of a contusion or sprain. In considering the next subject we shall see, however, that wounds may frequent- ly be made into the large joint of the knee, without being followed by any material in- flammation. But, when inflammation of a joint does arise from a wound, my experience leads me to suspect that the constitution is al- ways more disturbed than when the cqri.plaint occurs without a breach of continuity in the capsular ligament. 32 CHAP. IV. Preternatural cartilaginous Substances in the Joints. THE ancients have either neglected to no- tice this disease in their writings, or they have not been at all acquainted with it. Ambrose Pare1'' is the first author who mentions it. He had made an incision in order to evacuate some fluid from the cavity of the knee joint, when ahard, polished, whitebody,about as large as an almond, was discharged from the wound, i Since the time of this illustrious practitioneif many eminent men have called our attention to the particulars of the complaint. Of these Reimarus,f Morgagni,:}: Bromfield,§ Ford,|| * Livre xxv. Cliapitre 15. f Diss, de tumore ligamentorum circa articulos. 17.37. \ De sed et caus. moi-b. § Chirurgical Cases and Observations. Appendix to vol. i. || Med. Observ. and Inquiries. Vol. v. CARTILAGINOUS SUBSTANCES. 38 Desault,* Home,f Hey4 and Abernethy,§ form only a small number-, but as it is in their writings that we find the most interesting in- formation on the subject, I deem it superflu- ous to enumerate other authors. The external part of the extraneous sub- stances in question is commonly of a cartil- aginous consistence, while their central part is frequently osseous. Their figure is subject to great variety ; but they usually have one concave side, and another which is convex. They are, for the most part, formed in tilge knee-joint, and have been supposed by Re> imarus and some other writers to be met with in no other articulation. Morgagni, however, has seen ossified bodies of this kind in the articulation of the leg. Haller also discovered a great number of cartilaginous bodies in the articulation of the jaw, where the natural car- tilages of the joint had been destroyed. Mr. Hey mentions a case in which there were two * Journ. de Chirurgie. Tom. ii. f Med and Chirurg. Transactions. Vol. i. f Practical Observations in Surgery. § Surgical Observations. 1804. 34- CARTILAGINOUS SUBSTANCES bodies of this description in the elbow-joint, The largest that I have ever heard of is men- tioned by Mr. Home, as being nearly as large as the patella, and situated in the knee-joint of a soldier belonging to the fifty-sixth regi- ment. The greatest number ever known to be contained in one articulation is twenty-five. In most instances we only find one. Such preternatural substances are either at- tached to some part of the inside of the joint, or are quite unconnected and loose. It is only when they become so situated as to inter- pose themselves between articular surfaces, which glide over one another in the motion of the joint, that much inconvenience commonly results from their presence. While they con- tinue by the side of the patella they cause little trouble ; but when they slip under the ligament of that bone, or between the same bone and the condyles of the femur, or be- tween the latter bone and the head of the ti- bia, then they impede progression, cause con- siderable pain, and often excite inflammation. As cartilaginous substances in the joints are, very often, quite unconnected with any living IN JOINTS. 35 surface,and are moveable from one side of the articulation to the other, their formation has, been regarded with some degree of curi- osity. A modern author, to whom we are indebted for many excellent remarks on the diseases of the knee, has very absurdly im- puted the origin of a soft description of these preternatural substances to an inspissation of the synovia. " The portion which is inspis- sated may act as a nucleus to attract more of the surrounding matter, and may thus receive perpetual augmentation of bulk to an unljm- ited extent." I wish that I could as readily understand, as the author conceives his read- er cannot fail to do, how this class of tumours thus increases in size. He acknowledges that it is not an easy matter to comprehend " by what process those of a bony, or cartila- ginous nature, which have separated from their attachment, can become larger, though this is asserted upon very credible author- ity ! !"* * Russell on Morbid Affections of the Knee Joint, p. 88, 89. 36 CARTILAGINOUS SUBSTANCE? When we peruse the accurate account which Mr. Russell has given of the present disease, we cannot fail to be surprised that he should not have perceived how easily a sur- geon may imagine a tumour to be quite de- tached, while it still has connexion with the* inside of the joint, by means of a long slender pedicle, which allows the extraneous substance a considerable latitude of motion. When we remind ourselves o,f the true manner in which such preternatural cartilages grow, we shall at once see how they may continue to enlarge as long as they are attached to an ad- jacent living substance, and how they cannot possibly increase after this connexion has been destroyed. Considerable light was thrown upon the formation of loose cartilaginous tumours in the joints by the penetrating genius of the late Mr. Hunter, and the surgical profession is much obliged to Mr. Home for a paper in which he has given an able account of Mr. Hunter's ideas. It is almost too well known to need recital, that the latter immortal prac- titioner entertained an opinion that a coagu- IN JOINTS-. S7 lum of extravasated blood might frequently be converted into an organized vascular sub- stance by the vessels growing into it from the neighbouring living surface. No one doubts that the coagulating lymph has constantly a tendency to become vascular, when effused on the surface of an inflamed membrane. I do not think it of importance to investigate here whether a clot of red blood can be converted into an organized substance or not. It is quite sufficient for the explanation of the pre- sent subject to know, that effused coagulating lymph is capable of this change, and that, in many instances, it then assumes a resem- blance in structure to the contiguous parts. If we take the trouble of perusing the cases which are related by different authors, we shall find that the formation of loose car- tilaginous substances in the joints has gener- ally been preceded by violence done to the part, and by symptoms of inflammation. Of this sort are the cases related by Mr. Ford, M. Brochier (in Desault's Journ.), Mr. Aber- nethy, and Mr. Hey. Latta mentions four instances which were preceded by rheumatism. D 38 CARTILAGINOUS SUBSTANCES In this state I conceive that the capsular liga- ment, or its delicate layer reflected over the articular cartilages, effuses coagulating lymph, just in the same way as we know that the pe- ritoneum and peritoneal coverings of the vis- cera do, in consequence of inflammation in the,' cavity of the abdomen. Vessels very soon shoot from the adjoining living surface into a portion] of the extravasated lymph, which gradually • becomes converted into a structure more or I less similar to that of the nearest parts. Mr. Russell doubts the probability of this mode of formation,because similar cartilaginous and osseous bodies have been found in the cavi- ties of the bursas mucosae, in which situation, " had similarity of substance been a necessary " consequence of their attachment, these bod- " ies would not have been composed either of " bone or cartilage." (P. 85.) Mr. Abernethy has written some very valuable observations on the formation of tumours, and I shall take the liberty of quoting a passage from his work, as it tends to illustrate the present disquisition. " The structure of a tumour is sometimes like that of the parts near which it grows. IN JOINTS. 39 Those which are pendulous in the joints are of a cartilaginous or osseous fabrick •, fatty tumours frequently form in the midst of adi- pose substances, and I have seen some tumours growing from the palate, and having a slender attachment, which, in structure, resembled the palate. Sometimes, however, they do not resemble in structure the parts from which they grow. The instance, just mentioned, of the pendulous portion of fat growing from the peritoneum, will serve as an instance. The vessels which had shot into it made the tumour into fat, whilst the neck was of a fibrous and vascular structure. I have seen osseous tumours unconnected with bone, or periosteum ; and indeed, in general, the struc- ture of a tumour is unlike that of the part in which it is produced. Therefore we seem war- ranted in concluding that, in many cases, the nature of the tumour depends on its own action and organization, and that, like the embryo, it merely receives nourishment from the surr rounding parts."* * Surgical Observations, contaiping a Classification of Tumours, &c. 1804. 40 CARTILAGINOUS SUBSTANCES I have in my own possession a completely cartilaginous tumour, which I found envelo- ped in the fat which surrounds the kidneys. Hence it is obvious that the coagulable part of the blood, when effused, is very prone to be converted into a living substance, and that itsl structure does not necessarily resemble that of "■, the contiguous parts. If Mr. Russell should | doubt the truth of the above explanation of the manner in which loose cartilaginous sub- stances form in the joints, he has equal rea- son to doubt that all other tumours originate in the way which is commonly supposed. In many instances we could not possibly impute their origin to any such cause as an inspissation of the synovia j and, if we were to imbibe the idea for a moment, we should reject it the next, on reflecting that mere inspissations could not be endued with vascularity, which many tumours demonstrably possess. The foregoing statement seems more like- ly to be true,, when we consider that loose cartilages are usually connected with some part of the articular cavity, which does not suffer attrition when the joint is moved. Dr. IN JOINTS. 41 Alexander Monro, in dissecting the knee of a malefactor, found an osseous tumour, which was connected, by a ligamentous pedicle, with the exterior edge of the cartilage, covering the external cavity of the tibia. (Edinb. Es- says, vol. iv. p. 245.) We find that perfect quietude is essential to the growth of new vessels into coagulating lymph ; and, in the case just instanced, if the exudation had taken place in such a situation in the joint, that it would soon have been disturbed in the motion of the limb, its organization would not have taken place. Also, if such cartilaginous bod- ies were to be usually formed on a part of the articular cavity, necessarily exposed to friction in walking, &c. then patients would experi- ence pain from the first. But, as they do not feel inconvenience till the tumour has be- come very moveable by the gradual elonga- tion, or sudden rupture of its pedicle, and, only then, when the tumour glides into a sit- uation where it becomes pinched between the articular surfaces, we have a right to conclude that almost all cartilaginous bodies of this kind grow originally in a situation where they d2 42 CARTILAGINOUS SUBSTANCES are not particularly exposed to disturbance in the motion of the articulation. In most in- stances the communication of vascularity must also take place during the tenderness of the joint, at which period the patient naturally keeps his limb in a quiet state, in order to avoid pain. After all inflammation has sub- sided the limb is again moved with freedom ; the organized coagulum becomes gradually loosened by the motion, and, at length, it on- ly remains connected with the point to which it was originally attached, by means of a long slender pedicle, through which its nutrient vessels proceed. At last the pedicle breaks, and the cartilaginous substance is left quite loose, like an extraneous body, in the cavity of the joint. It is easy to conceive how it is likely, in this state, to glide into situations where it must obstruct the functions of the ar- ticulation, and cause considerable pain, and even other symptoms of inflammation. The irritation of loose cartilages in the knee often occasions an increased quantity of fluid in the capsular ligament; but this is not invariably the case- When the irritation IN JOINTS. 43 is such as to induce a degree of heat and ten- derness in the joint, there is usually a preter- natural quantity of synovia : when the loose cartilages have not lately created pain and in- convenience, the synovia is commonly not more abundant than it is in the natural state of the articulation. 44 CHAP. V. Treatment of preternatural cartilaginous Substances in the Joints. IF we except making an incision into the joint, for the purpose of extracting the cartil- aginous tumours, we are not acquainted with any certain means of freeing a patient from the inconvenience of this complaint. To this plan the danger attendant on all wounds of so large an articulation as the knee, is a very serious objection. Messrs. Middleton and Gooch endeavoured to conduct the extraneous body into a situation where it produced no pain, and to retain it in that position a long time by bandages, under the idea that the car» tilaginous substance would adhere to the con- tiguous parts, and occasion no future trouble. No conclusion, however, can be drawn from the cases brought forward by these gentlemen, because they had no opportunity of seeing their patients again at the end of a reasonable length of time, and we know that loose car- CARTILAGINOUS SUBSTANCES. 45 tilages in the joints sometimes disappear for half a year, and then make their appearance again. Mr. Hey, impressed with a just sense of the dangerous symptoms which have occa- sionally resulted from the most simple wounds penetrating the knee-joint, very laudably tri- ed the efficacy of a laced knee-cap, and the cases which he has adduced clearly demonstrate that the benefit, thus obtained, is not tempora- ry, at least, as long as the patient continues to wear the bandage. In one case the method had been tried for ten years, with all the suc- cess which the patient could desire. Contemplating the evidence which we have upon this subject, and the perilous symptoms sometimes following wounds of the knee-joint, I am decidedly of opinion that the effect of a knee-cap, or of a compress and roller, ap- plied over the loose cartilage, when this body is so situated as not to create pain, and to ad- mit of being compressed, ought generally to be tried before having recource to excision. I say generally, because the conduct of the surgeon ought, in such cases, to be adapted 46 TREATMENT OF to the condition and inclination of the patient. If a man be deprived of his livelihood by not being able to use his knee; if he cannot, or will not, take the trouble of wearing a band- age ; if he be urgently desirous of running the risk of the operation, after circumstances have been impartially explained to him •, if a bandage should not be productive of suffi- cient relief; and, lastly, if excessive pain, se- vere inflammation of the joint, and lameness, should frequently be produced by the com- plaint ; I think it is the duty of a surgeon to operate. It is very certain that success has generally attended the operation ; but small as the chance is of losing the limb, and even life, in the attempt to get rid of the disease; yet, since the inconveniences of the complaint are, in most cases, very bearable, and are e- ven capable of palliation by means of a band- * age, endangering the limb and life in any de- gree must seem to many persons contrary to the dictates of prudence. I am ready to allow, with M. Brochier,* * Desault Journ. de Chirurgie, torn. ii. CARTILAGINOUS SUBSTANCES. 47 that the danger attendant on wounds of the large joints has always been very much ex- aggerated, inconsequence of ancient prejudi- ces. But, making every allowance for the in- fluence of prejudice, a man must be very sceptical indeed, who does not consider the wound of a large joint, like that of the knee, attended with real cause for the apprehension of danger. The fatal event of the second case in this dissertation proves the veracity of the remark. At the end of Mr. Ford's case* we read on the subject of cutting loose cartilages out of the knee. " The society have been in- formed of several cases in which the ope- ration has been performed ; some, like this, have healed up without any trouble ; oth- ers have been-followed with violent inflamma- tion, fever, and death itself." * Medical Observations and Inquiries, vol. v. p. 334. 48 OPERATION. Under circumstances such as I have aires*. dy noticed, a surgeon is justifiable in underta- king to remove loose cartilaginous substancei from the knee-joint, by dividing the capsular ligament. We have no instance recorded in which the complaint, when situated in any other joint, was sufficiently urgent to require this practice. When we remember that the disorder is I often attended with a degree of heat and tenderness in the articulation ; when we re- collect that the danger of the operation is, in a great measure, proportioned to the subse- quent inflammation; and, when we also recal to » mind that, if the wound unite by the first in- tention, a great deal of the danger is removed} we can entertain no doubt that the advice, de- livered by several respectable surgeons, to keep the patient in bed a few days before operating, and to apply leeches and cold saturnine lo- tions to the knee during the same time, is fraught with the most commendable pru- CARTILAGINOUS SUBSTANCES. 