TREATISE
ON THE
/If 7

/"* 4/
'J  i  i
DISEASES OF THE JOINTS;
BEING THE OBSERVATIONS FOR WHICH THE
 PRIZE FOR l8o6 WAS ADJUDGED BT THE
 ROYAL COLLEGE OF SURGEONS IN LONDON.
IS
     BY SAMUEL COOPER,

MEMBER OF THE ROYAL COLLEGB OF SUR-
 GEONS,FELLOW OF THI MEDICAL SOCIETY
 OF LONDON, AUTHOR OF THE FIRST LINES OF
 THE PRACTICE OF SURGERY, &C.   -"\ , • *»^

HANOVER, N. H.
                   : ' .' . ..> - -\ V*
PUBLISHED BY JUSTIN HINBffiJ"'
1811.
CHARLES SPEAR, PRINTER. 
'Ji'. 
CONTENTS.
                                 Page
 Introduction       -           -     5

        f--V  PART I.
 A cursory and general Sketch of several
   principal Diseases of the Joints, and
   the Outlines of the Treatment adapted
   to themi       :i  .'.'

 CHAP. I.—Preliminary remark's  ?
     relative to the pathology of the
    joints    -    -     -    -    7
 CHAP.  II. — Inflammation   of
    joints    -    ...     16
 CHAP. III.—Treatment  of  in-
    flamed joints,  with two cases
    illustrative of the subject       23
 CHAP. IV.—Preternatural cartil-
    aginous substances in the joints  32
 CHAP. V.—Treatment of preter-
    natural cartilaginous substan-
    ces in the joints    -      -     43
CHAP. VI.—Of  collections ,of
    fluid ift th6 capsnlarrligamc*nts   52 
6          INTRODUCTION.

of practice, where alone they might in-
terest mankind and become of real im-
portance.
  The plan whichT have pursued in the
following pages, is to offer, in the first
place, a cursory and  general sketch of
several  principal diseases of the joints,
and the outlines of the treatment adapt-
ed to them.   Secondly ;  I have entered
into  a particular consideration of the
white swelling of the knee,and the treat-
ment .of the  disease.  Lastly ; I have
made the  morbid affection usually de-
nominated 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 intentional effort to dazzle
the judgment of my readers by an osten-
tatious* list of awthors in the margin, or
by quotations from  old  works,  which
are now almost as dead as the men who  J
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
  SEVERAL PRINCIPAL DISEASES OF THE
  JOINTS, AND THE OUTLINES OF THE
  TREATMENT ADAPTED TO THEM,
             CHAP.  I.

Preliminary remarks relative to the Pa-
         thology of the Joints.

  IF we recal to  our recollection the
anatomical structure of the joints, wc
shall find that the heads  of the bones,
which are concerned in the formation of
these parts, are of a spongy texture, and
connected together by strong ligaments,
while their articular surfaces are cover-
ed  with a beautifully polished, elastic
substance, called cartilage.  The smooth-
ness and elasticity of the curtilages are 
8      PRELIMINARY REMARKS.

qualities rendering them peculiarly pro-
per for  gliding with  ease  over one an-
other in the motion of the joints, and for
breaking the force of such shocks as the
limbs have to sustain in jumping, run-
ning, and other ordinary  exercises 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 char-
acters 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
vary different  aspect  from  what they
would do,  were they in a situation, in
which the circulation  is naturally lan-
guid, or in which there arc only (com*
paratively speaking) few  vessels, and
those of very small  diameter.    When
the port affected  is,  what  anatomists
term, highly organized, and vascular,
the disorder is generally more mild and 
       PRELIMINARY REMARKS.      9

tractable than if the part were only fur-
nished with  such small vessels,  that it
could not be rendered red by anatomical
injections.
   But,  besides great vascularity and
high organization of structure, a situa-
tion near the source of the circulation
Seems oftentimes to render parts less
disposed to become diseased,  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 intimately essential
to the continuance of life, then, as Mr.
Hunter observes, the natural operations
of universal health depend so much up-
on their sound  condition, 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  different
functions.
   When we apply these remarks to the
joints, we may in some measure account
for the frequency, obstinacy, and peril
of their diseases ; at least we may dis-
cover general principles, to which such
circumstances  may rationally be refer-
red.
   The  cartilages and ligaments,  the 
10    PRELIMINARY REMARKS.
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, exceedingly in-
considerable.   This is,  perhaps, one
principal cause that the joints in general
are so backward in recovering from the
effects 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 be-
ing nearer to the source of the circulation
than the whole of the lower extremity.
This circumstance may,  perhaps, ex-
plain why diseases situated in the arm
are  much more  under the  control of
surgery  than when they affect the leg.
How much more  seldom scrophulous el-
bow-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  articula-
tions.   When a patient has a complaint
in the elbow or wrist, he places his arm 
PRELIMINARY REMARKS.     H
in a sling, walks about, visits his friends,
and takes his usual exercise ; his gener-
al health is neither impaired by confine-
ment,  nor  by that dejection of spirits
which so frequently attends the long pri-
vation of locomotion, and the apprehen-
sion of losing this enjoyment forever.
   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 oth-
er joints, it is also furnished with par-
ticular ligaments,  named the crucial
ones,  and  with  interarticular semilunar
cartilages.   The  complication of its
 structure may also seem to the  contem-
 plative pathologist a reason why its dis-
eases should not only be more frequent,
but, at the same time, more obstinate,
 and difficult of cure, than those of other
joints.  The articular surfaces of the
 knee, and  the cavity of its capsular liga-
 ment, are  also much larger than those of
 any other  articulation.
   The hip-joint is greatly protected, by
 its derp situation, lrom blows and other
 species of external  violence ;  from the
 bad  effects of sudden  vicissitudes of
 temperature ; and from the operation of 
12     PRELIMINARY REMARKS.

outward damp.  These circumstances,
which, undoubtedly, aTe very frequently
the primary exciting causes of the worst
diseases of the joints, must affect the
knee with peculiar force, on account of
its exposed  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 latter artic-
ulation.
  No large joint in the human body is
so little strengthened and supported by
the conformation 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 head
of the os Jemoris is almost enclosed in a
complete  bony socket.   In the elbow
the deep  sigmoid  cavity of the ulnar
formed between the coronoid and ole-
cranon  processes, affords a very stable
lodgment to the internal 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
formed on the lower end of the os bra-
chii, and receives a portion of the ulna, 
       PRELIMINARY  REMARKS.    13

contributes very materially, to the sta-
bility of the articulation.   From  the
preceding observations it becomes  ob-
vious 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 ev-
ery 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  ex-
posed  to the effects of external vio-
lence, and is more remote than the el-
bow 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 ankle and the wrist,
"however, are very frequently 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 tarsus and carpus* and subsequent-
ly involves the ankle and wrist in its
ravages.' 
V4     PRELIMINARY REMARKS*.

  The great quantity of cartilaginous
and ligamentous structure surrounding
the bones of the tarsus and carpus, and
the spongy texture of the bones them-
selves, are  sufficient reasons,  without
enumerating others, to account for the
frequency of disease in these situations.
The morbid affections of the carpus are,
in general, much more  tractable  than
those of the tarsus.   The reason of this
fact  may very rationally be  referred to
principles which have been already no-
ticed.
  When we  recollect that the diseases,
which form the chief objects of investi-
gation in the subsequent pages, are of a
scrophulous nature,  wc  cannot be sur-
prised  that, situated as  they  are  in  a
structure peculiarly unfavorable to the
amendment of disease in general, they
should so frequently baffle ali 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 disorder 
       PRELIMINARY REMARKS.     15

of the  nervous system,  that the preser-
vation of life itself is at stake.  Hence
also diseases of the joints sooner induce
hectic symptoms than when there is an
equal quantity of disease  in almost any
other part.
   Having premised these general patho-
logical observations I next proceed to
delineate the outlines of several princi-
pal diseases to which the joints are sub-
ject.   All  accidental injuries, such as
fractures, luxations,  &c. and all subjects
not strictly surgical, such as gout, rheu-
matism, 8tc. are purposely omitted. 
16
             CHAP. II.

       Inflammation of Joints.

  IDIOPATHIC cases of this kind are
not common.  The complaint ordinari-
ly originates in consequence of a contu-
sion, sprain, wound, or some other kind
of injury, done to the part affected.
  Phlegmonous  inflammation,  where-
soever situated, is uniformly  attended
with certain local symptoms,  by which
both its presence and degree may be as-
certained.   Preternatural redness, in-
creased 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 consti-
tution is  disturbed by  the usual symp-
toms of inflammatory fever; but, in these
cases, they are apt to be exceedingly se-
vere. The inflammation attacks the cap-
sular ligaments,   and,  not remaining
confined  to  any  particular portion of
them, it very quickly diffuses itself uni-
versally over their whole extent, as is 
     INFLAMMATION OF JOINTS.   17