49 dence. Thus the joint is brought into a per- fectly quiet state before the incision is made. Nor should the operation be undertaken be- fore the bowels have been emptied by a mild saline purgative. As soon as the inflammato- ry swelling and tenderness have quite subsi- ded the excision may be undertaken. As the loose piece of cartilage may com- monly be moved round the joint, the surgeon can generally choose the place for making the incision. Mr. Ford, Mr. Latta, &c. have made the wound on the outside of the joint. Desault used to bring the loose cartilage to the inside of the articulation, against the at- tachment of the capsular ligament, and then make the incision in that situation. Mr. A- bernethy has recommended bringing the loose piece of cartilage on the outside of the inter- nal condyle of the os femoris, and dividing the capsular ligament in that situation. Mr. Russell has recommended pushing the movea- ble body upward on the inside of the thigh, in order that the incision may be as far dis- tant as possible from the moving surface of the joint. Mr. Hunter also preferred remov- E 50 EXTRACTION OF ing these loose bodies at the upper part of the joint, because there the bag, which contaiflp J the synovia, has less of the nature of a cap- sule. For my own part I do not believe that this is a matter of very great importance, and, if the loose cartilage could be more easily fixed , on one side of the articulation than the other, I should recommend the incision to be made in that situation. But the places chosen by j Desault and Mr. Abernethy certainly seem the best for fixing the pieces of cartilage, when they can be readily brought there. The in- ner surface of the internal condyle is of con- siderable extent, and when the loose cartilage is situated upon it there is no difficulty in con- fining the little tumour there, provided the assistant places the points of his fingers round • it in the manner which Mr. Abernethy has ' directed. It is of great consequence that the assistant prevent the loose cartilage from gliding away from the place where the wound is made, for, in this event, it often happens that the extra- neous substance cannot be immediately found CARTILAGINOUS SUBSTANCES. 51 again, so that the purpose of the operation is frustrated, and, if the capsular ligament should be divided, all the risk of the operation is to be encountered without the smallest chance of the least benefit. All operators have very properly adopted the plan of drawing the integuments to one 6ide before making the incision, so that as soon as the excision of the cartilage is achiev- ed) ed the wound in the capsular ligament may become immediately covered with the skin. Thus, whatever bad effect the entrance of air might have is, in a great measure, prevented. The piece of cartilage, being exposed by the incision, is to be immediately taken hold of with a tenaculum and extracted. In this sketch of the subject I can only add that the external wound is to be brought ac- curately together, and cool saturnine lotions are to be applied. If the patient be young and robust he ought to be bled. The limb is to be kept in an extended position, and com- pletely motionless, and the whole treatment is to be rigorously antiphlogistic. 52 CARTILAGINOUS SUBSTANCES. Though the union of the wound greatly diminishes the chance of future dangerous symptoms, experience shows that the limb ought to be kept in a quiet state for some days after the incision is quite healed. Mr. Bromfeild observes : " In most of the cases which I have seen, where the operation had been performed, and the proper attention paid to the situation of the limb, the patients did well j yet 1 must own that, in an instance or two, from mismanagement, I thought they would have lost their lives: for, as they suffer- ed but little in the operation, and the wound was seemingly healed in a few days, by too early a use of the limb the most threatening symptoms came on."* * Chirurgical Cases and Observations, vol. i. p. 335, 336. 53 CHAP. VI. Of Collections of Fluid in the Capsular Ligaments. VARIOUS fluids may accumulate in the cavities of the joints. That the synovia may collect in this manner we have already no- ticed. But, besides this affection, the joints are subject to a disease termed hydrops articuli, which consists of an accumulation of water in the capsular ligament, and is very analogous to the hydrocele, or collection of an aqueous fluid in the tunica vaginalis testis. Suppuration also sometimes takes place in the joints, so that the collection of fluid con- sists of a purulent matter, which, however, is generally blended with the synovial secre- tion. In violent contusions and sprains blood-ves- sels of the joint may be ruptured, and a large quantity of blood may be extravasated in the capsular ligament. e2 54 COLLECTION OF FLUID Of all the articulations in the body not one is so subject to hydrops articuli as the knee. Many other joints are, beyond a doubt, more frequently the seat of suppuration in conse- quence of injuries ; but none are so liable to dropsical disease. The largeness and loose- ness of the capsular ligament may, per- haps, afford a reason for this indisputable fact. The causes of hydrops articuli are often not discoverable. The disease, however, is very frequently preceded by severe rheumatic a£» fections and local violence. When the fluid is not so copious as to produce prodigious dis- tention of the capsule, a fluctuation is easily distinguishable. Also, if the limb be extend- ( ed, so as to relax the ligament of the patel- la, pressing the collection of fluid causes a ris- ing of that bone, and a kind of fulness on each side of it. The disease is commonly not attended with much pain ; but there is a de- gree of stiffness experienced in the affected joint, IN THE CAPSULAR LIGAMENTS. 55 Mr. Russell* has adopted the idea that some cases of this kind are venereal, and others scro- phulous ; but, as he has not any good argu- ments in support of the opinion, it seems un- necessary to say more than that the mere existence of hydrops articuli in a subject, affected at the same time with syphilis, or scrophula, is no proof that the drop- sical swelling of the joint depends upon the specific disease. Here also I must take the liberty to remark that, if a disorder yield to mercury, unreflecting writers are extremely apt to consider this as a criterion that the complaint is of a venereal nature. Let it be remembered, however, that mercury is one of the most powerful means of exciting the action of the absorbent vessels ; and it is up- on this principle that it cures numerous diseas- es of different natures without the least inter- ference of any specific virtue. Since' we see that hydrops articuli most frequently follows rheumatism, common inflammatory affections of the knee, and fevers , which greatly debil- * On the morbid Affections of the Knee, p. 67. 1 56 FLUID IN JOINTS. itate the system ; and since the disease most- ly yields to such treatment as is not potent enough to subdue scrophulous and venereal complaints j we have every reason to believe that, though the disorder may occur in scro< phulous and venereal patients, yet it is always quite independent both of lues venerea and struma. It seems to me that the only sound conclusion to be drawn from the coexistence of hydrops articuli and one of these latter dis- eases, is that the presence of venereal, or scro- phulous complaints, in any particular subject, is ] no reason why he should not be liable to be- come affected, at the same time, with another kind of disease. If we were to adopt the oppo- site mode of reasoning we might infer that a chancre was connected with the existence of > a dropsical affection of the knee, because the sore was contracted, and made its appear- ance, during the prevalence of the disease of the joint. 57 TREATMENT. When hydrops articuli occurs during the debility, consequent to typhoid and other fe- vers, the complaint can hardly be expected to get well till the strength of the constitution is, in some degree, restored. The connection between the local and constitutional disorder is well illustrated in a case which Mr. Russell has related (p. 192), and in which every lo- cal remedy was tried without avail. The dis- ease, which would not yield as long as the de- bility consequent to a typhus fever lasted, got well spontaneously, immediately after the pa- tient had regained his strength. During eight or nine years I have been in the habit of frequently seeing, in St. Bar- tholomew's Hospital, collections of aqueous fluid in the joints ; and I can conscientiously assert that I never witnessed any case, which did not ultimately yield to blistering the part, and maintaining a discharge from the blister- ed surface by means of the savin cerate. 58 TREATMENT OF FLUID. When the disease is the consequence of fevers, a blister easily disperses the swelling as soon as the patient has recovered a little of his former natural vigour. The oppera- tion of a blister may always be very material- ly assisted by the pressure of a bandage. Mod- erate exercise ; frictions with flannel impreg- nated with the fumes of vinegar j camphora- ted mercurial ointment ; electricity ; and purging the patient with calomel, or kali acet.; are also means possessing peculiar ef- ficacy. As I have never seen any case in which the circumstances seemed to justify making an opening into the joint for the purpose of e- vacuating the fluid, I shall not dwell upon this head. But excessive distention, in some neg- lected cases, might certainly become an ur- gent reason for performing such an operation. Also, if the complaint should resist all other plans of treatment, and the irritation of the tumour should greatly impair a weak consti- tution, the practice might be justifiable. A case answering this description is related by Mr. Latta, in which twelve ounces of fluid SUPPURATION OF JOINTS. 59 were discharged. (System of Surgery, vol. ii. p. 490.) SUPPURATION OF JOINTS. When an abscess forms in the cavity of a joint the violence of the preceding inflam- mation is enough to inform us of the nature of the case. But, as abscesses are also liable to form on the outside of the capsular ligament, and we might sometimes be warranted in opening such collections, while we should not be so if they were contained in the joint it- self, I think it may be useful to say a few words upon the mode of discriminating the two cases, when in the situation of the knee. When the matter is within the joint pres- sure applied to the tumour causes an elevation of the pattella, as in hydrops articuli. Also, on placing the fingers on one side of the joint, and striking the opposite part of the tumour gently with those of the other hand, the distinct impulse of a fluid is communicated from one side of the articulation to the oth- er. The same kind of fluctuation may be 60 SUPPURATION OF JOINTS. felt on making the same experiment on any two different points, where the capsule is only covered with the integuments. An abscess of this kind has always been preceded by alarming disturbance of the constitution. When the matter is on the outside of the joint, the tumour usually extends beyond the limits of the capsular ligament: for instance, the swelling ascends higher up the thigh, or descends lower down the leg, than the capsu- lar ligament itself naturally reaches. The tumour is usualy confined to a part only of the circumference of the knee, and there it causes a more sudden prominence than results from an abscess in the joint. If the swelling extend around the patella, this bone seems more sunk than in the natural state. A FEW PRACTICAL REMARKS. When an abscess has taken place in the vi- cinity of a large joint, there can be little doubt concerning the propriety of discharging the matter by an early incision. Such purulent collections, when situated about the knee, SUPPURATION OF JOINTS. 61 frequently lie under the femoral fascia, and it is highly deserving of notice that all tendinous expansions powerfully retard the progress of matter to the surface of the body. In this circumstance the pus is apt to diffuse itself extensively on all sides, and even to make its way, by means of ulceration, into any neigh- bouring cavity. Hence, in order to avoid the possibility of the latter occurrence, it is best to make an opening into the abscess. When the matter is in the joint itself, we should feel exceedingly reluctant to make an unnecessary opening. Here the degree of dis- tention, occasioned by the abscess, ought t« decide the proper line of conduct. As puss has not that power of corroding which was attributed to it by the antient surgeons, its mere presence in the joint will not be produc- tive of any bad consequences. When, how- ever, its quantity is so large that it forcibly distends the capsular ligament, and causes great pressure on the articular cartilages, its longer continuance in the joint may occasion the most irreparable mischief, and even death. Cases of the description which we are now F 62 SUPPURATION OF JOINTS. considering, are always highly perilous, and frequently oblige the patient to submit to am- putation as the only means of preserving life. The cartilages and ligaments cannot bear this state of disease, in which they are violently inflamed, and, at the same time, ir- ritated by the pressure of the matter. They ulcerate and slough, and the articular surfaces of the bones become bare, while the matter also makes its way through the capsule, and presents itself under the integuments. If, un- der such circumstances, the state of the con- stitution should allow the surgeon to perse- vere in an attempt to save the limb, the pro- priety of opening the abscess is too obvious to. admit of doubt. The operation should be done so as to occasion as little irritation as possible. A small puncture with a lancet will suffice, and it seems safer to endeavour to heal the wound by the first intention, and to re- peat the operation, if circumstances should demand it, rather than to leave the wound un- closed. If the contents of the abscess should be dis- charged through an ulcerated opening, the SUPPURATION OF JOINTS. 63 treatment is to be conducted almost on the same principles as are applicable to all acute abscesses ; and it seems unnecessary to expa- tiate further on the subject. OF TUMOURS OCCASIONED BY BLOOD. When the collection of fluid in a joint makes its appearance almost immediately after a severe sprain, or violent contusion of the part, and continues to increase gradually for some time afterwards, there is every reason for sup- posing that the principal part of the contents must be blood. The formation of pus, and the secretion of any aqueous fluid, could not have taken place in so short a time. The ex- travasation of blood within the large joints is, I believe, exceedingly uncommon. Tumour? composed of this fluid, and set down in sys- tematic works as extravations within the cap- sular ligaments, are generally on the outside of the cavities of the articulations. 64 TUMOURS OCCASIONED If blood, however, should be known to be certainly effused in the cavity of a joint, it would not be warrantable practice to make an opening for its evacuation. Its mere pres-, ence is not likely to produce bad consequences, and in the end it will be absorbed. Frictions with camphorated liniments would accellerate this desirable event. If an opening were made, the coagulated state of the blood would, in many cases, render its evacuation impossi- ble. With respect to extravasated blood in gen- eral surgeons are now well aware how un- necessary, and even injurious it is, to make an opening into almost all tumours of this kind) The opening frequently fails in pro- curing its discharge, and the admission of air occasions the blood to putrify in cases in which, under different treatment, it might have con- tinued without producing the smallest irrita- tion. Mr. Hey mentions a case in which the knee-joint was wounded, and blood insinuated itself into it. Though it was impossible to BY BLOOD. 65 prevent the circumstance, yet no harm re- sulted from the extravasation ; and the fluid was absorbed without having created the least trouble.* * Practical Observations on Surgery. Case, p. 354. <*' F 2 *.':■ PART II- OF THE WHITE SWELLING OF THE KNEE, AND THE TREATMENT OF THE DISEASE. CHAP. I. Preliminary Remarks. THE white swelling, or spina ventosa, ;as it :"s not unfrequently called, in imitation of the Arabian writers, Rhasis and Avicenna, is a disease in this country particularly common and peculiarly intractable. The nations of the continent are, unquestionably, as subject as we are to chronic enlargements of the knee-joint. Foreign surgeons describe nu- merous varieties of a disease, which many English writers would term rheumatic white swellings ; but they acknowledge that the 68 PRELIMINARY REMARKS scrophulous species of this disorder does not commonly occur to their notice.* Wiseman was the first who used the term white swelling, and, as Mr. Pott observes, the expression is not very unapt, because it con- veys an idea of one mark of the distemper, which is, that notwithstanding the increase of size in the joint, the skin is not inflamed, but retains its natural colour. It is not my intention to occupy the time of my readers by considering the white swelling, * Fungus scrophulosus, terribile profecto malum, ra- riiis in Germania occurrit, frequentius in Britannia.r-C. G. bid joints in which the bones, ligaments, and cartilages, can hardly be said to be materially diseased. The whole of the distemper seems to consist in the deposition of a glutinous lymph, which adheres to the most subtile to- ON THE WHITE SWELLING. 