commonly the case in all inflammations
of smooth membranes.   That there is
this peculiarity in inflammation of mem-
branes, is often strikingly proved in the
instance of peritonitis, arising after the
operation oflithotomy.  Here  we know
that the inflammation commences in the
bladder, is communicated to the portion
of the peritoneum,  which  covers the
fundus and posterior surface of this vis-
cus, and thence rapidly spreads over the
whole extent of the abdomen.
  The capsules of the joints are natural-
ly endued with little sensibility;  but,
like many other parts similarly circum-
stanced,  they become acutely painful
when inflamed.   The complaint is ac-
companied by an increased secretion 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 lubricating the  articular  surfaces,
and preventing the effects of friction, as
it is in the natural condition of the joint.
This circumstance  may explain why a
grating sensation is often perceived on
moving the patella, when the knee  is in-
flamed.   The increased quantity of sy-
            a 2 
16
INFLAMMATION
 riovia, in cases of inflamed joints, has
 often appeared to me an argument  a-
 gainstthe existence of a spasmodic con-
 striction of the minute vessels in inflam-
 mation.
   The capsules of  the joints may, like
 other membranes,  be thickened by in-
 flammation.  At other times an exuda-
 tion of coagulating lymph, or  an effu-
 sion of a gelatinous fluid, may take p!ac6
 irfpon their internal surfaces.  According
 to a general law of the animal economy
the contiguous vessels always have a ten-
 dency 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 interior of the joint.
  If the  inflammation be more vehem-
ent, suppuration may happen within the
 capsular  ligament.  Indeed this  is by
no means an unfrequent occurrence. At
length the capsular ligament ulcerates,
and purulent  matter is effused  beneath
the integuments.    The skin may next
ulcerate, so that the  abscess is discharg-
ed, and the case seems to be somewhat
benefited. The openings through which
such collections of matter are discharg-
ed, will be found,  upon  examination 
OF JOINTS.           19
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
inflammation, without the constitution
being, at the same  time, so  disturbed
that life itself is greatly endangered. In
the most vehement state of the inflam-
mation, or that which is the immediate
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 adapt-*
ed to resist the ravages of disease.  Th$
patient's skin is dry and hot j he is rest-
less and vigilant ;  and, I have known
 persons, under these circumstances, be-
 come affected with delirium and  coma,
 and ultimately perish.
    But  the rapidity with which the com-
 mon inflammatory fever assumes,  in
 such cases, the hectic type, is a circum-
 stance  which it would be inexcusable to
 pass over in silence.  When suppuration
 has occurred in a large  joint,  in conse-
 quence of a severe attack  of common
 inflammation, the patient immediately
 begins to be affected with hectic symp-
 toms,  and the  strong action, attendant 
20         INFLAMMATION
on  the inflammatory fever, suddenly
ceases.
  Local consequences, even worse than
those which I have described, may fol-
low inflammation of a joint.  As the
layer of the capsular ligament, reflected
over the  cartilages of  the articulation,
is often inflamed, the cartilages them-
selves are very  apt to have  the inflam-
mation communicated to them.   Parts
partaking of a  cartilaginous structure,
being very incapable of bearing the irri-
tation 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, complete-
ly denuded of its natural covering.  At
length the heads of the bones, entering
into the formation of the  affected joint,
inflame and become carious.
  Sometimes only such parts as are ex-
terior to  the cavity of the joint are in-
flamed, and, in this case, the symptoms
are  never  so severe,* nor so  obstinate,
as when the complaint interests  the cap-
sular ligament, and parts contained in it.
Even when suppuration  takes place on

  *  Treatise on the Morbid Affection* of the Knee
Joint, by James Russell, p. 60. 
OF JOINTS.
21
 the outside of the capsule, the case is
 not dangerous, provided the cavity of
 the joint be not involved in the inflam-
 matory attack.  Every inflammation of
 a large joint may, upon the whole, be
 deemed a case  of considerable impor-
 tance.  I  do not  mean to  assert that
 cases, in which the inflammation is mild
 in a degree, and simple in its nature, are
 dangerous : no ; I  only wish to inculcate
 that, though the inflammation be origin-
 ally genuine,yet it is always very likely to
 be converted  into one of a specific na-
 ture, whenever there is  a tendency in
 the system to scrophulous disorder.  A
 person, whose constitution is scrophu-
 lous, may sometimes continue,  during
 life, exempt  from  any local diseases of
 this specific nature, provided he  be for-
 tunate enough to avoid all irritation of
 parts on which scrophula is most partic-
 ularly disposed to make its attack.  A-
 mong such parts we must class the joints,
 especially the  knee, hip, elbow, and an-
 kle.   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 c;ise of simple inflammation
 is  very apt to be the  exciting cause of 
22   INFLAMMATION  OF JOINTS.

the white swelling, one of the most se-
yerc and intractable diseases which in-
crease the catalogue of human miseries.
  After what has been said it must be
obvious that, whatever may be the cur-
ative means indicated, they ought to be
most rigorously adopted, not merely on
account of an abstract view of the pres-
ent state of  the case, but also on account
of the opportunity which is now afforded
for a terrible disease to arise,  which
often remains previously in a dormant
state. 
23
             CHAP.  III.

 Treatment sf inflamed Joints ; and titio
     Cases illustrative of the subject.

   IT will considerably shorten this part
 Of my1 observations to state, that the an-
 tiphlogistic 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 to1 the same pur-
 pose, it seems necessary to  offer a few
 remarks on those which lay the 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 ex-
 ample.
 '  From what I have seen of this affec-
tion I have no hesitation in  asserting
that there are few other surgical cases,
in which general, and, especially, topical
bleeding,  is  more strongly  indicated.
The violence of the inflammation, and
the strength, age, and pulse of the pa-
tient, must determine with regard to the
use of the lancet;  but the topical appli-
cation  of  leeches may  be said to be in- 
24         TREATMENT OF
 variably proper.   When the leeches fall
 off, the bleeding is to be promoted by
 fomenting the part. The surgeon should
 daily persist in this practice, until the a-
 cute stage of the inflammation has en-
 tirely 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 inflammation are the appli-
 cation of cold lotions, and the mainten-
 ance of a constant evaporation from the
 surface of the part'affected, more strik-
 ingly advantageous.
  In a few instances, however, the pa-
tient  seems to derive more ease  and
benefit from the employment of fomen-
tations and emolient 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 vehemence of inflammation, as the
 duty of the surgeon is not materially dif-
 ferent from what it is in other inflam-
 matory cases.
  When the acute stage of the inflam- 
INFLAMED  JOINTS.        2"5
mation has abated, the plan of treatment
may be a little altered.  The grand ob-
ject now is to remove the effects, which
have been left by the preceding affection.
These are a thickened state of the cap-
sular ligament, and parts surrounding
the articulation ; a stiffness of the joint,
and pain when it is moved; a collection
of fluid in the capsule, &c.  This state
of the complaint,  when  neglected, and
there is a tendency to scrophula, may
prove exceedingly obstinate, and even
terminate in an irremediable, specific
distemper of the joint.   Common  in-
flammation  of an articulation, like the
same affection of the eye,  is peculiarly
apt to end in a chronic species of the af-
fection, even more difficult of  cure than
the acute stage of the complaint. When,
therefore, the redness, tension,  throb-
bing, and symptoms of inflammatory fe-
ver subside, the  activity of the practi-
 tioner ought  not  to be relaxed. The
 application  of a blister is what  I have
 found particularly  efficacious in the se-
 cond stage of the  inflammation, and a
 discharge should  be kept up from the
 blistered surface, for a few days,  by
 means of the savin cerate.
            u 
26        TREATMENT OF-
  I have often seen exceedingly large
collections of fluid  in the capsular liga-
ment, the thickening about  the joint,
and other remaining effects  of  the in-
flammation,  totally dispersed,  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 inflamma-
tion has been more trivial, and the effects
which it has left are slight, lotions, com-
posed of vinegar and sal ammoniac, suf-
fice for the removal of the chronic com-
plaints,  continuing after the abatement
of the acute stage of the disorder.  My
own experience enables me  to confirm
the reputation which such applications
have most justly-acquired.
  To illustrate the  present  subject  I
shall select the two following cases from
several  others, which have  fallen under
my own observation.

              CASE I.

  A young man, about twenty-three years
of age, fell from the top of a coach* Au-
gust 20th, 1799,  and bruised his knee
against  the  back part of the carriage.
As soon as I was called to the patient I 
CASES.             27
 applied a saturnine lotion to his injured
 knee, and gave him some purgative med-
 icine, consisting of the infusum sennsc,
 and natron vitriolatum.   Notwithstand-
 ing these measures I found the joint, on
 the following  dav,  very considerably
 swollen ; the pain  in the part very acute ;
 and all motion of the articulation utter-
 ly  insupportable.   The  patient's  pulse
 was accelerated, and his skin dry.   Ten
 leeches were put  on  the joint, and 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
 indifferently,  and  a good deal of pain
 was still experienced in the injured part.
 As the redness, 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 tinctu-
 ra  opii.
   August 23.  The man  had enjoyed
 some refreshing sleep.    This morning
 his pulse,  was eighty, and the redness,
 swelling,  tension, and  heat about the
joint, were somewhat diminished.
  August 30.  All the acute symptoms 
28
CASES.
 were  now removed.   The  treatment
 since the last date  merely consisted in
 applying continually the saturnine lo-
 tion.  However,  the patient  still com-
 plained of a degree of pain in the articu-
 lation, and there was obviously a preter-
 natural quantity of fluid in the capsular
 ligament.   Though  the tumefaction of
 the integumeflts had subsided,  yet this
 accumulation of fluid, and some thicken-
 ing 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 man-
 ner.  The patient found infinite relief,
 and  said that the part  was less painful
 than it had been ever since the first oc-
 currence of the accident.   The cuticle
 was removed, and  the blistered surface
 was dressed with the ceratum sabinae.
  September 3.  The blister discharged
copjously, and the pain  and  swelling of
thejoint were daily diminishing.
  September 17.  The blister was heal-
 ed, and the knee was not larger than the
 other. 
29
            REMARKS.

  This case places in a very strong light
the utility of employing active measures
for the removal of such effects as fre-
quently remain after the acute stage of
the inflammation has subsided.  Had
nothing been done to reduce the thick-
ened state of the capsular ligament, and
to disperse  the fluid in the cavity of the
joint ;  had the patient  imprudently at-
tempted  to walk about,  instead of re-
maining  quietly in his bed ; I really be-
lieve, from the degree of pain which he
continually experienced in the articula-
tion  until the blister was applied, that
the affection might have been converted
into  a very serious disease.   Had the
patient been of a scrophulous habit  the
hazard would have been still greater.

              CASE II.

   The following case  is mentioned to
show  how violent  the  constitutional
symptoms  sometimes are when the knee
joint  is  vehemently inflamed in conse-
quence of a wound. 
 30              CASES.

   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 a 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 prodigiously sw ol-
 len,  and the patient  in a very feverish
 state.   Notv.'ithstanding  general  and
 local bleeding was extensively and  re-
 peatedly practised,  while  other evacua-
 tions were not neglected, the tumefac-
 tion  of the part  continued to increase,
 and  a  most violent symptomatic fever
 supervened.   In short, the lad became
 delirious  on the  fifth day, and died on
the seventh.   When the first dressings
 were  removed on the  fourth day, the
 svuund, however, had shown a disposi-
 tion to unite in a favorable manner. 
31
           REMARKS.

  I believe the severity of the constitu-
tional symptoms is always greater, when
the inflammation of a joint arises from
a wound, than when it is the conse-
quence  of a  contusion or  sprain.   In
considering the next subject we shall see,
however,  that wounds may frequently
be made into the large joint of the knee,
without being followed by any material
inflammation.  But when inflammation
of a joint  does arise from a wound, my
experience leads me to suspect that the
constitution  is always more disturbed
than when the complaint 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 notice this disease in their writings,
or they have not been at all acquainted
with  it. Ambrose Pare*" is the first au-
thor who mentions it. He had made  an
incision in order to evacuate some fluid
from the cavity of the knee joint,  when
a hard, polished, white  body, about as
large as an almond, was discharged from
the wound.   Since  the time of this il-
lustrious  practitioner  many  eminent
men have called our attention to the par-
ticulars of the complaint.   Of these Re-.
imarus,t Morgagni,J Bromfield,*> Ford,J|

  *  Livre xv;v. Chapitre 15.
  +  Diss, de tumore  ligamentorum ciica articulo*.
1757-
  J  De sed et caus. inorb.
  ^  Chirurgical Case* and Observations.  Appen-
dix to vol. i.
  ij  Med. Observ. and Inquiries, vol. v, 
     CARTILAGINOUS SUBSTANCES.   33

Desault,* Home,t Hey,:]: and Abernc-
thy,§ form only a small number ; but as
it is in their writings that we find  the
most interesting information on  the
subject, I deem it superfluous to enume-
rate other authors.
  The  external part of the extraneous
substances in question is commonly of a
cartilaginous 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 the knee
joint, and have been supposed by Reim-
arus 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 hg. Hol-
ier  also discovered  a  great number of
cartilaginous bodies in the articulation
of the jaw, where the natural cartilages
of the joint had been destroyed.   Mr.
Hey mentions a case in which there were
two bodies of this description in the el-
bow-joint.  The largest that I have ever

  *  Journ. de Chirurgie.  Tom.  ii.
  +  Med. and Chirurg. Tranaclions.  Vol. i.
  J  Practical Observations in Surgery.
  ^ Surgical Observation;, j8cj. 
:^S4  CARTILAGINOUS SUBSTANCES

 heard of is mentioned 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  regiment.
 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  ei-
 ther attached 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 interpose themselves
 between articular surfaces, which glide
 over  one  another in the motion  of the
 joint, that much inconvenience common-
 ly results from their presence.   While
 they  continue 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 between the latter bone
 and the head of the tibia, then they im-
 pede progression, cause  considerable
 -pain, and often excite inflammation.
   As  cartilaginous substances  in  the
 joints are, very often, quite unconnected
 with any living surface, and are movea-
 ble from one  side of the articulation to
 the other, their formation has been re- 
IN JOINTS            35
garded with some degree of curiosity.
A modern author, to whom we are in-
debted for many excellent remarks on
the diseases of the knee, has very ab-
surdly imputed the origin of a  soft de-
scription of these preternatural substan-
ces to an inspissation of the synovia.
" The portion which is inspissated may
act as a nucleus to attract more of the
surrounding  matter^ and may thus re-
ceive perpetual augmentation of bulk to
an  unlimited  extent."   I wish that  I
could as readily understand, as the au-
thor conceives his reader cannot fail to
do, how this  class of tumours thus in-
creases in size.   He acknowledges that
it  is not an easy matter to comprehend
" by what process those of a bony, or car-
tilaginous nature, which have separated
from their attachment, can become larg-
er,  though this is asserted upon very
credible authority ! !5'*
   When we peruse the accurate account
which Mr. Russell has given of the pre-
sent  disease, we cannot fail to be sur-
prised that he should not have perceived
how easily a surgeon may imagine a tu-

   * Rus«ell on Morbid Affections of the Knee
 Joint, p. 88, 89. 
36   CARTILAGINOUS  SUBSTANCES

mour to be quite detached, while it still
has  connection with  the inside of the
joint, by means of a long slender pedi-
cle,  which allows the extraneous sub-
stance a considerable latitude of motion.
When we remind  ourselves of the true
manner in which such preternatural car-
tilages grow, we shall at once see how
they may continue to enlarge as long as
they are attached to  an adjacent living
substance, and how they cannot possibly
increase  after this connection has been
destroyed.
  Considerable light was thrown upon
the formation  of loose cartilaginous tu-
mours 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
practitioner entertained an opinion that
a coagulum of extravasated blood  might
frequently he  converted into an organ-
ized vascular substance by the vessels
growing into  it from the neighbouring
living surface.  No one doubts that the
coagulating lymph has constantly a ten-
dency to become vascular, when effused 
IN JOINTS.           37
on the surface of an inflamed membrane.
I do not think it of importance to inves-
tigate here whether a clot of  red blood
can be converted into an organized sub-
stance or not.  It is quite sufficient  for
the explanation of the present subject to
know, that effused coagulating lymph is
capable of this change, and that, in many
instances, it then assumes a resemblance
in structure to the contiguous parts.
   If we take the trouble of perusing the
cases which are related by different  au-
thors, we shall find that the  formation
of loose cartilaginous substances in the
joints has generally  been preceded by
violence done to  the part, and by symp-
toms of inflammation.  Of this  sort are
the cases related by Mr, Ford, M. Bro-
chier (in Desault's Journ.)  Mr. Aber-
nethy, and Mr. Hey.    Latta mentions
four  instances  which   were   prece-
ded  by  rheumatism.   In this state I
conceive that the capsular ligament, or
its delicate  layer reflected over the ar-
ticular  cartilages, effuses coagulating
lymph, just in the same way as we know
that the peritoneum and peritoneal  cov-
erings of the viscera do, in consequence
of inflammation in  the cavity of the ab-
domen.  Vessels very soon shoot from 
 38  CARTILAGINOUS SUBSTANCES

 the adjoining living surface into a por-
 tion of the extravasated lymph, which
 gradually  becomes converted into n
 structure more or 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 cavities of the bursa;
 mucosae, in which situation, " had sim-
 " ilarity of substance been a necessary
 " consequence of their attachment,  these
 " bodies wouldnot 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
 ofquoting a passage from his work, as it
tends to illustratetheprescntdisquisition.
"The structure of atumour is sometimes
like that of the parts near which it grows.
 Those which are pendulous in the joints
are of a cartilaginous or osseous fabric ;
fatty tumours frequently form in the
midst of adipose substances, and I  have
seen some tumours growing from the
palate, and having a slender attachment"
which, in structure, resembled the pal-
ate.  Sometimes, however, they do not
resemble  in structure the parts  from 
IN JOINTS^           39
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 per-
iostium ; and  indeed, in general, the
structure of a tumour is unlike that of
the part in which it is  produced. There-
fore we seem warranted in concluding
that, in many cases, the nature of the tu-
mour depends on its own action and or-
ganization, and that, like the  embryo,
it merely  receives nourishment from
the surrounding parts."*
   I have in my own  possession a com-
pletely cartilaginous  tumour,  which I
found enveloped  in  the fat which sur-
rounds the kidneys. Hence it is obvious
that the coagulable  part of  the  blood,
when  effused,  is very prone to be  con-
verted into a living substance, and that
its structure does not  necessarily resem-
ble  that of the contiguous  parts.   If
Mr. Russell should  doubt the truth of

  * Surgical Observations, containing a Classification
 of Tumours, &c. 1804. 
40  CARTILAGINOUS SUBSTANCES

the above explanation of the manner in
which  loose cartilaginous  substances
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 v/e could
not possibly impute their origin to any
such cause as an inspJssation of the syn-
ovia ; and, if we were to imbibe the idea
for a moment, we  should reject it the
next, on reflecting that mere inspissa-
tions could not be endued with vascular-
ity, which many tumours demonstrably
possess.
   The foregoing statement seems more
likely 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. 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. Essays, vol.  iv. p. 245.)   We
find that perfect quietude is essential to
the growth of new vessels into coagulat-
ing lymph ; and, in the case just instan-
ced, if the exudation  had taken place ia 
             IN JOINTS.           41

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 bodies were to be
usually formed on a part of the articular
cavity, necessarily exposed to friction
in walking, &c. then patients would ex-
perience  pain  from  the first.   But, as
they do not experience inconvenience
till the tumour has become very movea-
ble by the gradual elongation, or sudden
rupture of its  pedicle,  and, only then,
when the  tumour glides into a situation
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 are not particularly
exposed to disturbance in  the motion of
the articulation.  In most instances the
communication of vascularity must also
take place during the tenderness of the
joint, at which period the  patient natur-
ally keeps his  limb in  a quiet state, in
order to avoid pain.   After all inflam-
mation has  subsided the  limb is again
moved with  freedom  ; the organized
coagulum becomes  gradually loosened
            b  2 
 42   CARTILAGINOUS SUBSTANCES.

 by the motion, and, at length, it only re-
 mains 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 ex-
 traneous 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 inflamma-
 tion.
  The irritation of loose cartilages  in
 the knee often occasions an increased
 quantity of  fluid  in  the  capsular  liga-
 ment; but  this is not invariably the case.
 When the  irritation is such  as to induce
 a degree of  heat and  tenderness in the
joint,  there  is usually a preternatural
 quantity of synovia: when the loose car-
 tilages have  not lately created  pain and
 inconvenience, the synovia is commonly
 not more abundant than it is in the nat-
 ural state of the articulation. 
43
            •3HAP.  V.

Treatment of preternatural cartilaginous
       substances in the joints.