71 minae of the cellular substance, and to the surface of the tendons, ligaments, and capsule of the articulation. Brambilla has named this disease fungus articulationis, and he says that it is more common in Germany than in any other European country.* But such a malady is certainly known in Great Britain, and most surgeons would call the complaint a white swelling. I see other morbid affections of the knee, in which the bones are not at all diseased, though the ligaments and cartilages have suf- fered considerable alterations; though the joint appears to the surgeon to be enormously enlarged, and the malady has even been so severe as to require amputation. I see another frequent form of disease in this articulation, in which kind of affection the ligaments, cartilages, and bones are not the parts principally diseased ; in which disorder the joint is greatly enlarged, and the bulk of the swelling arises from a morbid condition of parts on the outside of the capsular liga- * Acta Acad. Josephin. Vindob. p. I. 72 PRELIMINARY REMARKS ment ; and in which case the disease does not consist of a thick kind of lymph diffused throughout the structure of the parts on the outside of the joint, but of a morbid change^ in which such parts become, at once, enlarg- ed, thickened, and bereft of all their original firmness. This malady also is oftentimes so terrible as to render amputation of the limb indispensable. There are other cases in which the bones are softened in their texture, while the liga- ments are distempered, the cartilages absorb- ed, and the bones carious in an advanced stage of the disease. In some instances there are spinous, angular depositions of osseous matter upon the surface of the diseased bones; while in the neighbor- hood of the articular part of the same bones there are deep excavations in consequence of caries. I might enumerate several other varieties not deduced from the morbid anatomy of the joints, but from the difference in the symp- toms and progress of the complaint, as well as from the particular constitutions in which such ON THE WHITE SWELLING. 73 forms of disease occur. Were I to proceed further at present I should not leave room for the discussion of such points as I particularly wish to comprehend in this production. At some future opportunity, perhaps, I may re- new the consideration of this important part of the subject: at all events I confidently hope that the few suggestions here made may awake the attention of others, and be of some litt e use to any succeeding writer, who may attempt to discriminate the different natures of the various morbid enlargements of the knee. Caries of the bones has been mentioned by the majority of writers as necessarily attendant on white swellings. Some limitation, howev- er, ought undoubtedly to be made to the re- mark. If the term caries be meant to denote that morbid process in a bone, which is analogous to ulceration of the soft parts, surgeons are not warranted in applying the expression to the true scrophulous affection of the head of the tibia. Whether the disorder first originate in the bones, or ligaments of G 74 PRELIMINARY REMARKS the knee, it is not till after the disease has made considerable progress, and actually de- stroyed the cartilaginous coverings of the ar- ticular surfaces of the bones, that we find the tibia and femur affected with any morbid change at all analogous to caries. The scrophulous disease of the bones » most prone to attack such as are soft and of a spungy texture : so is caries j but then the effects of the former are widely different from those of the latter. The peculiar alterations which the scrophulous affection first produces, are a partial absorption of the earthy particle* of the diseased bone, and a deposition of a softish matter into the interstices of its struc- ture. There is no breach whatever occasion- ed in the seat of the disease by this change. i On the other hand, in caries, as the osseous particles are absorbed, or crumble away, no effort is made to repair the breach of contin- uity, and an excavation is necessarily the con- sequence. Such is the first and most common morbid change, which the head of the tibia undergoes »n the disorder implied by the scrophulous ON THE WHITE SWELLING. 75 white swelling. In several strumous joints which I have dissected, I have also found that a morbid deposition of a cheesy kind of sub- stance, blended with phosphate of lime, took place on the outside of the heads of the dis- eased bones. I have pieces of scrophulous bones in my possession, on which these depo- sitions, before they were considerably destroy- ed by maceration, had the appearance of o- paque crystallizations. I have seen similar specimens in Mr. Abernethy's anatomical mu- seum. The caries which attends a more advanced stage of the white swelling follows the ulcera- tion and destruction of the articular cartilages, or accompanies the formation of abscesses around the articulation. In these cases we find, on dissection, that a part of the bone is rough ; and where this roughness is situated a chasm more or less extensive and deep has been formed in the substance of the bone. I have wished to be particular in exposing the absurdity of confounding the scrophulous alteration of the bones with caries, because 76 PRELIMINARY REMARKS the matter seems to me not to have been hith- erto properly explained by any author. By caries, however, several writers seem to imply the mortification of part of a bone. This misapplication of the term is exceedingly censurable j first, because it is meant to signify what very rarely happens in scrophulous dis- eases of the joints, or in any species of white swelling whatever; and, secondly, because the sentiment which it now conveys has led to very unwarrantable practices, with a view of promoting an exfoliation, which was judged to be inevitable. It is observed by a gentleman, who has writ- ten a very good practical treatise on the pres- ent subject, that, " in the carious stage of this disease it has been said, that to expedite a cure exfoliation should be promoted j but experi- ence tells us that exfoliation rarely occurs; and when the complaint does not seem to re- quire it, may we not infer that it should not be encouraged ? It is very probable that if means had not formerly been used to produce ON THE WHITE SWELLING. 77 this effect, it would have occurred as seldom then as we now find to be the case."* From the manner in which I may have ex- pressed myself I should be sorry to be misun- derstood. I do not mean to deny that the ar- ticular parts of the bones are not very frequent- ly found carious in this disease ; but only tQ assert that caries is so far from constituting an essential feature of the disorder, that it rarely occurs until the cartilages of the joint have been more or less destro) ed ; (for, after this it always takes place) and that the morbid alteration previously observable in the bones is widely different from a true caries. The circumstance of the bones being some- times quite free from disease, even when the knee seems of considerable magnitude, must greatly strengthen the tenor of the above ob- servations. In this instance the ravages of the disorder particularly affect the ligaments of the joints, and the fat and cellular substance on the outside of the capsule. Mr. Russell, * Practical Observations on the Disease of the Joints, commonly called White Swelling. By B. Crowther. P. 6—7. G2 78 PRELIMINARY REMARKS (p. 30.) diligently describes how much the soft parts contribute to the swelling in the *..isea*e. Speaking of the appearances on dissection he observes: " The great mass of the swelling appears to arise from an affection cA the parts exterior to the cavity of the joint, and \\h\u\, besides an enlargement in size, seem also to have undergone a material change in structure. There is a larger than natural proportion of a viscid fluid intermixed with the ctlJuiar sub- stance ; and the cellular substance itseif has be- , come thicker, softer, and of a less firm consist- ence than in a state of health." (P. 15.) Mr. Crowther says: " I have shown to my medical friends some diseased joints, of which upon examination it was impossible to decide with accuracy as to the state of the parts; some of the cases they, as well as myself, con- i sidered only as an enlargement of the bone; but after the application of leeches, and an artificial drain derived from the integuments '' covering the joint, there did not appear the smallest enlargement of the heads of the bones." ON THE WHITE SWELLING. 79 I have seen many amputated joints dissect- ed, in which it was doubtful whether the car- tilages were in the least affected, while the heads of the bones were not more softened than in the natural state. Still the operation was rendered necessary by the hectical condi- tion of the patients. In these instances the whole disease seemed to consist in such an alteration of the soft parts surrounding the articulation, as is described by Mr. Russell, to- gether with a thickened and softened state of the capsular and other ligaments, and a collec- tion of a purulent, shining coagulated matter in the cavity of the joint. Mr. Russell appears to adopt the opinion, that the disease always commences in the lig- aments and membranes of the articulation, and even asserts that he never heard or knew of an instance in which the tibia was enlarged from an attack of white swelling. (P. 37.) It was this declaration, made by a surgeon of experience, which first called my attention to this point, and, though it was long after niy first perusal of Mr. Russell's book that I form- ed a decided opinion on the matter, yet can- 80 PRELIMINARY REMARKS dour obliges me to state that I derived the ori- ginal intimation from the above mentioned publication. Many surgeons, I feel certain, will be dispos- ed to grant Mr. Russell a very small portion of praise on this account ; and indeed his judg- ment might be criticised for mentioning >o lightly a fact which is highly deserving of the most extensive publicity. When we consider that numerous joints are amputated sooner than they otherwise would be, in consequence of the surgeon's firm persuasion that the bones are enormously enlarged, we must acknowl- edge that the removal of this erroneous opin- ion ought to be effected in such a manner as will leave a strong and lasting impression on the minds of the great mass of surgical practitioners. The slight allusion which Mr. Russell has made to the subject, is little calcu- lated to excite general attention, and, even at present, there are very few surgeons who dd J not place the most implicit faith in the ex- pansion of the heads of bones, in cases of white swellings. ON THE WHITE SWELLING. 81 It was in my First Lines of the Practice of Surgery that the doctrine of the enlargement of the heads of the bones was first publicly op- posed with any degree of force. The oppo- sition is still more vigorously maintained in this dissertation. Here I cannot deny myself the pleasure of giving praise to my friend Mr. Lawrence, a gentleman whose heart is enriched with the most generous qualities, and whose mind is a- domed with every requisite for forming a tru- ly great man. His penetration had detected the error into which surgeons had fallen re- specting the expansion of the heads of the bones, quite independently of any writer what- soever j and the frequent conversations which I had with him upon this subject tended, in a very powerful manner, to dispel the few last doubts which I entertained. I must candidly confess that, deceived by the feel of many diseased joints, and influenced by general opinion, I once imbibed the idea that there is often a regular expansion of the heads of scrophulous bones. But, except- ing an enlargement which arises from the de- 82 PRELIMINARY REMARKS position of osseous matter on the outside of the heads of the tibia, ulna, &c. so as to form sharp, angular, scabrous projections on them, and which alteration cannot be called an expan- sion of those bones, I have never been an eye- witness of the head of a bone being of preter- naturally large dimensions, in consequence of the disease known by the name of white swell- ing. I have frequently been in the habit of inspecting the state of the numerous diseased joints which are annually amputated in St. Bartholomew's Hospital, and though I have for several years been attentive to this point, my searches after a really enlarged scrophu- lous bone have always been in vain. The change which the head of the tibia undergoes in many cases, is first a partial absorption of the phosphate of lime throughout its texture, while a soft kind of matter seems to be secre- ted into its substance. In a more advanced stage, and indeed in that stage which most fre- quently takes place before the joint is ampu- tated, the head of the bone has deep excava- tions formed in it in consequence of caries> ON THE WHITE SWELLING. 83 and its structure is now so thoroughly distem- pered and softened that, when any instrument is pushed against the carious part, it easily pen- etrates deeply into the bone. A cursory examination of a diseased joint, even when it is cut open, will not suffice to show that the bones are not preternaturally enlarged. I dissected one this morning (No- vember 12, 1806,) and, on first looking at the parts, the swelling had every appearance of arising from an actual expansion of the bones. An intelligent medical friend who was pre- sent felt the ends of the tibia and fibula, after the integuments were removed, and coincided with me that the feel, which was even now communicated, seemed to be caused by a real swelling of the bones themselves. But, on cleaning them more, the enlargement was de- , monstrated to arise entirely from a thickening of parts on the outside of the bones. However, from all that I have seen of the disorder under consideration i am led to be- lieve that surgeons have good reason for sup- posing that some white swellings commence in the ligaments, and afterwards affect the 84 ON THE WHITE SWELLING. bones; while others begin in the spongy tex- ture of the bones, and afterwards affect the ligaments. At this opportunity I cannot re- frain from remarking that, as the ligaments are almost invariably found distempered, and the bones are not so, we must infer that in the majority of instances the disease commences in the former parts. The morbid enlargement of scrophulous joints is always made to appear greater than it really is, by the emaciation of the limb both above and below the disease. This fact is so obvious that I need not detain my readers with further observations on the subject. From such preliminary remarks I proceed to treat of the symptoms of white swellings. 85 CHAP. II. An Account of the Symptoms, and Progress of White Swellings. THE large joints, such as the knee, ankle, wrist, and elbow, are most exposed to the at- tack of this direful malady. In the first stages of the disease the skin is not at all altered in colour. Sometimes the swelling yields in a certain degree to pressure ; but it never pits, and is generally sufficiently firm to make an uninformed examiner believe that the bones contribute to the tumour. In some cases the pain is vehement from the very first, while, in other instances there is hardly any pain in the incipient stage of the affection. But what- ever the degree of pain may be, it particularly affects only one part of the articulation, and this is usually its centre. In some cases the pain seems to be situated in the head of the tibia j but wheresoever it occurs, I have always ob- served that it is always confined to one partic- ular spot. Sometimes it is incessant ; at oth* H 86 SYMPTOMS AND PROGRESS er times it intermits ; and, in a few cases, it recurs so regularly, at stated times, that it de- serves to be called periodical. When the pa- tient is warm, and especially when he is heat- ed in bed, he commonly seems to experience an exasperation of the pain. In most cases the tumour is at first very tri- vial, or there is even no swelling at all, though the pain be very considerable. A fulness is first observed to occupy the little hollows, hich are naturally situated on each side of the patella. This prominence augments, and the whole articulation soon becomes every where palpably augmented in circumference. As the patient cannot bear the weight of his body on the affected limb without a con- siderable increase of pain, he gets into the habit of only touching the ground with his toes, and thus the knee is generally kept a lit- tle bent, and the power of completely extend- ing the limb again is soon lost. In advanced cases the knee is always found in a permanent state of flexion. It is observed that, in this disorder, the swelling is always preceded by pain j but the interval between the first oc- OF THE WHITE SWELLING. 