  IF we except making an incision into
the joint,  for the purpose of extracting
the cartilaginous tumours, we  are not
acquainted with  any certain  means of
freeing a patient from the inconvenience
of this complaint. To this plan the dan-
ger attendant on all wounds of so large
an articulation as the knee, is a very se-
rious objection.   Messrs. Middlcton
and Gooch endeavoured to conduct the
extraneous  body into a situation where
it produced no pain,  and to retain it in
that position a longtime by bandages,
under the idea that  the cartilaginous
substance would adhere  to the contigu-
ous parts, and occasion no future  trou-
ble.  No conclusion, however, can be
drawn from the cases  brought forward
by these gentlemen, because they had no
opportunity of seeing their patients a-
 gain at the end of a reasonable length of
 time, and we know that loose  cartilages
 in the  joints . sometimes disappear for 
 44'        TREATMENT OF

 half a year, and then make their appear-
 ance again.
   Mr. Hey, impressed with a just sense
 of the dangerous symptoms which have
 occasionally resulted from the most sim-
 ple wounds penetrating the knee-joint,
 very laudably tried the efficacy ofalaced
 knee-cap, and  the cases which he  has
 adduced clearly demonstrate that  the
 benefit, thus obtained,  is not temporary,
 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 success 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 o-
 piniovi that the effect of a knee-cap, or of
a compress and roller, applied over the
loose cartilage, when this body is so sit-
uated as not to create  pain, and to ad-
mit of being compressed, ought general-
ly to be tried  before having recourse to
excision.  I say generally, because the
couduct of the  surgeon ought, in such
cases, to be adapted to the condition and
inclination of the patient.   If a man be
deprived of his livelihood by not being 
     CARTILAGINOUS SUBSTANCES.   45

 able to use his knee ; if he cannot,or will
 not, take the trouble of wearing a band-
 age j  if he be urgently desirous of run-
 ning the risk of the operation, after cir-
 cumstances have  been  impartially ex-
 plained to him ; if a bandage should not
 be productive of sufficient  relief ; and,
 lastly, if excessive pain, severe  inflam-
 mation of the joint, and lameness, should
 frequently be produced by the complaint;
 I think it is the duty of the 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 lifcr in attempting to get
 rid of the disease ; yet, since the incon-
 veniences of the complaint are, in most
 cases, very bearable, and are even capa-
 ble of palliation by means of a bandage,
 endangering the limb and life in any de-
 gree  must seem to  many persons con-
 trary to the dictates of prudence.
  Iain ready to allow, with M.Brochier,*
 that the  danger attendant on wounds
of the large joints has always been very
much exaggerated,  in consequence  of
ancient prejudices.  But, making every
* Dciault Journ. dc Chirurgie, torn. ii. 
46  CARTILAGINOUS SUBSTANCES.

allowance for the influence of prejudice,  '
a man must be very sceptical indeed,
who does not  consider the wound of a
large joint, like that of the knee, attend-
ed with real cause for the apprehension
of danger.  The fatal event of the se-
cond 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 car-
tilages out of the  knee.   " The society
have been informed of several cases in
which the operation  has  been perform-
ed ;  some, iike  this, have healed up
without any trouble ; others have  been
 followed with  violent inflammation, fe-
ver, and death itself."

   *  Medical Observations and Inquiries, *ol. v.
 P- 334- 
47,
           OPERATION.

   Under circumstances such as I have
 already noticed, a surgeon  is justifiable
 in undertaking to remove loose cartilag-
 inous substances 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 often attended with a degree of heat
 and tenderness in the articulation; when
 we recollect that the danger of the oper-
 ation is, in a great measure, proportion-
 ed to the subsequent inflammation ; and,
 when we  also recal to mind that, if the
wound unite by the first intention,  a
great deal of the danger is removed ;
we can entertain no doubt that the  ad-
vice, delivered  by  several respectable
surgeons, to  keep the patient in bed  a
few days before operating, and to apply
leeches and cold saturnine lotions to the
knee during  the same time,  is fraught
with the  most commendable  prudence.
Thus the joint is brought into a perfect- 
48        EXTRACTION OF
ly quiet state before the incision is made.
Nor should the operation be undertak-
en before the bowels have been emptied
by a mild saline purgative.  As soon as
the inflammatory swelling and tender-
ness have quite subsided the  excision
maybe undertaken.
   As the loose piece  of cartilage may
commonly 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.  De-
sault used to bring the loose cartilage to
the inside of the articulation, against the
attachment of the  capsular ligament,
and then make the incision in that situ-
ation.  Mr. Abernethy has recommend-
ed bringing  the loose  piece of cartilage
on the outside  of the internal 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 distant as possible from the mov-
ing surface of the joint.  Mr. Hunter
also preferred removing these loose bo-
dies at the upper part of the joint,  be-
cause there the bag, which contains the 
     CARTILAGINOUS SUBSTANCES.   49

synovia, has less of the nature  of acap-
sule.
   For my own part I do not believe that
this is a matter  of very great impor-
tance, and  if the loose cartilage could
be more easily fixed on one side of the
articulation than the other, I should re-
commend  the incision to be made in
that situation.  But the places chosen
by Desault and Mr. Abernethy certainly
seem the best for fixing the pieces of car-
tilage, when they can be readily brought
there.  The inner surface of the intern-
al condyle is of considerable extent, and
when the loose cartilage is situated up*
on it there is no  difficulty in  confining
the little tumour there, provided the as-
sistant places the points of  his fingers
round it in the  manner which Mr. Ab-
ernethy has directed.
   It is of great consequence that the as-
sistant prevent the loose cartilage from
gliding away from the place where  the
wound is made, for, in this event, it of-
ten happens that the extraneous sub-
stance  cannot be immediately found a
gain,  so that the  purpose of  the opera-
tion is frustrated, and, if the capsular
^ligament should be  divided, all the risk
            c 
50        EXTRACTION OF

of the operation  is to  be encountered
without the smallest chance of the least
benefit.
  All operators have  very properly a-
dopted the plan of drawing  the intcgu-
mc.nts to one side before making the in-
cision, so that as soon as the excision of
the cartilage is achieved the wound in
the capsular ligament may become im-
mr diat-Jy covered with the skin. Thus,
whatt-wr bad effVct the entrance  of air
might haw is, in a great measure, pre-
vented.  The piece of cartilage,  being
expose] by the incision, is to be imme-
diately thken 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  accurately together, and cool
saturnine lotions are to be applit d.  If
the patient be young and robust he ought
to be bled.   The limb is to be kept in
an  extended position, and  completely
motionless,  and the whole treatment is
to be rigorously antiphlogistic.
   Though the union of the wound great-
ly diminishes the chance of future dan-
gerous s} mptoms, experience shows that
the limb ought to be kept in a quiet state
for some days after the incision is quite 
    CARTILAGINOUS  SUBSTANCES.  51

healed.   Mr. Brorofield observes : " In
most of the cases which I have seen,
where the operation had  been perform-
ed, and the proper attention paid to the
situation of the limb, the patients did
well; yet I must own that, in an instance
or two, from mismanagement, I thought
they would have lost their lives : for, as
they suffered 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. 
52
              CHAP. VI.

  'Of Collections  of Fluid in  the Capsular
               Ligaments.

    VARIOUS fluids may accumulate in
  the cavities of the joints.  That the sy-
  novia may collect in this  manner we
  have already noticed.  But, besides this
 •affection, the joints are subject to a dis-
 ease termed hydrops articuli, which con-
 sists of an accumulation of water in the
 -capsular ligament, and is very analogous
 to the hydrocele,  or collection of an a-
 queous fluid in the tunica vaginalis tes-
 tis.
    Suppuration  also  sometimes  takes
 place in the joints, so that the collection
 of fluid  consists of  a purulent matter,
 which, however, is generally  blended
 with the  synovial secretion.
   In  violent contusions and  sprains
 blood-vessels of the joint may be ruptur-
 ed, and a large quantity of blood may
 be extravasated in the  capsular ligament.
   Of all the articulations in the body not
 one is so subject to hydrops articuli as
tthe knee. Many other joints are, bevond 
        COLLECTION  OF FLUID.     SS-

 adoubt, more frequently the seat of sup--
 puration in consequence of injuries ; but"
 none are so liable to dropsical disease.
 The largeness and looseness of the cap-
 sular ligament may, perhaps, afford  a
 reason for this indisputable fact.
   The causes  of hydrops articuli are of-
 ten not  discoverable.    The disease,
 however, is very frequently preceded by
 severe rheumatic affections and local vi-
 olence.  When the  fluid is not so copi-
 ous as to produce prodigious distention
 of the capsule,  a fluctuation  is easily dis-
 tinguishable.   Also, if the  limb  be ex-
 tended,  so as  to relax the  ligament of
 the patella, pressing the collection of
 fluid causes a rising 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 degree of stiff--
 ness experienced in the affected joint.
   Mr. Russell* has  adopted the idea
 that some cases of this kind  are vene-
real, and others scrophulous ; but, as he-
has not  any good arguments in support
of the opijiion,  it seems unnecessary to
say more than that the  mere  existence
of hydrops articuli is  a subject, affected-

  * On the Morbid Affectiontof the Knee, p. 67* 
54     COLLECTION  OF FLUID
at the same time with syphilis, or scro-
phula,  is  no proof that the dropsical
swelling of the joint depends upon  the
specific disease.  Here also I must take
the liberty to remark that,  if  a dis-
order 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 remem-
bered,  however, that mercury is one of
the most powerful means of exciting the
action of  the absorbent vessels ; and it
is upon this principle  that it  cures nu-
merous diseases of  different natures
without the least interference of  any
specific virtue.  Since we see that hy-
drops articuli  most frequently follows
rheumatism, common infnmmatory af-
fections of the knee, and k vers, which
greatly debilitate the system ; ur.d since
the disease mostly yields to such treat-
ment as is not potent  enough  to subdue
scrophulous and venereal complaints ;
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
venera and struma.  It seems  to me
 that the  only sound conclusion to he
drawu from the coexistence of hydrops 
  IN THE CAPSULAR LIGAMENTS.  55

articuli and one of these latter diseases,
is that the presence of venereal, or scro-
phulous complaints, in any  particular
subject, is no reason why he should not
be liable to become affected, at the same
time, with another kind of disease.  If
we were to adopt the opposite 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
appearance, during the prevalence of the
disease of the joint.