87 currence of the two affections is very various in different cases. At length the diseased joint attains an en- ormous size •, but the skin is not materially affected. The only changes observable in it are the appearance of varicose veins, and a shining smoothness. The latter circumstance seems to be owing to the distention, which obliterates the natural wrinkles of the1 integu- ments. The skin also cannot now be pinched up into a fold, as it co.ud in the early state of the disorder. When the distemper ha- proceeded further, abscesses generally form around the joint, and their contents are, in time, usually discharg- ed through the ulcerated openings. These ulcerations sometimes Heal, and other similar abscesses take place. The period at which such collections of matter occur, after the commencement of the disease, is extremely various in different cases. In some cases such abscesses form in a few months after the joint has become affected ; in others they do not take place for many years. SYMPTOMS AND PROGRESS The patient's health, in the mean time, be- comes gradually impaired in consequence of the local disease. His appetite fails; he can- not sleep at night ; his pulse is small and fre- quent ; he has profuse perspirations ; and his bowels are not unfrequently very much disordered with an obstinate and debilitating diarrhoea. Under such symptoms dissolution soon follows, unless the constitution be speed- ily freed from the irritation of the local mala- dy. In different subjects, however, the pro- gress of the disease, and its effects on the constitution, are very different in regard to the quickness with which they take place. In some instances the swelling of the knee, and the derangement of the health, do not arrive at a considerable pitch till several years have expired after the first attack of the complaint. In other examples the disease of the joint ac- quires an immense size, and falls into a state of suppuration in the course of half a year, at the end of which short time the patient's strength also may even be quite exhausted by hectic complaints. OF THE WHITE SWELLING. 8!J Such white swellings as have been termed rheumatic are certainly very distinct diseases from the true scrophulous affection of the large joints. In the former the pain is said never to occur without some swelling being evident, nor does the acuteness of the pain subside in proportion as the tumefaction in- creases. Genuine white swellings, on the contrary, are always preceded by pain, which is usually not so acute after the swelling ap- pears as it was before. I believe that all those instances in which the bones are found not at all altered in tex- ture, and the whole mass of disease seems to be confined to the soft parts, are not scrophu- lous white swellings. In rheumatic cases of this kind the pain is not confined to a partic- ular point ; but extends over the whole joint. If a man live till the ag"e of five and twenty, quite free from every symptom of scrophula, I believe he can never, after this period, become first affected with a scrophulous disease of the knee. I believe also that all cases in which the head of the tibia loses a good deal of its natural firmness, in consequence of a morbid H 2 SYMPTOMS AND PROGRESS alteration, which I have already endeavoured to describe, are scrophulous cases. The limphatic glands in the groin are often enlarged in consequence of the affection of the knee ; but I never saw this secondary com- plaint prove permanently troublesome. Mr. Russell makes a similar observation. The head of the tibia seems to suffer con- siderably more than the condyles of the fe- mur. I have dissected several scrophulous knee-joints, in which the articular surface of the femur had not a single rough or carious point, while that of the tibia had suffered con- siderably from caries all round its circumfer- ence. The decay of the cartilages of the joints is observed to commence at their edges, and to extend gradually toward their centre ; and this mischief is always much more advanc- ed on the tibia than on the os femoris. When white swellings commence in the bones there is great reason to believe that, in knee cases, the tibia is the bone in which the disease has its origin. In young subjects the distemper sometimes, though very rarely, produces such a complete OF THE WHITE SWELLING. 91 destruction of all the ligaments of the knee that the bones of the leg become drawn up the posterior part of the thigh bone, by the strong action of the flexor muscles of the leg. I have been informed by Mr. Lawrence that he saw in the country, last summer, a child with a scrophulous knee joint, which had a very singular appearance, in consequence of the great retraction of the bones of the leg in the above manner. Mr. Langstaff lately showed me a patient with a diseased knee, whose leg could be bent to each side, for a very considerable distance, both when the knee was extended and bent. This was cer- tainly not a scrophulous case ; but the above extraordinary looseness of the joint could only result from some affection of the ligaments. In an advanced stage of white swellings I believe that a partial luxation, consisting of a retraction of the heads of the tibia and fibula upwards, towards the tuberosity of the ischi- um, is not very uncommon. I have never seen any case in which the head of the tibia was completely separated from the body of the bone, in the way in which it is said some- times to be in young subjects. 92 CHAP. HI. Of the Causes of the White Swelling, and the Grounds on which it is rtgardtd as a scrophu- lous Disease. I AM one of those persons who believe that every subject of a scrophulous habit is predisposed to certain forms of disease in the joints, and it is to these forms alone that I shall allude, when I make use of the term white swelling, in the present chapter. In the constitution which I have just men- tioned, every cause which is capable of pro- ducing inflammation, or any morbid and irrita- ble state of the knee-joint, is very likely to be productive of such mischief as may terminate in the severe disease of which we are now treating. A cold stream of air blowing a- gainst the neck of a scrophulous subject, or exposure to damp, will often produce an in- flammation and enlargement of the lymphatic CAUSES OF THE WHITE SWELLING. 93 glands, in the vicinity of the basis and angle of the jaw, and this affection may terminate in a scrophulous disease of those glandular parts. It is also a fact, which Mr. Burns * of Glas- gow has accurately noticed, that causes which would scarcely induce inflammation in a healthy person, may induce a local disease and inflammation in a scrophulous habit. Hence, an enlargement of the glands of the neck is more apt to occur in such a temperament than in a person of a sound constitution. These obser\ations are also applicable to the knee-joint. External \iolence, exposure to damp and coid, will much more readily pro- duce irritation in that articulation, when the patient is scrophu.ous, than when he is of a sound haSit of body. Even when such irritation is produced in the knee of a healthy person, by these causes, it is more easy of cure, and betrays no tendency to specific morbid action. But when the knee-joint is at all irritated in a scrophulous subject, that morbid affection * Dissertations on Inflammation, vol. ii. p. 341r—351. 94 CAUSES OF THE which constitutes the white swelling is very likely to ensue. Thus, rheumatic complaints of the knee often become the exciting cause of scrophulous disease in the articulation, when the constitution is what is called scrophulous. From the preceding statement we may ea- sily discern why white swellings, in a great number of instances, appear to originate with- out any known cause. Mankind are little in- clined to suspect that going out in the damp, exposing themselves to cold, or meeting with a trival contusion of the knee some weeks be- fore any serious uneasiness is felt in the joint, can have any connection with the origin of the complaint. Such occurrences are fre- quently not even remembered. In young subjects, who are certainly more liable than adults to white swellings, we cannot wonder that no reason can generally be assigned for the commencement of the disorder. They are frequently mere infants, and the slight in- juries which larger children meet with in play are no sooner received than forgotten. Hitherto I have assumed the point that the white swelling is a scrophulous disease, and it WHITE SWELLING. 95 remains for me to notice the arguments on which this doctrine is founded. We shall soon perceive that the most weighty reasons, the opinions of the most accurate observers, and the evidence of daily experience, combine to establish the theory. Wiseman calls the spina ventosa a species of scrophula, and re- marks that infants and children are generally the subject of this disease. (Book iv. chap. 4.) Senerinus* observes that this disorder is al- most peculiar to youth. Petrus de Marchet- tisf has seen both men and women afflicted with the disease as late as the age of five and twenty ; but not afterwards, unless they had suffered from it before that period, and had not been cured. R. Lowerus also maintains that adults never become affected with the mala- dy, unless they have been attacked by it in their youth. Chun, however, who informs us (in a dissertation on paedarthrt caces) of the opinion entertained by Lowerus, adduces some cases to show that the disease may now * De Psdarthrocace, cap. xii. and xvii. f Obs, Med.Chir. rarior.p. 118. 96 CAUSES OF THE and then occur, for the first time, in persons of advanced age. But in the present enlighten- ed state of surgical knowledge we may doubt that such cases were truly scrophulous white swellings. At all events the hVt occurrence of the latter kind of tumours, like the first oc- currence of scrophula, in adults older than twenty-five, is equally rare. I have several times asserted that every diseased knee-joint is not to be indiscriminately set down as a scrophulous disease. The white swelling, like other scrophulous affections, seems very often to be an heredi- tary disease. Foreign writers, among whom I need only mention the celebrated Petit and Brambilla, have very justly remarked that the English, who are peculiarly liable to scrophu- la, are also particularly subject to white swel- ling. But what occasion is there for further evidence on this point ? Daily experience informs us that young persons affected with this disease are, for the most part, either man- ifestly scrophulous, or have formerly been so, Many have, at the same time, enlarged lym- phatic glands in the neck or other situations; WHITE SWELLING. 97 and many are known to be descended from parents who had scrophulous diseases. Mr. Crowther says, " most of the patients whom I have seen afflicted with this disorder were of a strumous habit, and descended from parents of a similar constitution. In some cases it has also appeared that many of their families have been destroyed by phthisis pulmonalis." (p.4«.) The fine skin, the tumid,pale,unhealthy coun- tenance ; the delicate complexion ; the light blue eyes ; and the swelling of the upper lip ; those striking appearances so indicative of a scrophulous habit are also frequently observa- ble in persons affected with white swellings. But what I consider as one of the strongest tests of the disorder being of a scrophulous nature, is the coagulated, shining matter, re- sembling the white of an egg, so frequently found, not only in the cavity of the morbid articulation, but also on the outside of the capsular ligament, particularly in the abscesses which form in an advanced stage of the dis- ease. I believe that such shining, flaky, co- agulated matter is peculiar to scrophulous af- fections. We frequently find flakes of this i 98 CAUSES OF WHITE SWELLING. kind of substance blended with the pus which is discharged from lumbar abscesses ; and it almost always constitutes a large portion of the matter which collects in the suppurated state of scrophulous lymphatic glands in the neck. If this kind of matter be a criterion of scro- phulous disease, the species of white swelling in which such a secretion takes place, without any softening of the heads of the bones, is also to be considered as a strumous affection. 99 CHAP. IV. Treatment of White Swellings. BEFORE entering upon this important part of the subject I think it of great consequence to state that white swellings, whether of that description which has been termed rheumatic, or of that kind which is denominated scro- phulous, present themselves in practice in two very different stages : in one stage there is a degree of acute inflammation about the joint, in the other the affection is altogether chro- nic. In the incipient, and indeed very often in the more advanced period of the disorder, it is exceedingly difficult to persuade patients to keep the joint entirely at rest. Imprudent at- tempts to walk too frequently produce a state of the affected joint, in which the skin is ten- der when touched, and seems to the fingers of an examiner hotter than the integumentsof the opposite knee. Besides, we have already no- 100 TREATMENT OF ticed that common inflammation often be- comes the exciting cause of most obstinate dis- eases in the articulation. In the ordinary state of white swellings the skin does not appear to be hotter than that of a healthy knee, and the integuments can be handled without producing any particular un- easiness to the patient : in short, we have ev- ery reason to regard the malady as one of a chronic nature. When a surgeon is called to a case in which there is evidently acute inflammation present, there can be no doubt that topical bleeding and cold saturnine lotions are means which may be eminently serviceable ; and what is implied by the phrase antiphlogistic treatment may now be advantageously employed. But such are my feelings upon this matter that I cannot withhold my strongest censure from those practitioners who lose weeks and months in the adoption of such treatment. The plan is truly beneficial and scientific as long as the integuments are hot and tender, and the joint is affected with very acute and general pain, and the patient is indisposed with the usual WHITE SWELLINGS. 101 symptoms of inflammatory fever. But no sooner is this stage past than such treatment becomes ridiculously inert, and by preventing the employment of really efficacious measures it may even be considered as, in some degree, conducive to the increase of a most terrible disease. Having treated of inflammation in the joints in the first part of the dissertation, I feel it quitesuperfluous tosay anything here concern- ing such means as are adapted to remove the unusual tenderness and heat of the skin some- times attendant on white swellings. The best plan of arresting the morbid process in the bones, ligaments, cartilages, and soft parts sur- rounding the articulation, and the most suc- cessful method of diminishing the chronic enlargement of the joint, are subjects much more worthy of our present investigation. If we consult the writings of Hippocrates, Celsus, Rhases, JEtius, Hieron, Fabricius, &c. and compare their remarks with the inculca- tions contained in modern books, we shall soon discover that the practice applied to the morbid affections of the joints by the very best i 2 102 TREATMENT OF practitioners of the present day, is not mate- rially different from what was employed by our predecessors many centuries ago, in sim- ilar cases. As Mr. Crowther accurately re- marks, we learn from the ancients that "fhey used local and general blood-letting, the actual and potential cautery, with vesicating and stimulating applications to the skin. They further maintainedthat soresproduced by these means should have their discharge promoted, and continued for a considerable length of time." Some mild cases of white swelling, but not scrophulous ones, I should conceive, may be cured by using topical applications composed of strong astringents of the mineral and vegeta- ble kingdom. Mr. Russell recommends a decoction of oak bark, containing alum. There are other instances in which the em- ployment of sea water, as a lotion to the knee, is certainly beneficial. I have seen several cases in which the enlargement of the joint has been diminished by this application ; but I cannot say that I have ever known one exam- ple iij which a cure was accomplished by it. WHITE SWELLINGS. 103 Sea air and sea bathing together undoubtedly have very powerful effects on scrophulous af- fections in general, and most particularly so on such diseases when situated in the joints ; and, I believe, few will be inclined to question this irrefragable truth, that residing in a mari- time situation and bathing in the sea have im- mense influence in checking the progress of scrophulous diseases of the joints. However, though this favourable opinion ought to be en- tertained of sea air and bathing unitedly, yet, as I have seen sea water alone very extensive- ly used as a lotion for white swellings in this metropolis, and, upon the whole, have seen only very little benefit result from the prac- tice, I should be guilty of perversion were I to say a great deal in its commendation. Also, with respect to residing on the sea coast and bathing, as means to be tried together, my own individual opinion is, that such a plan ought only to be valued as an auxiliary one, to be pursued at the same time that other more potent measures, hereafter to be noticed, are put in execution. 