          TREATMENT.

   When hydrops articuli occurs during
 the debility, consequent to typhoid and
 other fevers, the complaint  can hardly
 l« expected to get well till  the strengh
 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
 local remedy  w ;s tried without avail.
 The disease, which  would  not yield as
 long as the debility consequent to a ty-
 phus fever lasted, got well spontaneous- 
56     TREATMENT OF FLUID.

ly,immediately after the patient had re-
gained his strength.
  During eight or nine  years I have
been  in the habit of frequently seeing,
in St. Bartholomew's Hospital, collec-
tions  of aqueous fluid in the joints ; and
I can conscientiously assert that I never
witnessed anyr case, which did  not ulti-
mately yield, to blistering the part, and
maintaining a discharge from the blist-
ered surface by means of  the savin cer-
ate.
  When the disease is the consequence
of fevers, a blister easily disperses the
swelling as soon as the patient has recov-
ered alittleof his former natural vigour.
The operation of a blister may always
be very materially assisted by the pres-
sure of a bandage.  Moderate exercise 5
frictions with flannel impregnated with
the fumes  of vinegar ;  camphorated
mercurial ointment;  electricity;  and
purging the patient with calomel, or kali
acet.; are also means possessing peculiar
efficacy.
  As I  have never seen any case in
which the circumstances seemed to jus-
tify making an opening into the joint for
the purpose of evacuating the  fluid, I
shall ucf dwell upon this head.  But tx- 
       SUPPURATION OF JOINTS*    57

cessive distention  in  some  neglected
cases, might certainly become an urgent
reason for performing such an operation.
Also,  if the complaint should resist all
other plans of treatment,,  and the irrita-
tion of the tumour should greatly im-
pair a weak constitution, the practice
might be justifiable.  A case answering
this description is related by Mr. Latta,
in*which twelve ounces of fluid were dis-
charged.   (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
inflammation is enough to inform us of
the nature of the case.  But,  as absces-
ses  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 itself, 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. 
58     SUPPURATION OF JOINTS.

  When the matter is  within  the joint
pressure applied to  the tumour causes
an elevation of the patella, 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 im-
pulse  of a  fluid is communicated from
one side of the articulation to the other.
The  same kind of fluctuation may be
felt on making the same experiment on
any two different points, where the cap-
sule is  only covered with the integu-
ments.  An abscess  of this kind has al-
ways  been preceded by alarming distur-
bance of the constitution.
   When the matter is on the outside of
the joint,  the tumour usually extends
beyond the limits of the capsular liga-
ment : for instance,the swellingascends
higher up trft  thigh,  or descends  lower
down the leg, than the capsular ligament
itself naturally reaches.   The tumour
is usually confined to a part only of the
circumference of the knee,  and there it
c ;uses a more sudden prominence than
results from an abscess in the  joint.   If
the s v.lling exttrd around th? patella,
this bone seems more sunk than in the
natural state. 
59
A FEW PRACTICAL REMARKS.

  When an abscess has taken place in
the vicinity of a large joint, there can be
little doubt concerning the propriety of
discharging the matter by an early inci-
sion.   Such purulent collections, when
situated about the knee, frequently lie
under the femoral fascia, and it is highly
deserving of notice that all tendinous
expansions powerfully retard the pro-
gress 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 neighbour-
ing 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 distention, occasioned by
the abscess,ought to decide the proper
 line of conduct.  As pus has not that
 power of corroding wh'w h was atii ibut-
 ed to it by the ancient surgeons, its mere 
60    SUPPURATION OF JOINTS.

presence in the joint will not be produc-
tive of any bad consequences.   When,
however, its quantity is so large that it
forcibly distends the capsular ligament,
and causes great pressure on the articu-
lar cartilages, its longer continuance in
the joint may occasion the most irrepar-
able mischief, and  even  death.  Cases
of the description which we are now con-
sidering, are  always highly perilous, and
frequently oblige the patient to submit
to amputation as the only means of pre-
serving life.   The  cartilages and liga-
ments cannot bear  this state of disease,
in which they are violently inflamed,
and, at the same time, irritated 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, under such circumstances, the state
of the constitution should allow the sur-
geon to persevere in an attempt  to save
the limb,  the propriety 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 suf-
fice, and it seems saltr to endeavour to 
      SUPPURATION OF JOINTS.     61

heal the wound  by the first intention,
and to repeat the operation, if circum-
stances  should demand it, rather than
to leave the wound unclosed.
  If the contents of the abscess should be
discharged through an ulcerated open-
ing, the treatment is to be conducted al-
most  on the same principles  as are ap-
plicable to all acute abscesses;   and it
seems unnecessary to  expatiate further
on the subject.


OF  TUMOURS  OCCASIONED
           BY  BLOOD.

  When the collection of fluid in a joint
makes its appearance almost immediate-
ly after a severe sprain, or violent con-
tusion of the part, and continues to in-
crease gradually for some time after-
wards, there is every reason for  suppos-
ing that the principal  part of the  con-
tents must be blood.   The formation of
pus, and the secretion of any aqueous
fluid,  could not have  taken place  in %o
short  a time.   The  extravasation  of
blood within the large  joints is,  I be-
lieve,  exceedingly uncommon.   Tu-
mours composed of this fluid,  and set 
62     TUMOURS OCCASIONED

down in systematic works as extravasa-
tions within the capsular ligaments, are
generally  on the outside of the cavities
of the articulations.
   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 e-
vacuation.  Its  mere presence  is  not
likely to produce bad consequences, and
in the end it will be absorbed.  Frictions
with camphorated  liniments  would ac-
celerate this desirable event.   Ifano-
pening were made, the coagulated state
of the blood would, in many cases, ren-
der its evacuation impossible.
   With respect to  extravasated  blood
in general surgeons  are now well aware
how unnecessary, and  even injurious it
is, to make an opening into  almost all
tumours  of this kind.   The opening
frequently fails  in  procuring  its dis-
charge, and the admission of air occa-
sions  the  blood to  putrify in cases in
which, under  different  treatment, it
might have continued without produc-
ing the smallest irritation.
   Mr. Hry mentions  a  case in which.
the knee-joint was wounded,  and blood
insinuated itself into it.   Though it was 
              BY BLO#D.            63

impossible to prevent the circumstance,
yet no harm resulted from the extrava-
sation ; and the fluid was absorbed with-
out having created the least trouble.*

* Practical Observations en Surgery. Case, p. 35$. 
 
PART II.
OF THE WHITE SWELLING OF THE KNEE,

  AND THE TREATMENT OF THE DISEASE.
             CHAP. I.

        Preliminary Remarks.

  THE white swelling, or spina vento-
sa,  as  it is not  unfrequently called, in
imitation of the Arabian writers, Rhasis
and Avicenna, is a disease in this coun-
try particularly common  and peculiarly
intractable.  The  nations of the conti-
nent are, unquestionably, as subject as
we  are to chronic enlargements of the
knee-joint.   Foreign surgeons describe
numerous varieties of a disease, which
many English writers would term rheu-
matic white swellings; but they acknowl-
edge that the scrophulous species of this 
 66      PRELIMINARY REMARKS


  disorder does not commonly occur to
  their notice.*
    Wiseman was the  first who used the
  term white  szuelling, and,  as Mr. Pott
 observes, the expression is not very un-
 apt, because  it conveys an  idea of one
 mark of the distemper, which is, rhajt
 notwithstanding the increase of size in
 the joint, the skin is  not inflamed, but
 retains its natuual colour.
    It is not my intention to occupy the
 time of my readers by considering the
 white swelling, pgedarthrocacesvand spi-
 na ventosa,"!" as distinct varieties of dis-


   * Fungus scrophulosus terribilc profecto malum,
 rarius in Gcrmania*occurrit, frequentius in  Britan-
 nia. —C. G.  T.  Kortum in Comment, de Viiio
 Scrophuloso, torn. 333  ii.  Edit. 1790.
   Scrophulosa materia sane  potest pessim.t indolis
 fuogum causare, ec quamquam is apud nos comma-
 niter  nonobtinet, scire tamen juvat, scrophulas An-
 glis nominatas morbum esse in ilia regione ut fre-
 quentem, sic ipsi nationi  peculiarem, &c.—Bram-
 bi.'la in  Aci Acad. Medico. Chirurgicje Vindob.
 torn. i. p. 20.
   Peiit, speaking of the spina  ventosa, remarks :
 " Je crois cependant qu'il faut s'en rapportcr aux
 Angloii plus qu' a tout autres, vu qu'il en arrive tres
 touvent dans Uur pays,  et encore plus dans quelques
 islet  du nord qui le-ur appartitrd."—Mai. act Os,
 torn, ii  ;5?, edit. 17^1.
  i Many  modern author!  imply  by  this term,
 a collection of matter in the  medullarystructure of
a bone.  Such a case, however, I believe, is very
uncommon. 
     ON  THE  WHITE SWELLING.   67*

ease.   A  few  observations, however,
will be offered in the course ofthe disser-
tation, for the purpose of marking more
particularly the  discriminating  char-
acters ofthe scrophulous distemper of the
knee, to which I could wish that the ap-
pellation of white swelling were confined.
   The morbid enlargements of the knee
are certainly sufficiently  numerous  and
various to admit of some useful classifi-
cation, and I cannot refrain from lament-
ing that English surgeons, who are gen-
erally  the foremost in the promotion of
their particular science, should not at-
tempt to arrange the diseases to which
 I allude,  in a better  manner  than  they
 now arc.  This, however,  would form
 a work of considerable magnitude, and
 the plan is quite incompatible with the
 usual extent of a dissertation.   The on-
 ly distinctions which systematic writers
 have  drawn,  are into  rheumatic  and
 scrophulous white swellings ;  the latter
 kind of which tumours they further dis-
 tinguish  into  such as primarily  affect
 the bones,  and then  the ligaments and
 soft parts;  and into  others which first
 interest the ligaments  and soft parts,
 and, at length, affect the bones.
   These views of the subject have some 
618"    PRELIMINARY REMARKS
 foundation ;  but they are by no means-
 sufficiently comprehensive; and the pro-
 priety of denominating some of the af-
 fections rheumatic might be questioned
 by pathologists, whom we could not, in
 this instance, upbraid with unseasonable
 scepticism.
   If I should be asked the reason why
 I am  dissatisfied with the few distinc-
 tions  introduced into  the  cubjrct, my
 answer is, that  I  frequently see more
 numerous forms of such disease in the
 knee than are distinguished by names,
 or than ought to be arranged under the
 head  of white  swellings.  I see some
 morbid joints in which the bones,  liga-
 ments, and cartilages, can hardly be 6aid
 to be materially diseased.  The whole
 ofthe distemper s  ems to consist in the
 deposition of a  glutinous lymph, which
 adheres  to the most subtile lamina? of
 the cellular substance, and to the surface
 of the tendons,  ligaments, and capsule
of the   articulation.    Brambilla  has
named thisdiseaseyw/7^5 articulationisy
and he says that it is more common in
 Germany than  in  any other European
tountry.*  But such a malady is cer-