104 TREATMENT OF I am sorry that the observations which I have had opportunities of makingarenot much in favour of electricity as a means of curing white swellings. In a few instances, it is true, it has appeared to do good ; in a few others, however, according to my judgment, it appear- ed rather to exasperate than diminish the dis- ease. In by far the majority of cases in which I have seen electricity tried the effects were so insignificant that it was difficult to pro- nounce whether they were of a favourable or an unfavourable nature. The greatest evil of employing inert means is the false confidence excited, which only leads the surgeon to postpone the adoption of such measures as can alone be useful, and, what is the more to be regretted, effectually useful, in most cases, only in the less advanced stages of the mala- dy. With regard to fomentations and poultices I consider them as perfectly inert, and quite unworthy of the praises which some writers bestow on them. Vjnunti occurrite morbo is a maxim which I should particularly wish to inculcate in this branch of surgery. Whoev- WHITE SWELLINGS. 105 er does nothing does harm, because he is al- lowing an insidious disease to gain ground ; and, as inert measures create a semblance of something being done, they ought to be most strongly reprobated, as, in fact, preventing other really proper steps from being pursued. Humanity in the practice of surgery does not consist so much in withholding strong and vigorous measures, as in boldly deciding to employ them the very first moment when they are indicated. Let this be an axiom, which every lecturer should instil into the minds of his pupils ; let the sentiment be con- stantly alive in every one who professes the noble art of surgery. Then we should no longer behold the instruments of surgery in the hands of men whose indecision paralyses whatever knowledge they possess ; then we should see the due degree of benefit accrue to the world, that degree, which the present cul- tivated state of surgical science ought to af- ford. I am aware that the French surgeons have extolled warm stupes, and, indeed, they sup- port their commendations on the solid basis 106 TREATMENT OF of stubborn facts. But it is to be noticed that the mildness of white swellings on the conti- nent will not allow us to consider them as a malady at all like what we find them to be in this island, and consequently it would be ab- surd to take French practice as a model for English practitioners. The only method of treatment which my own personal experience enables me strongly to recommend, consists in keeping up a dis- charge from the surface of the diseased joint. The opportunities which I have had of observ- ing the effects of blisters and cauttic issues, rather incline me to prefer the former to the latter. I have seen great good derived from both ; but more from blisters than from the other kind of issue. There are instances in which I should employ vesicating applications; there are others in which I should prefer mak- ing an eschar with caustic. To keep a blister open a very long time with the savin cerate, is generally attended with a good deal of pain to the patient and trouble to the surgeon. The cuticle is secreted so rapidly on the sur- face of the cutis that it becomes necessary to WHITE SWELLINGS. 107 scrape the white matter off the blistered sur- face very frequently, in order to keep it from healing. This operation always gives infinite pain, which is the more distressing, because it is to be so often reiterated. When a blister is preferred it is best to ap- ply a large one. Some practitioners recom- mend blistering first one side of the Joint and then the other, alternately, for a considerable time. Thus, while one blister is heatng an- other is forming, and the method is said to be attended with considerable success. I can- not say that I have seen this plan followed up as it ought to have been; but from all I have seen and heard I am induced to entertain a very favourable opinion of such practice, and shall certainly very soon take an opportunity of giving it a fair trial. I have only to repeat that, in my opinion, a large blistered surface properly kept open by means of the savin cerate, has some advan- tage, in point of efficacy, over issues made with caustic and kept open with peas or beans. The plan of dressing blisters with the savin ointment was first introduced into practice by J08 TREATMENT OF Mr. Crowther, and he is entitled to the whole of the honour attached to this improvement. The former method of dressing excoriated surfaces with the ointment of cantharides was often productive of very troublesome strangu- ries and retentions of urine, complaints which never occur from the external employment of savin. With respect to caustic issues, they are at first evon more painful than blisters ; but they afterwards become more like indolent sores, and are more easily kept open for a length of time, than a blister. They are usually made on each side of the diseased joint, and their size, for an adult, is commonly about the same as that of a half crown. I need not detain my readers with an account of the manner of mak- ing them and keeping them open, such cir- cumstances being familiarly known to every novice at all initiated in the surgical profes- sion. It has been a disputed point, whether blis- ters and issues produce benefit upon the prin- ciple of counter-irritation, or in consequence of the discharge which they occasion. I am WHITE SWELLINGS. 109 inclined to believe that they act beneficially in both ways. Rubefacients are certainly effica- cious in exciting the action of the absorbents, and probably also in modifying the action of the vessels in diseased parts. I have not men- tioned them in this dissertation because I am decidedly of opinion that, whenever such ap- plications might be, in some degree, servicea- ble in cases of whi-e swelling, a blister would be so in a still greater degree. Rubefacients must obviously act altogether on the principle of counter-irritation. A blister operates in the same way, but much more powerfully ; and, if efficacy also result, and I firmly believe that it does result, from maintaining a copious dis- charge from the vicinity of the disease, vesicat- ing applications must always be preferable to mere rubefacient ones. With regard to constitutional remedies in cases of white swellings, little is to be said. Many diseased joints are undoubtedly connect- ed with a kind of constitution, which we call scrophulous. In the present state of medical science we are not acquainted with any medi- cine which has any certain power of altering K HO TREATMENT OF this kind of temperament. It seems rational, however, to combine such general remedies as have been known to be serviceable in other strumous diseases with the local treatment al- ready noticed. Hectic symptoms are such as we commonly have to palliate in the cases un- der consideration. When the stomach can bear bark this medicine should be given, con- joined with the aromatic confection. I have seen so much comfort derived from the pru- dent administration of opium to patients afflict- ed with diseased joints that 1 cannot refrain from strongly praising it, and declaring that the objection made to its employment, on the ground that it increases perspiration, seems to me exceedingly frivolous when I call to mind the great good which this excellent medicine produces in keeping off a debilitating diarrhoea, alleviating pain, and procuring sleep. Nothing is more serviceable in all cases of diseased joints, than keeping the morbid parts perfectly motionless. Foolish attempts to walk frequently frustrate the most scientific plan of treatment. Some surgeons are in the habit of confining the diseased knee in splints, WHITE SWELLINGS. Ill and impute a good deal of benefit to this plan. I am very much inclined to think veil of the method ; but 1 can say nothing particular in its recommendation from my own personal ex- perience. We see that one constant effect of disease in the knee is to produce a contrac- tion, or permanently bent state of the articula- tion. This might undoubtedly be prevented by splints, and, by altering the position of the joint, as well as by keeping it completely motionless, some beneficial change might also be made in regard to the malady itself. Here I shall take the liberty of laying be- fore my readers four original cases of diseas- ed joints, which were materially benefited by maintaining a discharge from blisters op issues. 112 CASE III. Hannah Hussey, when eleven years of age, and a month after she had recovered from the small pox, was attacked with pain and swelling of the right knee. Various lo- tions and plasters were made use of, but with- out any good effect, the disease still continu- ing to increase. In the month of July, 1803, two years after the patient first complained, the whole joint had become prodigiously swollen under the inert treatment and even neglectful plan which had hitherto been a- dopted. At this time the integuments were hot and tender to the touch; a fluctuation was per- ceptible in the anterior part of the tumour, and the condyles of the femur communicated a deceitful sensation, when handled, as if they were really very much enlarged. On moving the joint a grating noise could be heard, and considerable pain was experienced v| under the knee pan, andjn the centre of the CASES OF WHITE SWELLINGS. 113 articulation. The patient's health was also much impaired. Leeches were applied to the joint, and the saturnine lotion was continually made use of. The leeches were repeated three times, and at the expiration of a week, the heat, acute pain, and tension had considerably abated. A blister was now put on each side of the joint, and dressed with the savin ce- rate. Tonic medicines were, at the same time, internally administered. A copious discharge was in this manner kept up for three months, during which time all the symptoms gradually diminished. As there was some difficulty in keeping up a sufficient discharge from the blistered sur- faces, in consequence of inattention on the part of the patient and her friends, the blis- ters were now allowed to heal, and issues were made with caustic in their stead. A dis- charge was continually kept up from these for five months. At the end of this time the pain in the ar- ticulation was entirely removed ; the whole collection of fluid in the capsular ligament K L» 114 CASES OF WHITE SWELLINGS. absorbed ; and the girl's health perfectly re- stored. She was able to walk a considerable dis- tance without much inconvenience, though the joint was still somewhat enlarged. In this amended state she continued for three months, when her health began to de- cline again j fluid was accumulating in the joint j and the pain was returning. Blisters and the savin- cerate were once more em- ployed, and tonic medicines administered. This plan was unremittingly pursued for three months, when the disease of the joint seemed to be completely stopped. As the knee had a tendency to contract, it was con- fined in as straight a position as possible by means of a splint. Sufficient attention, how- ever, was not paid to this method, and a de- gree of contraction took place. The joint now remains somewhat larger, less flexible, and strong, than the other ; but the pain is entirely removed, the morbid af- fection has ceased^ and the event of the case may be deemed a very successful one. 115 CASE IV. Elizabeth Goddard, fourteen years of age, applied for surgical assistance on account of pain and enlargement of the ankle-joint. The complaint had existed, in a slighter de- gree, for three years, and had originated in consequence of an external injury. Various applications had been made use of without benefit. The articulation was now very much swol- len, particularly about the internal maleolus. The patient was equally incapable of using her ankle, and bearing any weight upon it. As there was no appearance of active in- flammation a blister was immediately applied to each side of the joint, and afterwards dres- sed with the savin cerate. A copious dis- charge was thus maintained for five months. Very soon after the application of the blisters a material change for the better took place, and when the excoriated surfaces were healed the fullness and pain of the joint had subsi- 116 CASES OF ded, and scarcely the smallest degree of en- largement could be perceived. A trivial stiffness and weakness alone remained. CASE V. John Talmage, thirty-six years of age, applied for surgical advice four years ago last spring, on account of an enlargement of his left knee. The disorder had existed five weeks, and was attended with a degree of pain and heat in the articulation. Some purging medicine was prescribed for him, and he was directed to apply linen, wet with the saturnine lotion, to the affected knee. No more was seen of the patient for nine months, during which time he had been under the care of different medical men with- out obtaining any benefit whatever. On his second application the tumefaction of the articulation was much increased •, the pain, heat, and tension were very considera- ble j and a sensation was communicated on feeling the condyles of the os femoris, jut as if they were actually enlarged. WHITE SWELLINGS. 117 Leeches and the saturnine lotion were made use of, till the knee became in a more quiet state, and then a copious discharge was kept up on each side of the articulation, with very little intermission for a year and a half. The discharge was obtained, partly by means of blisters and partly by means of caustic is- sues. Though this treatment diminished the swelling around the joint, as weil as the quan- tity of fluid in the capsular ligament, yet the pain in the articulation, after having been at first relieved, returned, and continued in so great a degree that the patient could not bear to stand on the leg, nor suffer the slight- est motion of the knee. For a long time he was also under the necessity of taking opium at night. Besides the above remedies, camphorated mercurial ointment was well rubbed into the knee, and mercury was internally exhibited, so as to affect the system. A fair trial was also given to the muriate of lime, which is sometimes serviceable in scrophulous diseases of the bone*. This case, however, was prob- 118 CASES OF ably not of a scrophulous nature; for it had originated in a man thirty-six years of age, in consequence of external violence, and in a constitution in which there were no vestiges of a scrophulous habit. In the present instance therefore, as might be ex- pected, neither mercury nor the muriate of lime proved of any utility. In December, 1805, he was-admitted into one of the London hospitals, where he re- mained ten weeks without deriving the least benefit from the various applications which were tried. Latterly he has declined doing any thing for his complaint. Great pain is still experi- enced in the affected joint, and some enlarge- ment of the part is still manifest. There is a degree ofmoveableness in the articulation; but all motion is attended with a grating noise. and considerable pain. The leg and thigh , ] are both very much emaciated, and this cir- i cumstance, as I have stated in a foregoing j chapter, always makes a joint seem more en- larged than is really the case. As his gen- eral health does not materially suffer, he WHITE SWELLINGS. 119 seems negligent of the local disease. He continues to enjoy some share of locomotion, by transmitting the weight of his body to the ground, by means of a strong forked stick, which is made fast to the hip, and supports the leg and foot. In this case we must allow that the prog- ress of the disease was arrested by the blisters and issues, though they did not accomplish a complete cure. They did not permanently relieve the pain ; but they diminished the thickening of the soft parts around the articu- lation in a very considerable degree. CASE VI. William Paley, aged forty, and a robust man, was seized three years ago with an affec- tion of his right knee. The complaint had been coming on about three weeks before he applied for advice. The joint was now con- siderably swollen, and affected with severe pain, extending all over the articulation. There was likewise a good deal of fever. 120 CASES OF Leeches and the saturnine lotion were ap- plied to the joint, and purga'ive, h-brwuge, and opiate medicines .eie yitcribed. At the expiration often days the febrile symp- toms had abated -, but the state of the joint was scarcely altered, and, as the pain continu- ed to be excessive, emollient fomentations and poultices were used as topical applications. This plan was certainly productive of infinite relief. A month elapsed before the joint became sufficiently quiet to warrant the topical em- ployment of stimulants. The articulation was greatly enlarged, and handling it created ] uneasiness ; but as the heat and pain were now diminished, I applied a blister to each side of the joint. As soon as the cuticle was removed the excoriated surfaces were dressed two or three times with the savin cerate, 4 This produced so much irritation that the < former symptoms returned, and it was necessa- ry to have recourse atja n to the emollient plan of treatment, till the inflammation, &c. | had abated. m WHITE SWELLINGS. 