   * Acta Acad. Josephin.  Vindob. p. 1. 
      ON THE WHITE SWELLING.   69

tainly 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 car-
tilages have suffered considerable alter-
ations ; 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 af-
fection  the  ligaments, cartilages,  and
bones are not the parts principally dis-
eased ;  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
ligament; and in which case the disease
does not consist of a thick kind of lymph
diffused throughout the structure ofthe
parts on the outside of the joint, but of
a morbid change, in which  such parts
become, at  once, enlarged, thickened,
and bereft of all their original firmness.
This malady also is oftentimes so terri-
ble as to render amputation ofthe limb
indispensable. 
70     PRELIMINARY REMARKS

  There are other cases  in which the
bones  are softened in their texture,
while the ligaments are  distempered,
the cartilages absorbed, and  the bones
carious in an advanced stage of the dis-
ease.
  In some instances there are spinous,
angular depositions of osseous matter
upon the surface ofthe diseased bones ;
while in the neighborhood  ofthe articu-
lar part ofthe same bones there are deep
excavations in consequence of caries.
  I might enumerate several  other va-
rieties  not deduced from the morbid
anatomy ofthe joints, but from the dif-
ference in  the symptoms and  progress
of the complaint,  as  well as  from the
particular constitutions  in which sueh
forms of disease occur.  Were I to pro-
ceed further at present I shouldnotleave
room for the discussion of such points
as I particularly wish to comprehend  in
this production.  At  some future op-
portunity, perhnps, I may renew the con-
sideration 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 little use to any succeeding writer,
who may  attempt  to discriminate ths 
      ON THE WHITE SWELLING.    71

 different natures of the various morbid
 enlargements of the knee.
   Caries ofthe bones has been mention-
 ed by the majority of writers as neces-
 sarily attendant on  white  swellings.
 Some limitation, however,  ought un-
 doubtedly to be made to  the remark.
   If the term caries be meant to denote
 that morbid process in a  bone, which is
 analogous to ulceration ofthe 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 the knee, it
 is not till after the disease  has  made
 considerable progress, and actually de-
 stroyed the  cartilaginous  coverings of
 the articular surfaces ofthe bones, that
 we find the tibia and femur affected with
 any  morbid  change at all analogous to
 enries.
   The scrophulous disease ofthe bones
 is most prone to attack such as are soft
 and of a spongy texture  : so is caries ;
 but then the  effects of the former are
 widely different  from tnose of the latter.
 The peculiar alterations which the scro-
 phulous affection first produces, are a
partial absorption ofthe caithy particles
m 
72     PRELIMINARY  REMARXS

of the diseased bone, and a deposition
of a softish matter into the interstices of
its structure. There is no breach what-
ever occasioned in the seat of the dis-
ease by this change.
  On  the other hand, in caries, as the
osseous particles are absorbed, or crum-
ble away, no effort is made to repair the
breach of continuity, and an excavation
is necessarily the consequence.
  Such is  the  first and  most common
morbid charge, which the head of the
tibia undergoes in the disorder implied
by the scrophulous white swelling.   In
several strumous joints  which  I have
dissected, I have also found that a mor-
bid deposition  of a cluesy kind of sub-
stance, blended with phosphate of lime,
took place on the outside ofthe heads of
the diseased bones.   I have  pieces of
scrophulous bones in my possession, on
which these depositions,  before  they
were considerably destroyed by macer-
ation, had  the appearance  of  opaque
crystallizations.   I have seen  similar
specimens  in Mr. Abernethy'sanatomi-
cal museum.
   The caries which attends a more ad-
vanced stage of the  white swelling fol-
lows the ulceration and destruction of 
     ON  THE WHITE  SWELLING.    73

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 sit-
uated a  chasm more  or less extensive
and  deep has been  formed in the sub-
stance of the bone.
   I have wished to be particular in  ex-
posing the absurdity of confounding the
scrophulous alteration of the bones with
caries, because the matter seems to  me
not to have  been hitherto properly ex-
plained 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 ; first,
because  it is meant to signify what very
rarely happens in  scrophulous diseases
ofthe joints, or in any species of white
swelling whatever ;  and, secondly, be-
cause the sentiment  which it now con-
veys has led to very unwarrantable prac-
tices, with a view of promoting an exfo-
liation, which was judged to be inevita-
 ble.
   It is  observed by  a gentleman, who
 has written a very good practical treatise
             D 
74     PRELIMINARY REMARKS
 on the presentsubject, that," in the ca«~
 rious stage  of this disease it has been
 said, that to expedite a cure exfoliation
 should  be promoted.;  but  experience
 tells us that exfoliation  rarely occurs ;
 and  when the complaint does not seem
 to require 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 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 expressed myself I should be sorry
 to be misunderstood.  I do not mean to
 deny that the articular parts of the bones
 are not very frequently found carious in
 this disease ; but only to assert that ca-
 ries is so far from constituting an  essen-
 tial feature of the disorder, that it rarely
 occurs until  the cartilages of the joint
 have been more or less destroyed ; (for,
 after this italways takes place) and that
 the morbid alteration previously  obser-
vable in the  bones is widely different
 from a true caries.

  * Practical Observations on the Disease of  the
Joints, commonly caJled White Swelling.   By B.
Crowtber.  P. 6—7.                 °    ' 
      ON THE WHITE SWELLING.    75-

   The circumstance of the bones being
 sometimes quite free from disease, even
 when  the knee  seems  of considerable
 magnitude, must greatly strengthen the
 tenor of the above  observations.   In
 this instance the ravages ofthe disorder
 particularly affect the  ligaments of the
 joints, and the fat and cellular substance
 on the outside  of the capsule.    Mr.
 Russell, (p. 30s) diligently  describes
 how much the  soft parts contribute to
 the swelling in the disease.   Speaking
 of the appearances on dissection he ob-
 serves : " The great mass of the swel-
 ling appears to arise  from an affection
 of the parts exterior to the cavity of the
joint, and which, besides an enlargement
 in size, seem  also to have undergone a
 material change in structure.  There is
 a larger than natural proportion of a vis-
 cid fluid intermixed with the cellular
 substance ;  and  the cellular substance
 itself has become thicker,  softer, and of
a less firm consistence than in a state of
health."   (P.  15.)
   Mr. Crowther says : u 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 
 76    PRELIMINARY  REMARKS        .

 cases they, as  well as  myself, consider-
 ed only as an enlargement ofthe bone ;
 but after the application of leeches, and
 an artificial  drain derived from the in-
 teguments covering the joint, there did
 not appear  the smallest enlargement of
;the heads of the bones."
   I have seen many  amputated joints
 dissected,  in  which  it was doubtful
 whether the cartilages 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 con-
 dition of the  patients.   In these in-
 stances the  whole disease  seemed  to
 consist in such an alteration of the soft
 parts surrounding the  articulation, as is
•described by Mr. Russell, together with |
 a thickened  and  softened  state  of the
 capsular and other ligaments, and a col-
 lection of a purulent, shining coagulated I
 matter in the cavity of the joint.
   Mr. Russell appears to adopt the o-
 pinion, that the disease  always com-
 mences in the ligaments and membranes
 ofthe 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 
      ON THE  WHITE SWELLING.    77

 was  this declaration,  made by a sur-
 geon of experience, which  first called
 my attention  to this point, and, though
 it was long after my first perusal of Mr.
 Russell's book that I formed a decided
 opinion on the matter, yet candour o-
 bliges  me to state that 1  derived the
 original intimation from the above men-
 tioned publication.
   Many surgeons, I feel certain, will be
 disposed to grant Mr. Russell a very
 small portion of praise on this account ;
 and indeed his judgment might be criti-
 cised  for mentioning so 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 per--
 suasion that the bones  are enormously
 enlarged, we must acknowledge that the
 removal of this erroneous opinion ought
 to be effected  in such a manner as will
 leave a strong and lasting impression on
 the minds ofthe great mass of surgical
 practitioners.    The   slight  allusion
 which Mr. Russell has made to the sub-
ject, is little calculated to excite general
 attention, and, even at present,there are
 very few surgeons who do not place the 
7B     PRELIMINARY REMARKS

most implicit faith in the expansion of
the heads of bones, in cases of white
swellings.
  It was in my First Lines ofthe Prac-
tice of Surgery that the  doctrine of the
enlargement  of the heads of the bones
was first publicly opposed with any de-
gree of force.  The opposition  is still
more vigorously maintained in this dis-
sertation.
  Here 1 cannot deny myself the  pleas-
lire of giving praise to  n>y friend Mr.
Lawrence, a gentleman whose heart is
enriched with the most generous  quali-
ties, and whose mind is adorned with
every requisite for forming a truly 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  whatsoever; and  the frequent
conversations which I had with him up-
on this subject tended, in a very power-
ful manner, to dispel the few last doubts
which I entertained.
  I must candidly confess that, deceivi d
by the feel of many diseased joints, and
influenced by general opinion,  I once
imbibed the  idea  that there is often a
regular expansion pf the heads of scro-
phulous bones.  But, excepting  an en- 
     ON  THE WHITE  SWELLING.    79

largement which arises from the deposi-
tion of osseous matter on the outside of
the h-ads ofthe  tibia, ulna, &c. so as to
form sharp, angular, scabrous projections
on them, and which alteration cannot be
called  an expansion of those  bones, I
have never been an eye-witness  of the
head of a bone being of preternaturally
large dimensions, in consequence of the
disease known by  the  name  of white
swelling.  I have frequently been in the
habit of  inspecting the state of the nu-
merous diseased joints which are annu-
ally  amputated  in St. Bartholomew's
Hospital, and though 1 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 ofthe tibia
undergoes in many cases, is first a par-
tial absorption ofthe phosphate of lime
throughout its texture, while a soft kind
of matter seems to be secreted  into its
substance.   In a more advanced stage,
and indeed in that stage which most fre-
quently  takes place before the  joint is
 amputated,  the head of the bone has
 deep excavations  formed in it in conse-
 quence of carie3, and its structure is now
 so thoroughly distempered and softened 
80     PRELIMINARY REMARKS

that, when any instrument is pushed a-
gainst the  carious part, it easily pene-
trates 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 (November 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
present felt the ends ofthe tibia and fib-
ula, after the integuments were remov-
ed, and coincided with me that the feel
which was even now  communicated,
set med to  be  caused by a real swelling
ofthe bones themselves.  But, on clean-
ing them  more, the enlargement was
demonstrated 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 believe that surgeons  have good
reason for supposing that some whit«
swellings commence in the  ligaments,
a:id afterwards affect the bones ; while
others begin in the spongy texture ofthe
bones, and afterwards  affect  the  liga- 
     ON  THE WHITE  SWELLING.    81

ments.  At  this opportunity I cannot
refrain from  remarking that, as the lig-
aments are almost invariably found dis-
tempered, and the bones are not so, we
must inftr that in the  majority of in-
stances the disease commences in the
former parts.
  The morbid enlargement of scrophu-
lous joints is always  made to appear
greater than it really is, by  the emacia-
tion 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. 
82
             CHAP. II.

An account of the Symptoms,  and Pro-
       gress of White Swellings.

   THE large joints, such as the knee,
ankle, wrist, and elbow,  are most  ex-
posed to the attack of this direful mala-
dy.  In the first  stages of the disease
the skin  is not at  all altered  in col-
our.   Sometimes the swelling  yields in
a certain degree to pressure ; but it nev-
er 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 whatever
the degree of pain may be, it particular-
ly affects only one part of the  articula-
tion, and this is usually its centre.   In
some cases the pain seems to be situated
in the head ofthe tibia ; but wheresoev-
er it occurs, I have: always observed that
it is  always confined to one particular
spot.  Sometimes it is incessant; at o-
ther times  it intermits ; and,  in a  few 
         WHITE  SWELLING.        83

cases, it  recurs so regularly, at staled
times, that it deserves to be called peri-
odical.  When the patient is warm, and
especially when he is heated in bed, he
commonly seems to experience an exas-
peration of the pain.
   In most  cases  the tumour is at first
very trivial, or there is even no swelling
at all, though the pain be very considera-
ble.  A  fulness is first observed  to oc-
cupy the little  hollows, which are natur-
ally situated on each side ofthe patella.
This  prominence augments,  and the
whole articulation soon becomes every
where palpably augmented in circumfer-
 ence.
   As  the patient cannot bearthe weight
 of his body on the affected limb without
 a considerable increase of pain, he  gets
 into  the habit  of only  touching the
 ground with his toes, and thus the knee
 is generally  kept  a  little bent, and
 the power of completely extending the
 limb again is soon lost.   In advanced
 cases the knee is always found in a per-
 manent state  of flexion.  It is observed
 that, in this disorder, the swelling is  al-
 ways preceded by pain ; but the interval
 between the first occurrence of the two
 affections  is  very various in different
 cases. 
 84    SYMPTOMS  AND PROGRESS

   At length  the diseased joint  attains
 an enormous size ;  but  ttic skin is not
 materially affected.  The only changes
 observable in it are the  appearance of
 varicose veins, and  a  shining smooth-
 ness.  The latter circumstance seems
 to be owing to the distention, which ob-
 literates the  natural wrinkles of the in-
 teguments.   The  skin also cannot now
 be pinched up into a fold, as it could in
 the early stage ofthe disorder.
   When the  distemper has proceeded
 further, abscesses generally form around
 the joint, and their contents are, in time,
 usually discharged through the ulcerat-
 ed openings.   These ulcerations some-
 times heal, and other similar abscesses
 take place.   The period at which such
 collections of  matter occur,  after the
 commencement of the disease, is ex-
 tremely various in different case3.   In
 some cases such abscesses form in a few
 months after the joint has become af-
 fected ; in others they do not take place
for many years.
   The  patient's health,  in  the mean
time, becomes  gradually impaired  in
 consequence of the local disease.   His
appetite  fails;   he  cannot  sleep  at
night;  his  pulse   is  small  and   fre-
quent; he has profuse perspirations; and 
     OP THE WHITE  SWELLING.   85

his bowels are  not unfrequently very
much disordered with an obstinate and
debilitating diarrhoea.   Under such
symptoms dissolution soon  follows, un-
less  the  constitution  be speedily freed
from the irritation of the local malady.
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 derange-
ment of the health, do not arrive at a
considerable pitch till several years have
expired after the first  attack ofthe com-
plaint.  In other examples the  disease
ofthe joint acquires 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.
   Such white  swellings as have  been
termed  rheumatic are certainly very dis-
tinct 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 sub-
side in proportion as the tumefaction in- 
 86    SYMPTOMS  AND PROGRESS

 creases.  Genuine white swellings, on
 the  contrary, are always preceded  by
 pain, which is usually not so acute after
 the swelling appears as it was before.
   I believe that all those instances in
 which the bones are found not at all al-
 tered in texture, and the whole mass of
 disease seems to  be confined to the soft
 parts,  are  not scrophulous white swel-
 lings.   In  rheumatic cases of this kind
 the  pain is not confined to a particular
 point; but extends overthe whole joint.
 If a  man live to the age of five and
 twenty, quite free from every symptom
 of scrophula, I believe he can never, af-
 ter this  period, become first  affected
 with a scrophulous disease of the knee.
 I believe also  that all cases in which the
 head ofthe tibia loses a good deal of its
 natural firmness,  in consequence of a
 morbid alteration, which I have already
 endeavoured to describe, are scrophu-
 lous cases.
  The limphatic glands in the groin are
 often enlarged in consequence of the af-
fection ofthe knee.; butT never saw this
 secondary complaint prove permanently
troublesome.   Mr.  Russell  makes a
similar observation. 
      OF THE WHITE SWEELING.   87

  The head of  the tibia seems to suffer
considerably more than the condyles of
the femur.  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 considerably
from caries all round its circumference.
The decay of the cart'dages of the joints
is observed to commence at their edges,
and to  extend  gradually  toward their
centre; and this mischief is always much
more advanced- 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 destruction of  all the
ligaments of the knee that the  bones of
the leg become  drawn up the posterior
part ofthe thigh bone, by the strong ac-
tion ofthe 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-jointj
which had a very singular appearance,
in consequence of the great retraction of 
88       -WHITE SWELLING.

the bones oftheleg in the above manner.
Mr.  Langstaff lately showed me a pa-
tient w'/th  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
certainly not a scrophulous case ; but the
above  extraordinary  looseness of the
joint could only result from some affec-
tion of the ligaments.
   In an  advanced stage of white swel-   I
lings  I believe that a partial  luxation,   j
consisting of a retraction of the heads of   \
the tibia and fibula upwards, towards the   ,i
tuberosity  of the ischium, is not  very
uncommon.   I have never  seen any
case in which the head of the tibia war
completely separated from the body of
the bone,  in the way in which it is said
sometimes to be in young subjects.
•f 
89
             CHAP. III.

■Ofthe Causes ofthe White Swelling, and
   the Grounds on -which it is regarded as
   a Scrophulous Disease.

   I AM one of those persons who be-
lie ve 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 ofthe term white swelling, in
the present chapter.
   In the constitution which I have just
mentioned,  every cause which is capa-
ble of producing inflammation,  or any
morbid and irritable  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 treat-
ing.   A  cold stream of air blowing a-
gainst the neck of a scrophulous subject,
or exposure to damp, will often produce
an inflammation and enlargement of the
lymphatic glands, in the vicinity ofthe
basis and angle of the jaw, and this affec-
tion may terminate in a scrophulous dis-
ease of those glandular parts. 
 90         CAUSES' OF  THE

   It is also a fact, which Mr. Burns* of
 Glasgow has  accurately noticed, that
 causes which would  scarcely induce in-
 flammation in a healthy person, may in-
 duce a local disease and inflammation in
 a scrophulous  habit.   Hence,  an en-
 largement of the glands  of the neck is
 more apt to occur in such a temperament
 than in a person of a sound constitution.
   These observations are also applica-
 ble to the knee-joint. External violence,
 exposure to damp and  cold,  will much
 more readily produce irritation  in that
 articulation, when the  patient is scro-
 phulous, than when he is of a sound hab-
 it of body.   Even when such irritation
 is produced in the knee of a healthy per-
 son, 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 which con-
 stitutes the white swelling is very likely
 to ensue.   Thus, rheumatic complaints
 ofthe  knee often become the exciting
 cause of scrophulous disease  in the ar-
 ticulation, when the constitution is what
 is called scrophulous.

 * Dissertations on lDflammatiort,Yo!. ii. p. 341—35^. 
         WHITE SWELLING.        93.