121 The blisters were once more applied ; the same consequences ensued, and the same remedies were again adopted. The next time, when the joint had become free from pain and preternatural heat, a large issue was made with caustic on each side of the part, and kept open by means of beans. The strictest quietude was enjoined, and the Peruvian bark administered. As the discharge continued, so did the dis- ease gradually subside ; and as the patient was sensible of the benefit which he reaped from the mode of treatment, he persevered in it with all that fortitude and attention which could be desired. A continual discharge was kept up for fourteen months, at the end of which time his knee was considerably reduced in size, and he was able to walk and bear upon it with very little inconvenience. However, there is still some enlargement of the joint, and the patient has not so much motion and strength in it as in the other knee. In this case we clearly see that perpetual blisters cannot always be employed, on account of the excessive irtitation which they some- L l22 CASES OF WHITE SWELLINGS. times produce throughout the joint ; and that, under such circumstances, caustic issues may be advantageously made instead of them. I believe, this is most frequently the case with some kinds of rheumatic white swellings, and very seldom with such as are truly scrophu- lous ; for these latter are naturally very chron- ic affections, and bear the stimulating effect of a blistered surface without the production of a general irritation through the diseased joints. But this observation applies only to cases which are not in an inflammatory state, or (in other words), which are unattended with heat of the skin, throbbing pain, &c. I need scarcely notice that the last case was undoubtedly not of a scrophulous nature : the disease began at too advanced a period of life, and the pain, instead of affecting one particular part of the joint, was general and / diffused. 123 CHAP. V. Treatment of the White Swelling concluded. WHILE the patient's constitution contin- ues equal to sustain the irritation of a scro- phulous or other inveterate disease of the knee-joint, no humane practitioner would ev- er think of proposing amputation of the limb, however difficult, or impossible he might hith- erto find it to cure the malady, or even retard its progress. Such sudden alterations for the better do sometimes succeed a long duration of intractable disorder in a joint, that no man can pronounce with certainty that every chance of preserving the limb is at an end. The state of the general health, and not of the local disease, is the only thing that can form a solid reason for the removal of the af- fected member. When the strength of the system has been almost exhausted by the se- vere effects of the local malady on the consti- tution, I see no rational alternative. A long- 124 TREATMENT OF er attempt to preserve the limb would only plunge the patient into so feeble a condition, that no mortal effort, no human skill, nor sci- ence, could again recal the sad, though con- solatory dilemma, of loosing the limb for the sake of preserving life. What man of common understanding, a- ware of the severe nature of hectical symp- toms, after they have lasted a considerable time, can feel a want of decision in these cases ? What reasonable being can suppose that a speedy dissolution will not result from the total loss of appetite, rest, and strength, profuse night sweats, and as profuse purgings, which foil, as Mr. Pott very ably describes, all the efforts of medicine, and bring the pa- tient to the brink of destruction ?* But never let the surgeon undertake the important operation of amputation merely on account of the unpromising aspect of a diseased joint. If, governed by this consid- eration alone, he should presume to advise the * Chirurgical Works, vol iii. Remarks on Amputa- tion, p. 371. Edit. 1783. WHITE SWELLINGS. 125 use of the knife, he is guilty of the most cul- pable ignorance. I again repeat (for I think it a subject of the highest consequence), that the debilitated state of the constitution,the im- paired state of the health, is the only thing which can ever urge the performance of am- putation in cases of white swellings. If the strength is still remaining, though the diseased joint may be immensely enlarged; nay, though it may be surrounded with abscesses ; the operation of removing the limb is not indi- cated ; and thaf man evinces a very mistaken judgment, who recommends, under such cir- cumstances, the employment of the knife. As I have already said, while the constitution shows itself equal to the struggle, it is impos- sible to prognosticate with certainty that a white swelling, however bad it may be at pre- sent, will not have such a termination as shall enable the patient to preserve his limb. Doctor Jeffray, professor of anatomy and surgery in the college of Glasgow, laid before the public, a short time ago, all the facts which are extant on the subject of the excision of L2 126 EXCISION OF carious joints, as an operation to supersede the removal of the whole limb.* The observations which I have to make on this subject are few; but, I hope, they will be to the point. My sentiment has been already stated with regard to the time when every hope of curing a diseased joint ought to be abandoned. I have stated that the approach of dissolution, in other words, the sunk state of the system, can be the only solid reason for amputation, and that, as long as the patient's strength is not subdued by the irritation of the local dis- I ease, humanity dictates the propriety of perse- vering in an attempt to save the affected limb. Indeed I would reprobate any man who should inculcate the premature practice of a severe operation, as being either defective in profes- sional judgment, or destitute of a proper re- gard for his fellow-creatures. * Cases of the Excision of Carious Joints, by H. Parke, i Surgeon in the Liverpool Hospital; and P. F. Moreau, , {] M. D. de l'ecole de Paris: with Observations by J. Jef« fray. 1806. CARIOUS JOINTS. 127 Will a patient, greatly reduced by hectic symptoms, be able to recover from so bold and bloody an operation as the dissection of the whole of the knee-joint out of the limb ? If some few should escape with life and limb preserved, would the bulk of persons, treated in this manner, have the same good fortune ? I cannot admit that the extirpation of the whole of so large an articulation as the knee, can be compared with the operation of am- putation, in point of simplicity and safety. However, it is nqj on the difficulty of practi- sing the former that I would found my objec- tions ; for I believe that any man, possessing a tolerable knowledge of the anatomy of the leg, might contrive to achieve the business. The grounds on which I shall at present withhold my approbation from the attempt to cut out large joints are the following. 1. The great length of time which the healing of the wound requires. Whoever peruses the case of Hector M'Caghen (P. 18.) will find that the operation was performed on the 2d of July, 1781, and that it wasFebrua- 128 EXCISION OB ry 28th of the following year before all the subsequent abscesses and sores were perfectly healed. This space of time is very nearly eight months! Mr. Parke describes the pa- tient as a strong robust sailor; and gives us no further particulars concerning the state of his constitution, at the time of the operation, than that his health was declining. I entertain lit- tle doubt that if the excision of the knee had been performed in that state of the health in which amputation becomes truly indispensa- ble, this man would not have survived the op- eration. The only other case in which Mr. Parke extirpated the knee ended fatally. In the instance related by Moreau (P. 129.) there seemed indeed to be considerable debility. This patient escaped the first dangers conse- quent to so severe an operation ; and, after three months confinement, the patient was in such a state that M. Moreau expected that he would be able to walk upon crutches in another month, or six weeks ! The young man in the mean time was attacked with an epedemic dysentery, which carried him off. CARIOUS JOINTS. 129 2. Even supposing the excision of the knee- joint to be followed with all possible success, is the advantage of having a mutilated, short- ened, stiff limb, in lieu of an artificial leg, suf- ficiently great to induce any man to submit to an operation infinitely more dangerous in the result than amputation ? I think not. I should be sorry to appear prejudiced a- gainst any branch of practice ; but particular- ly so when the method is, in some degree, supported on the basis of fact, and the recom- mendations of very respectable characters. I profess myself to be a sincere admirer, and a warm, though feeble, patron of all rational in- novations and improvements, and it would be with heart-felt pleasure that I should foresee. any likelihood of the present proposal becom- ing really beneficial to mankind. The es- teem in which I hold my profession will al- ways render me anxious for its cultivation. But the very same principles which would urge me to extoi certain introductions into practice, will always force me to condemn oth- ers, of which I cannot form so propitious an opinion. 130 EXCISION OF CARIOUS JOINTS. It seems to me not unlikely that such cases as are related by Mr. Parke and M. Moreau may even occur again, and be laid before the public, with circumstances, forming a strong- er recommendation of the practice. But I am afraid that the events of such examples will always be considered rather as escapes than scientific cures; as instances rather to be remembered than imitated. I shall say nothing concerning the extirpa- tion of other articulations, except that the op- eration in the elbow would not be so formi- dable as in the knee. When the disease is in this situation, however, amputation is also less severe than when performed on the thigh. These are all the remarks which I presume to offer at present on the subject of white swel- lings of the knee. PART III. DISEASE OF THE HIP-JOINT. CHAP. I. Description of the Complaint. IT is far from my intention in the subse- quent columns to take a view of the whole of this interesting subject. If I succeed in tra- cing the characteristic features of the present disease, explaining the most efficacious plan of treating it, and laying before my readers a few interesting cases, I shall feel that my undertaking, however incomplete, will not be altogether destitute either of useful or original matter. In performing this task I 132 DISEASE OF shall aim at adopting the same simplicity of style, which it has been my wish to diffuse throughout the preceding pages. To such readers as may admire a more ornamented and florid production I can only say with Celsus, " morbi non eloquentid sed remediis cu- rantur." Prsef. lib. i. The first proposition with which I shall commence is that the complaint commonly called the " disease of the hip-joint," is very analogous in its nature to the white swelling of other articulations. Like the latter mala- dy it probably has its varieties, some of which are undoubtedly connected with scrophula, while others cannot be suspected of having any concern with a strumous habit. I believe that in a given number of cases there are more diseased hips, quite independent of scrophula, than there are white swellings of other joints. We have noticed, in the second part of this dissertation, that young subjects are most particularly subject to scrophulous diseases, and of course to that affection of the joints which is commonly considered to THE HIP JOINT. 133 be connected with a strumous constitution. It has been stated that if a person live to the age of five-and-twenty, perfectly free from all scrophulous symptoms, the hazard of his ever becoming afterwards afflicted with a true scrophulous complaint, may be regarded as almost paat. Hence all morbid affections of the joints, first occurring after this period of life, and under such circumstances, I think, may be justly deemed to have no connexion with scrophula. Disease of the hip-joint is most commonly met with in children under the age of four- teen ■, in this respect it is very analogous to the true white swelling. But no age is ex- empt from the malady; so that though chil- dren form a large proportion of those sub- jects who are afflicted, yet the number of adults, and even of old persons, is much more considerable in a given number of these cases than we find to occur in the same num- ber of cases in which the knee is diseased. This is my reason for thinking that there are more hip cases unconnected with scrophula, than M 134 DISEASE OF there are examples of white swellings being similarly circumstanced. Of course I apply the observation only to a definite number of cases of each disease ; for the much more frequent occurrence of morbid knees, ankles, wrists, and elbows, than of diseased hips, would destroy the accuracy of the remark, if taken in a general sense. The approach of the hip disease is far more insidious than that of 3 white swelling. The latter is generally preceded by severe pains, while the only forerunner of the former is frequently a slight weakness and limping of the affected Hjmb. This state is too often overlooked, and when noticed by men little versed in the profession is commonly treated on principles the most repugnant to surgical science. Embrocations are generally prescrib- ed, without any injunction to keep the limb in a quiet state. The application is also of- ten made to the knee, or other part of the extremity ; for as there is frequently an un- easiness about that joint, when the hip is af- fected, and as no pain whatever is sometimes THE HIP JOINT. 135 mentioned, as occurring in the latter situation, till a more advanced period of the malady, it is not uncommon to see careless practitioners directing their remedies to some situation very different from that of the disease. While such applications as stimulating lini- ments are directed, the shrewd observer may remark that the error is a fortunate one, and that it is better to apply nothing than what is of an irritating nature. I coincide most sincerely with this sentiment; but how shall we excuse such supine neglect, such guilty ignorance, when we are informed that this incipient period of the complaint is the only one in which a favourable prognosis might be made ! for mere rest and repeated topical bleeding will now have more effect, in the course of a fortnight, than large pain- ful issues will afterwards generally have in the long space of a twelvemonth. The first diagnostic symptoms of disease in the hip joint, if we merely look for them in the situation of that articulation, are not particularly conspicuous. It is true that a 136 DISEASE 01 fixed pain behind the trochanter major, in some instances, very soon excites the atten- tion of the most careless surgeon to the seat of the morbid affection. But mere pain in a joint, quite free from visible enlargement and external change of colour, is generally dis- regarded as a complaint of no importance in young subjects, and as a mere rheumatic or gouty affection in adults. Even when the pain begins to be severe, it is commonly not confined to the seat of the disease ; but shoots downward in the course of the vastus exter- nus muscle to the knee, and along the outer part of the fibula to the malleolus externus. I have often found that patients refer most of their painful sensations to the groin. In short, there is no particular symptom, occur- ring in the precise situation of the morbid affection, so as to form an infallible pathogno- monic mark of its existence. But still the characters of the disease are very strong, when examined by a surgeon who has paid attention to the subject. Almost as early as the least limping can THE HIP JOINT. 137 be perceived, some diminution in the cir- cumference of the leg and thigh has actually taken place, as may be easily found by an accurate measurement. The hip joint is deeply situated, so that its accidents and diseases cannot be examin- ed as readily as those of many other articu- lations. The generality of surgeons little think that the proper place for pressing on the hip joint, with a view of ascertaining the presence of disease, is a little on the outside of the femoral artery, soon after it has descended below the brim of the pelvis. At this spot the surgeon may apply pressure to the front of this large articulation, and if it be diseased considerable pain will be the consequence of the experiment. The limping gait denotes that something is wrong in the limb ; and if this symptom cannot be attributed to some affection of the vertebrae, or some recent accident ; also if it be conjoined with the above-mentioned ema- ciation of the affected member, and exasperr ation of pain on pressing the front of the M 2 138 DISEASE OF acetabulum ; then the evidence of disease in the hip becomes more and more convincing. The weakness of the lower extremities from diseased vertebrae, I believe, always affects both limbs at once, and is unattended with pain about the knee ; circumstances com- pletely discriminating this complaint from the feebleness of the limb arising from a disorder in the hip joint. Another remarkable symptom is the elon- gation of the limb in the incipient stage of the hip disease. Mr. Ford* has very ably pointed out the right method of discovering the circumstance, by comparing the condyles of the os femoris, the patella, the trochanter major, and the malleolus internus of the dis- eased limb, with the same parts of the sound one. I think that the great elongation of the lower extremity, in consequence of disease in the hip, has never been accurately explain- ed. It is a fact that the limb not unfrequent- * Observations on the Disease of the Hip Joint, &c. p. 12, THE HIP JOINT. 139 ly becomes three or four inches longer than the sound one. Dr. Falconer* of Bath says that, «* if the cartilage or periosteum be thickened in the superior parts of the head of the os femoris or acetabulum, it will thrust the head of the bone downwards and length- en the limb." The error of this explanation is easily exposed by stating, that the diam- eter of the acetabulum itself is not so great as the lengthening of the limb, and that it re almost completely occupied by the head of the thigh bone, so that the degree of perpen- dicular motion of the femur must, as long as the acetabulum continues entire, be very in- considerable. No relaxation of ligaments, if ever there were such a state, could account for the fact ; for in the most healthy condi- tion of the hip joint no ligaments, (if we ex- cept that which completes the bony deficiency at the lower and inner part of the acetabu- lum), are concerned in preventing the os femoris from descending downward. The ligamentum teres resists the dislocation of * Dissertation on I»chia?, &c. p. 17. 140 DISEASE OF the head of the bone upward, but not down- ward. The orbicular ligament is naturally lax, and like all other capsules of the joints, must rather be considered as a bag for con- taining the synovia than as a means of in* creasing the strength of the articulation. I am very much disposed to believe that, in the very early stage of the hip disease, the car- tilage and ligament completing the lower and inner part of the acetabulum are destroyed.* If this be not the case I acknowledge myself totally incapable of conceiving how the limb can become lengthened to the extent which k frequently does, in cases of diseased hip joints. The bone is certainly not pushed out of the cotyloid cavity in a lateral direc- tion, for if it were so, the muscles would ; * Mr. Ford has given an account of the morbid ap- pearances found in a recent case, and attended with 1 elongation of the limb. It does not appear that in this I instance there was a destruction of the ligament and cartilage completing the lower and front part of tho acetabulum. How the limb cou!d4be elongated while the head of the bone was in its socket, I am at a loss to con- jecture. . THE HIP JOINT. 141 draw the bone upward and shorten the limb, as we find actually occurs as soon as the up- per and posterior part of the acetabulum and the ligamentum teres are so destroyed that they make no resistance to this kind of dis- location. Mr. Ford is entitled to the merit of having first pointed out to surgeons, " the " alteration with respect to the natural ful- " ness and convexity of the nates, that part " appearing flattened which is usually most " prominent." The glutaeus magnus be- comes emaciated, and its edge no longer forms so bold a line as it naturally does at the upper and back part of the thigh, in the sound state of the limb. This is one very strong feature of the early state of the dis- ease, and it has been accurately represented in an engraving in Mr. Ford's work. Though there may be more pain about the knee than the hip, at some periods of the malady in its insipient state, yet the former joint may be bent and extended without any increase of uneasiness ; but the thigh bone. cannot be moved without augmenting the suf- ferings of the afflicted. 142 DISEASE OF Patients with diseased hips soon get into the habit of bearing the weight of the body chiefly on the other extremity, so that they bend the thigh of the affected side forward in order to touch the ground only partially with the foot. It ought also to be noticed that this is found at all times to be the most easy position of the limb, and every attempt to extend it proves productive of pain. Such is the first stage of the disease in its ordinary form, in which we generally find the health little disturbed. The malady is usually not very painful to the touch, except the pressure be applied to the.front of the joint, the part which is un- doubtedly the most superficial. But there are instances, and I have frequently been an eye-witness of such, in which all the soft parts surrounding the joint are tense, exceed- ingly painful when handled, and in which the integuments are even tinged with a light pink blush. I have generally observed the complaint to assume this appearance in pa- tients who have been guilty of imprudent THE HIP JOINT. H3 exercise, and in the children of the poor who cannot attend to the disorders of their offspring in a proper manner. We come now to the second stage of the disease, or that which is attended with sup- puration. The symptoms which are the forerunners of the formation of the pus are different in differ- ent cases. This variety depends upon the pres- ence of acute, or only chronic inflammation. When the former occurs, the parts surround- ing the joint become tense and extremely pain- ful, the skin is even reddish, and the patient experiences an attack of sympathetic inflam- matory fever. As the local pain abates rigors take place, a swelling forms in the vicinity of the joint, and very soon points. When the abscess is the consequence of that languid kind of inflammation which usually occasions scrophulous collections of matter, there is not so remarkable an increase of pain in the articulation previously to the occurrence of suppuration. Mr. Phillot, sur- geon to the Bath General Hospital, says that 144 DISEASE OF startings and catchings during sleep are, in this stage of the disease, among the most cer- tain signs of the formation of matter.* When the pus forms in this chronic manner, it does not make its way to the surface of the body so quickly as when the abscess has been the immediate result of active inflammation at- tacking the morbid joint. A large fluctuating tumour forms, but does not immediately point. The patient suffers greater uneasiness in the part; yet his sensations do not amount to that acute description of tenderness which affects, in the foregoing instance, not only the deep, but also the most superficial parts around the articulation. At length the limb becomes shortened, and this circumstance, when the retraction is very considerable, arises from nothing less than an actual dislocation of the head of the thigh bone, in consequence of the destruction of the cartilages, ligaments, and articular cavi- * See a note, p. 9, of Falconer's Dissertation on the Ischias. THE HIP JOINT. 145 ty. The shortening of the limb sometimes happens before suppuration ; for the most part, I believe, after it. There are instances in which the head of the bone is dislocated, and anchylosis follows without any occurrence of abscesses. Sometimes patients are seriously dejected by hectic symptoms before matter forms. In the suppurative stage of the malady these effects on the constitution always become worse. The patient loses his appetite, can- not sleep at night, has a small frequent pulse, colliquative sweats, and often a very obstinate and debilitating diarrhoea. The openings through which such abscesses as I have described are discharged, continue, in most instances, to emit an unhealthy kind of matter for a long time after their first formation. They become, in fact, the ter- minations of sinuses leading to the morbid joint. When disease in the hip joint follows ex- ternal violence, the advances of the malady are somewhat different from the above de- N 146 DISEASE OF scription. The symptoms which precede the affection are a violent pain at the instant of the accident, and an inability to move the limb. However, this privation of the faculty of moving the member is not so complete as when the neck of the os femoris is fractured •, j because the superior part of this bone, and the articular cavity, which have suffered no alteration, form a sufficient fulcrum to enable ] the muscle to act on the thigh. The injury . is very soon followed by more or less swell- i ing, pain, and fever. No diminution in the length of the limb can be perceived, nor is the position of the knee and foot at all al- tered. But afterwards the thigh becomes gradually shorter, and the foot turned in- ward. The patient cannot move without ex- periencing the most acute pain. An abscess commonly forms at the upper and middle j part of the thigh, and, if no amendment take place, hectic disorders sooner or later occa- '• . sion the patient's dissolution. To illustrate the progress of the disease when it is the consequence of external vio- THE HIP JOINT. 147 lence, and to point out the ravages which it produces in the parts affected, I have insert- ed the following interesting case, which is the abstract of one related by M. Sabatier in the Mem. de l'Acad. de Chirurgie. CASE VII. A boy, about fourteen years of age, had for two years a considerable abscess at the anteri- or and superior part of the right thigh. The extremity on this side was about three finger- breadths shorter than the other, and the toes were turned inward. An oedematous swelling occupied the lumbar region and the situation of the glutei muscles, and extended down the thigh even to the knee. There was a good deal of pain all round the abscess, and par- ticularly in the groin, where the glands were swollen and hard. The boy had fallen on his knee on the 15th of June, and afterwards experienced such pain, shooting from that joint to the top of the thigh, that he was obliged to remain in bed 148 DISEASE OF four days. The pains being abated, he got up and attempted to take his usual exercise again ; but he found that he could not sup- port himself, and was necessitated to make use of crutches until the 3d of January following. In the mean time the inguinal glands became considerably enlarged. This symptom was somewhat relieved by emollient and resolvent applications. The pain, however, continued to increase daily ; the difficulty of walking, even with crutches, became greater and great- er ; and the thigh began to be shorter than the other. An empirical practitioner, who was consult- ed, pronounced that the thigh was dislocated, and that it was proper to reduce it. Such ' attempts as he proposed with this view were put in execution. Some time afterwards he desired the patient to walk ; but he was quite incapable of walking without crutches, and without greater pain than ever. At length the glands in the groin swelled again, and the above mentioned abscess be- gan to manifest itself about the middle of Feb- ruary. THE HIP JOINT. 149 The contents of this abscess were after- wards let out through a small puncture, by a regular surgeon. The quality of the matter was fetid, and the quantity three pints. The immediate consequences of the operation were successful beyond expectation. The tumefaction of the thigh decreased; the ingui- nal glands became smaller ; the pains were not so acute as before ; and almost all febrile dis- turbance disappeared. Such symptoms, how- ever, soon recurred with greater vehemence than ever, and an abscess formed in the groin and burst spontaneously. The thigh became shorter every day. The leg and foot were attacked with an oedematous erysipelas, and the patient at length died five months and a half after the operation, On dissection several collections of pus were discovered, some among the glutei muscles, and others on the external surface of the os ilium, and in the situation of the cotyloid cav- ity. The muscles on the anterior and superi- or part of the thigh were covered with a large quantity of matter, similar to what was dis- K2 150 DISEASE OF charged from the principal abscess. The lat- ter collection extended even into the hip-joint. The femur was drawn upward above four fin- ger-breadths on the external surface of the os ilium. The cartilage which covers the head of the former bone was entirely destroyed •, and this part of the bone was altered, and marked wifh deep excavations in consequence of caries. In this case the acetabulum was to- tally destroyed, so that the femur had been luxated, because the brim of the articular cav- ity having been effaced, the head of the bone was obliged to obey the action of the mus- cles. All the outer surface of the os ilium, on which the head of the thigh bone had glided, was affected with a kind of carious distemper, and fragments of it easily crumbled off. No elongation of the limb is recorded in this case; but, in all probability, this circum- stance occurred in the early stage of the dis- ease, before a regular surgeon was consulted. THE HIP JOINT. 151 But to return to the description of the inter- esting malady now under consideration. It is observed by Dr. Falconer that the tuberos- ity of the ischium is, in many instances, lower on the affected side than on the other. To confirm this circumstance he mentions the pel- vis of a person who died in the Bath General Hospital. In this specimen, which was pre- served there many years, the fact was demon- strable. If this alteration were evident in the bones of the skeleton, the circumstance must arise from a permanent distortion of the pel- vis, and cannot be the mere temporary effect of any particular posture of the patient during life. As I have never seen this appearance, either in the dead or living subject, I shall not dwell upon it. The thing is curious and mer- its attention. With respect to the morbid anatomy of the disease in its incipient state, little is known. Two dissections related by Mr. Ford are, I be- lieve, the only ones throwing light on this point. In one there was a tea-spoonful of matter in the cavity of the hip-joint. Tl\e 152 DISEASE OF head of the thigh bone was a little inflamed, the capsular ligament a little thickened, and the ligamentum teres united in its natural way with the acetabulum. The cartilage li- ning the cotyloid cavity was eroded in one place with a small aperture, through which a probe might be passed underneath the cartil- age, into the internal surface of the os pubis, on one side, and, on the other, into the os ischii ; the opposite or external part of the os innominatum showing more appearance of dis- ease than the cotyloid cavity. In the other case the disease was more advanced. These examples are important, inasmuch as they prove that the hip complaint primarily affects the cartilages, ligaments, and bones, and not the surrounding soft parts, as De Haen and some others would lead one to believe. As the disorder advances the portions of the os is- chium, os ilium, and os pubis, forming the a- cetabulum, together with the investing cartil- age and synovial gland, are destroyed. The cartilage covering the head of the os femoris, the ligamentum teres, andjcapsule of the joint, THE HIP JOINT. 158 suffer the same fate; and caries frequently af- fects not only the adjacent parts of the o&sain- nominata, but also the head and neck of the femur. I believe, however, that the bones of the pelvis always suffer more than the thigh bone. The malady may even have made such ravages as to have completely destroyed the brim of the acetabulum,and dislocated the head of the os femoris ; and yet the substance of the latter part may be free from all distemper. The following fact illustrates the veracity of this remark. CASE VIII. A subject was brought to the dissecting room at St. Bartholomew's Hospital, and it was noticed by the gentlemen present that there was great retraction of one of the lower extremities, owing to some morbid affection about the hip-joint. On cutting into the parts a very large abscess was found on the dor- sum of the ilium, and, in the midst of the mat- 154 DISEASE OF ter, the head of the thigh bone was found lodg- ed on the ilium. The cotyloid cavity was completely destroyed by disease, together with all the ligaments and cartilages. The head of the femur was quite perfect, and free from the slightest mark of caries, though its car- tilage was slightly eroded in a few places. The preparation showing this fact is preserv- ed in the anatomical museum of the above hospital. The particulars of the case before death were unknown. As I believe no author has recorded a similar instance, and as the fact, that the ossa innominata are generally more affected than the femur, is very important, I thought the insertion of this interesting and striking example would be better than any long reasoning on the matter.* * Mr. Ford says ,M In every case of disease of the hip joint, which has terminated fatally, I have rem irked that the os innominatum has been affected by the caries in a moreextensive degree than the thigh bone itself." P. 107. The knowledge of the circumstance is extremely im. portant, because it displays the absurdity of attempting amputation in these cases. THE HIP JOINT. 155 Sometimes, however, the head and neck of the thigh are completely destroyed by the same morbid process, which annihilates the acetabulum. There is a specimen of this fact in the above mentioned museum, and Mr. Ford has given, in his valuable work, an engraving illustrative of such a case. I have only to say on the subject of the re- mote causes of the hip disease, that they are very imperfectly known. External violence is undoubtedly one, and the testimony of nu- merous respectable writers confirms that ly- ing down on the damp ground in summer time, and indeed all kind of exposure to damp and cold, are frequently conducive to the ori- gin of the malady. For this reason the low- er orders of society are rather more subject to the affliction than the higher. The particu- larities, however, in the affected joint,or in'the constitution, which cause the disease to take place in some persons, and not in others, though similarly circumstanced in life, are, per- haps, beyond the reach of human investiga- tion. A scrophulous habit is certainly one 15Q DISEASE OF THE HIP JOINT. predisposing circumstance ; but the disease often takes place without any suspicion of scro- phula, and without any apparent cause what- ever. 157 CHAP. II. Treatment of the Disease of the Hip Joint. BY referring to the writings of Hippocrates, Celsus, Caelius Aurelianus, &c. we shall dis- cover that our forefathers are indisputably en- titled to the honour of having employed ev- ery efficacious plan, even now known to the moderns, of treating the disorder of the hip joint. Forming an eschar, and keeping the sore open ; topical bleedings; fomentations; cupping; Sec. were all practised by the an- cients. The Bath water they certainly did not use ; and if it have such immense effect as Dr. Falconer has represented, I must candidly own that past ages have been very unfortu- nate in not having sooner found out the utili- ty of this remedy in the incipient state of the hip disease. Dr. Falconer has given a table of the state of the patients at their discharge, o 158 TREATMENT OF THE who were admitted into the Bath Hospital for hip cases, from May 1,1785, to April 7, 1801. The number amounts to five hundred and fif- ty-six, of which one hundred and three were cured, one hundred and sixty-eight were much better, one hundred and eleven were better, thirty-three were no better, one hundred and twenty-two were improper objects, the dis- ease being too far advanced, thirteen were dis- charged for irregularity, and six dead. Now from the numerous cases of this disease which I have seen I have not the smallest hesitation in asserting that the success at Bath far ex- ceeds any thing ever met with in this metro- polis. It is to be observed, however, that Drs. Charlton, Oliver, Falconer, and other advo- cates for the Bath water, agree that its utility as an external application, in these cases, is limited to that incipient state of the disease, unaccompanied either with hectic fever or suppuration ; and that as soon as one, or both the latter circumstances occur, the application then becomes injurious, and ill de-crves the name of a remedy. Patients, in order to derive DISEASE OF THE HIP JOINT. 159 benefit from the water, are placed in a warm baih for fifteen to twenty-five minutes, two or three times a week. When *re consider the nature of the dis- ease of the hip-joint, and reflect on its deep situation ; when we recal to mind the distem- pered state soon produced in the cartilages, li- gaments, and bones of the articulation ; we can hardly believe that the mere external use of any remedy, like Bath water, can have such powerful influence over the diseaseas we might be led to suppose from a perusal of Dr. Falcon- er's pamphlet. For my own part I regard the subject in a different point of view. I doubt whether all the numerous instances adduced in support of the practice, were really and tru- ly cases of the hip disease. Many of them might have been merely rheumatic affections. My suspicions originate in consequence of Dr. Falconer's admission, that cases attended with hectic fever or suppuration are never benefited by the same treatment ; in consequence of the facility of mistaking other maladies for in- cipient hip cases ; and in consequence of the 160 TREATMENT OF THE table, delivered by Dr. Falconer, being taken from a register of the hospital; a thing very likely to be drawn up in a careless manner. Such a statement was probably not formed by a man, whose talents and discrimination were equal to those of the respectable practitioner who is the author of the pamphlet on this subject. I am entirely of opinion with Mr. Ford, that any kind of warm bathing would have been productive of the same benefit. I cannot say that it has occurred to me to see much of the practice of placing patients, afflict- ed with the hip disease, in the warm bath; but I have repeatedly seen fomentations em- ployed. The latter applications undoubtedly relieve pain ; and in early cases are very prop- er to be tried in conjunction witlvtopical bleed- ing. I can, however, impute to them no ef- ficacy in producing any permanent amend- ment in the disease. Topical bleeding with leeches, and cupping the circumference of the affected joint, provided the case is attended with symptoms denoting inflammation of the joint, are the measures which I shall confi- DISEASE OF THE HIP JOINT. 161 dently recommend. The fomentations may be applied two or three tima, \ day ior half an hour ; but, as great utility does, in my o- pinion, originate from cold saturnine applica- tions to the part, I recommend them to be used during the remainder of the day. This plan of treatment, I think, ought nev- er to be employed, unless there are manifest marks of active inflammation in the joint; fcr, when no such state exists, the method can only be considered as preventing the employ- ment of a more beneficial plan, and therefore is liable to severe reprobation. As far as morbid anatomy can inform us the hip disease consists in the same alteration of the bones, ligaments, and cartilages, as we find exists in the generality of white swel- lings. As far as my experience extends both diseases ought to be treated on the same prin- ciples. But though I have found blisters most efficacious in checking disease in the knee, caustic issues have appeared to me to excel in hip cases. The benefits resulting from both applications are to be imputed partly to o 2 162 TREATMENT OF THE the counter-irritation, and partly to the dis- charge which they occasion. CASE IX. Showing the Efficacy of a Caustic Issue in an Example of the Hip Disease in a recent State. G. H., a boy eleven years of age, without any assignable cause began to experience a weakness and lameness in the left lower ex- tremity, and his complaint was attended with severe pain at the outer part of the knee. At length he became quite incapable of taking his usual exercise, lost his appetite, and became pale and wan in the countenance. When sur- gical advice was first requested the disease had existed about two months ; there was a good deal of pain in the groin ; the inguinal glands were even somewhat enlarged ; the glutei muscles did not seem so prominent as in the natural state ; and the whole limb was palpa- bly more emaciated than the other. The DISEASE OF THE HIP JOINT. 163 knee joint could be bent and extended with- out causing the least uneasiness; but the thigh bone could not be moved without exciting se- vere pain. Sept. 19th, 1805. An issue about as large as a half-crown was mada in the hollow just behind the trochanter major. About eight days afterwards the slough was detached, and 3s many beans as would conveniently lie in the cavity of the sore were placed there. The lad began to be materially better at the end of the following month ; he could then move the joint without pain, and there were no sensations of nervotls irritation shoot- ing down the extremity. About the middle of November he wa« able to walk tolerably well without crutch- es. The issue was kept open for six months, at the end of which time the emaciation of the limb had quite disappeared, and there was al- most as much strength in this member as in the one which had not been affected; in short, the lad found himself so well that his friends allowed the issue to be healed, and the boy to 164 TREATMENT OF THE go to sea ; a life for which he had a strong inclination. No medicines were administered during the whole of the treatment. CASE X. Terminating in Dislocation of the Os Femoris ,- the Disease stopped ; and the Patient recov- ered. Mr. W. S. H—, a gentleman twenty-eight years of age, was seized, whilst walking on the 13th of April, 1803, with so violent a pain in the groin that he reached home with difficulty. In the preceding October he had a swell- ing of the inguinal glands, unconnected with any venereal causes. This complaint ended in an abscess, which burst, and the aperture had closed shortly before the present attack A few years before he had a similar swelling in the axilla. The pain in the hip continued so DISEASE OF THE HlP JOINT. 165 violent as to confine him to bed. The limb was much lengthened at this period. Leeches, fomentations, and poultices, had been em- ployed at first, and an issue afterwards made behind the trochanter. When Mr. ----- was consulted, pressure on the trochanter gave great pain. The pa- tient kept his bed. The issue was allowed to heal. Leeches were repeatedly applied td the front of the joint. When moderate pressure could be borne without much incon- venience, a large blister was placed on the front of the hip, and dressed with cerat. sa- bin. ; but so much pain and irritation ensued that the excoriated part was allowed to heal. Soon afterwards the patient was attacked with violent pain in the joint, and spasm of the muscles, during which state the slightest motion could not be endured. An abscess formed, and burst in front of the trochanter. The patient experienced afterwards some res- pite ; but the fits of pain and spasm recurred with incre sed violence, and when they ceas- ed, (about the middle of August) it was man- 166 TREATMENT OF THE ifest that the limb had become dislocated ; for it was three inches shorter than the oppo- site one. The patent now become easy. A large issue was made behind the trochanter, and it discharged copiously. The gentleman completely regained his health and spirits. The dislocation of the bone occasioned a great swelling of the hip, and there were a strongly marked depression and vacancy in the groin. In October the limb was only two inches shorter than the opposite one. He can walk tolerably well with crutches ; but is not allowed to bear any weight on the limb. In November he went into the coun- try, and returned to town the following June. His health had been constantly good, and the limb free from complaints, the issue continu- ing open. He has never attempted to move fhe affected joint, nor to walk without crutches. DISEASE OF THE HIP JOINT. 167 CASE XL Terminating in the Dislocation of the Os Fe- moris, and, probably, Anchylosis. M. H—, aged fourteen, was admitted into St. Bartholomew's Hospital, afflicted with a disease in the hip joint. The case had ad- vanced to a suppurative stage before any issue was made. An eschar about as large as a half-crown was at last formed, and the issue wa- dressed with beans. Some amendment took ,;Ucc soon after, and the matter beneath the skin was certainly less in quantity than it was at first. The girl's health, which was at first in a very bad state, was also improved. Symptoms of active inflammation unfortu- nately came on ; the abscess became very large, and the surgeon felt himself obliged to puncture it in order to procure some degree of relief. The patient continued in the hospital near a year, sometimes better, some- 168 TREATMENT 01 THE times worse. The limb, some time before she was discharged, had become three or four inches shorter than the opposite one. The toes turned inward, and the joint was quite motionless. The sinuses leading to the joint healed, and the girl regained her health. She will always have, however, a stiff joint. The limb is now not quite so short as it used to be, and some hopes are entertained that she will be able to walk without crutches, by having a high-heeled shoe. When much retraction of the limb suc- ceeds disease in the hip we may be sure that either the neck of the thigh bone is destroy- ed, and the main portion of the bone drawn upwards, while its head remains in the ace- tabulum, if it be not also entirely annihilated by the morbid affection ; or that the head of the bone is dislocated in consequence of the destruction of the brim of the acetabulum and articular ligaments. If a case were to occur in which the limb was considerably shorten- ed, and the toes turned outward, I should conclude that the head of the os femoris was DISEASE OF THE HIP JOINT. 169 separated from the rest of the bone, and that the muscles had rotated the limb outward. But when the toes are turned inward, as all the great muscles of the thigh have a pro- pensity to twist the os femoris outward, we may conclude that this position of the limb is mechanically prevented from taking place, by the head of the thigh bone being situated backward on the dorsum of the ilium. CASE XII. Showing a curious Plan of Treatment adopted in a Case of diseased Hip, and followed by Effects which few would expect. A very respectable gentleman, residing in the wist of England, had a disease of the hip joint. Suppuration took place in the part aiFected, and the matter was discharged by spontaneous external openings. Very exten- sive sinuses remained, which discharged 170 TREATMENT OF THE largely. His health of course became ma- terially impaired. Two respectable practi- tioners, a physician and surgeon, attended the gentleman. After the patient had been under their care a considerable time, things still remaining in nearly the same state, another medical man was called in to a con- sultation. The latter boldly undertook to effect a cure. He injected the sinuses with oil of turpentine. Healthy inflammation was produced, without any considerable consti- tutional disturbance. The sinuses closed, and the joint anchylosed. The patient is now well, having only a stiff joint. The gentleman who favoured me with thi« interesting article, is a very respectable sur- geon, and a man endowed with talents far above those of the ordinary stamp. He very ingeniously states that the stimulus of turpen- tine is of a very peculiar nature : when ap- plied to the raw surface of a burn or scald it gives no pain, and the surface of a chronic abscess cannot be in a more irritable state. DISEASE OF THE HIP JOINT. 171 I make no comment on the case ; but the fact seems to me highly deserving of a place in the records of surgery. As I have not taken any notice of diseased vertebrae in the present dissertation, and it is an affection so very analogous to disorders of the knee and hip, already treated of, I think it may be proper to conclude these observa- tions with a case which I have lately attend- ed, and indeed visit now whenever occasion requires my presence. CASE XIII. Showing the Efficacy of Issues in Cases of diseased Vertebra. Miss E-----, a little girl, ten years of age, living in Prince's-Street, Soho, was brought to my house for advice respecting a weakness of the lower limbs. I begged to examine the M TREATMENT OF THE back, and found that three or four of the spinous processes of the middle dorsal verte- brae projected in a very preternatural degree. The child was losing its health very fast, and appeared to be very weak. Its appetite was impaired, and it could not sleep at night. Very severe affections of the stomach, resem- bling heartburn, also frequently occurred, but a little peppermint water regularly relieved this complaint. I formed two issues with caustic (the kali purum) on each side of the projection of the spine, making the eschars three inches long and half an inch broad. This was done on the 3d of June, 1805. I was much surprised on paying my next visit to find that all the child's constitutional complaints had taken a very favourable turn. The friends, who are very reputable people in business, informed me that a few hours after the eschars had been made the child became more full of spirit, ate better, and looked better than it had done for many months before. In the. course of a week, even before the sloughf DISEASE OF THE HIP JOINT. 173 came away, the child could walk without ex- periencing half the weakness it did previous- ly. This is one of the most convincing cases, which have ever occurred to me, that issues produce their good effects by counter-irrita- tion, as well as by the discharge which they occasion. In this instance most surprising amendment took place before thp eschars came away, or a drop of pus had been se- creted. The little girl has now had a discharge kept up from the part for nearly six months ; has recovered her health ; walks as well as she ever did ; and may, in every respect, be considered as cured. About two months ago I allowed one of the issues to be healed.* Whenever I meditate on the very great benefit which I have seen derived from caus- * A few weeks after both issues had been healed the child's mother thought there was a degree of weakness returning in the legs. This apprehension of a relapse has, however, now quite subsided ; for a short residence at Margate, which I recommended, has made the limbs completely recover their proper strength. p2 174 TREATMENT OF THE, &C. tic issues in cases of disease of the vertebrae, I always feel how much we ought to honour the memory of the late Mr. Pott, through whose transcendent abilities this and many branches of surgery were brought into a very improved state. THE END. .*j/|/v4' BY THE SAME AUTHOR, And lately reprinted by F. Nichols,- one volume 8vo. price three dollars, THE FIRST LINES OF THE PRACTICE OF SURGERY. " Such a work as Mr. Cooper has here giv- en to the public has long been a desideratum to the student of surgery. Though it must be principally regarded in the light of a com- pilation, yet judiciously to arrange, closely to compress, and clearly to detail, so great a va- riety of matter, require no inconsiderable ex- ertion of ability ; while the original remarks interspersed, and the candid spirit which eve*- 176 ry where prevails, entitle the author to praise of a superior kind." Monthly Review for Nov. 1807. " This work will prove a very valuable acquisition to the practitioners of surgery. It must form an essential part of the library of every medical student." Annual Review for 1807. S;a:F' K Cai: •'i^ *ii;,i.i;: \::'.C'^r,'{r::'d^W"%, |®il«P!";^ ' d. ■ ^d&l$%M$ tip :,^y"y^mki^M -..-;;-'• 1;; ^ .a-, .<* cV" $!j|IK"fiji • . ■■ ;;,a..]£>l'd\ddhwm\>*^$