  From  the  preceding statement  we
may easily discern why white swellings,
in a great number of instances, appear to
originate  without any known  cause.
Mankind are little  inclined to  suspect
that going out in the  damp, exposing
themselves to cold, or meeting  with  a
trivial contusion ofthe knee some weeks
before any serious uneasiness is felt in
the joint, can have any connection with
the origin of the complaint.  Such  oc-
currences are frequently not  even re-
membered.    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 injuries 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 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.  W iseman calls 
92         CAUSES Ol  THE
the spina verttosa a species of scrophula,
and remarks  that infants and children
are generally the subject of this disease.
(Book iv.  chap. 4.)   Senerinus* ob-
serves that this disorder is almost pecu-
liar to youth.   Petrus de Marchettisf
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 pe-
riod, and had not been cured.  R. Lovv-
erus also maintains that adults never be-
come affected with the  malady, unless
they have  been  attacked by it in  their
youth.  Chun, however, who informs
us (in a  dissertation on paedarthrocaces)
of the opinion entertained by Lowcrus,
adduces some cases to show that the dis-
ease may now and then  occur, for the
first time, in  persons  of advanced age.
But in the present enlightened state of
surgical knowledge we may doubt that
such cases were truly scrophulous white
swellings.  At all events the first occur-
rence of the latter kind of tumours, like
the first occurrence of scrophula, in a-
dults older than twenty-five, is equally

  * De Pxdarthrocace, cap. xii. and xvii.
  i Obs.  Med. Chir. rarior. p. ti8» 
WHITE SWELLING.        95
rare.  I have several times asserted that
every diseased knee-joint is not to be in-
discriminately set down as ascrophulous
disease.
  The white swelling, like other scro-
phulous affections, seems very often to be
an hereditary 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 scrophula,
are also  particularly subject to white
swelling.   But what occasion is there
for further evidence on this point? Daily
experience informs us that young per-
sons affected with  this disease are, for
the most part, either manifestlyscrophu-
lous, or have formerly been so.  Many
have,  at  the same time, enlarged lym-
phatic glands in the neck or other situa-
tions ;  and  many  are known to be  de-
scended from parents who  had scrophu-
lous 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 de-
stroyed by phthisis pulmonalis." (p. 4.)
Xhc fine skin, the tumid, pale, unhealthy 
rauut
 94  CAUSES OF  WHITE SWELLING.

 countenance ;  the delicate complexion ;
 the light blue eyes ; and the swelling of
 the upper lip ; those  striking  appear-
 ances so indicative of a scrophulous hab-
 it are also frequently observable  in per-
 sons affected with white swellings. But
 what I consider as one ofthe strongest
 tests ofthe disorder being of a scrophu-
 lous nature, is the  coagulated, shining
 matter, resembling the white of an egg,
 so frequently found, not only in the cav-
 ity 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 disease.  I
 believe that such  shining, flaky, coagu-
 lated matter is peculiar to scrophulous
 affections.   We frequently find flakes of
 this kind of substance blended with the
 pus which is  discharged from  lumbar
 abscesses ;  and it almost always consti-
 tutes a large portion ofthe matter which
 collects in the suppurated state of scro-
 phulous lymphatic glands in the neck.
 If this kind of matter be a criterion  of
 scrophulous disease, the species of white
 swelling in which such a secretion takes
rdace, without any softening of the heads
of the bones, is also to be considered as
 a strumous affection. 
95-
             CHAP. IV.

     Treatment of White Swellings.

   BEFORE entering upon this impor-
 tant part ofthe subject I think it of great
 consequence to state that white swel-
 lings, whether of that description which
 has been termed rheumatic,  or of that
 kind which is denominated scrophulous,
 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 al-
 together chronic.
  In the incipient, and indeed very of-
 ten in the more advanced period ofthe
 disorder, it  is exceedingly difficult to
 persuade patients to keep the  joint en-
 tirely at  rcst. Imprudent  attempts to
 walk too frequently  produce a state of
 the affected joint, in which the skin is
 tender when touched, and seems to the
 fingers of an examiner hotter than the
 integuments ofthe opposite knee.   Be-
 sides,  we have already noticed that
common inflammation  often  becomes 
96        TREATMENT OF

the exciting cause of most obstinate dis-
eases in the articulation.
   In the ordinary  state of white  swel-
lings the skin does not appear to be hot-
ter than that of a healthy knee, and the
integuments  can  be  handled without
producing any particular uneasiness to
the  patient :  in  short, we  have  every
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 inflam-
mation  present, there can be no  doubt
that topical bleeding and cold saturnine
lotions  are means which may be  emi-
nently serviceable  ; and what is implied
by the  phrase  antiphlogistic treatment
may now be  advantageously employed.
But such are my feelings upon this mat-
ter that I cannot withhold my strongest
censure  from those practitioners who
lose weeks and  months  in the adoption
ofsuch treatment.  The plan is truly
beneficial and scientific as long as the in-
teguments are hot and tender, and the
joint is affected with very  acute and
 general pain,  and the patient is  indis-
posed with the  usual  symptoms of in-
flammatory fever.  But no sooner  is
 this stage past than such treatment be- 
           WHITE SWELLINGS.      97

 comes ridiculously inert, and by prevent-
 ing the employment of really efficacious
 measures it may even be considered as,
 in some degree, conducive tothe increase
 xjf a most terrible disease.
   Having treated of inflammation in the
 joints in. the  first part of the disserta-
 tion,  I feel it quite superfluous  to say
 any thing here concerning 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 surrounding the articulation,
 ■and.the  most successful method of di-
 minishing  the chronic enlargement of.
 the joint, are subjects  much more wor-
 thy of our present investigation.
   If we consult the writings of Hippoc-
 rates,  Celsus, Rhases,  iEtius, Hieron,
•Fabricius,  &c. and compare  their re-
 marks with the inculcations contained
 in modern books, we shall soon discover
 that the  practice  applied to the morbid
 affections of the joints by the very best
 practitioners of the present day, is not
 materially different from what was em-
ployed by our predecessors many centu-
           e. .       ..... 
98        TREATMENT OF
ries ago,  in   similar cases.   As Mr.
Crowther accurately remarks, we learn
from the ancients that " they used local
and general blood-letting, the actual and
potential cautery, with  vesicating ai;d
stimulating applications to  the  skin.
They further maintained that son s pro-
duced by these means should have tl»» ir
discharge promoted, and continued for
a considerable length of time."
  Some mild  cases  of  white swelling,
but not scrophulous ones, I should con-
ceive, may be  cured by using topical ap-
plications composed  of strong astring-
ents of the mineral and vegetable king-
dom.  Mr. Russell recommends  a  de-
coction of oak bark, containing alum.
  There are  other instances in  which
the employment of sea water, as a  lotion
to the knee, is  certainly beneficial.  I
have seen sevi ral cases in which the en-
largement of the  joint  has been dimin-
ished by this application ; but I cannot
say that I h;ivc ever known  one example
in which a curt was accomplished by it.
Sea air and sea  bathing together un-
doubtedly have vu\  powerful effects -en
scrophulous affections  in general, and
most  particularly so  on  such diseases
when situated in  the joints ;  and, 1 be- 
         WHITE SWELLINGS.       99
 i
lieve, few will be  inclined to question
this irrefragable truth,  that residing in
a maritime situation and bathing in the
sea have immtnsi.  influence in checking
the progress of scrophulous  diseases of
the jiinis.   Iiovever, though tins-fa-
vci aid  opinion < ught to be entertained
of sea air and bathing unitedly, yet. as I
hive sjen sea water alone very txten-
Bivelv used as a lotion for white S'Wel-
lirgs in this n ttropolis, and, upon the
whole, have seen only very little benefit
result  from the practice, I  should be
guilt}' of pervi rsion were I to s;n a great
deal in its coiumendation.   Also,  with
respe.ct 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 aux-
iliary one,  to  be  pursued at the same
tiuse that other more  potent  measures,
hereafter to be noticed, are  put in exe-
cution.
   I am sorry that the observations which
I have had opportunities of  making are
not much  in  favor of electricity as  a
means of curing white swellings.  In a
few instances, it is true, it has appeared
to do good;  in a tew  others,  huwever,
according to my judgment,  it appeared 
«n
 lQO       TREATMENT OF

 rather to exasperate than to diminish
 the disease.  In by far the majority of
 cases in which  I  have seen electricity
 tried the  effects were  so insignificant
 that it was difficult to pronounce"wheth-
 er they were of a favorable Or an unfavor-
 able nature.   The greatest evil of em-
 ploying inert means  is^ the false confi-
 dence excited, which onlyleads the sur-
 geon to postpone the  adoption  of such
 measures as can alone be useful, and,
 what is the more to be regretted, • ffect-
 ually useful, in  most cases, only in the
 less  advanced stages ofthe malady.
   With regard' to  fomentations and
 poultices I consider them as perfectly
 inert, and quite  unworthy ofthe praises
 which some  writers |bestow  on them.
 Venienti occur rite  mOrbo  is  a maxim
 which I should  particularly wish to in-
 culcate in this branch of surgery.  Who-
 ever does nothing does  harm,  because
 he is allowing an insidious disease t)
 gain  ground ;  and, as  inert measures
 create a semblance  of something being
 done, they ought to be most strongly re-
 probated, as, in  fart,  preventing other
really proper steps from  being pursued.
 Humanity  in  the practice of  surgery
 does nOt consistso much in withholding 
         WHITE SWELLINGS.     101

strong and vigorous  measures,  as in
boldly deciding to employ them the ve-
ry first moment when they are indicated.
Li tthis be an axiom, which every lectur-
er should instil into the minds of his pu-
pils ;  let the sentiment be constantly a-
live in every one who professes the noble
art of surgery.   Then we  should no
Jonger   behold   the.  instruments  of
surgery in the hands of men whose in-
decision paralyses  whatever knowledge
they  possess ;  then  we should  see
the due degree of benefit accrue to the
world, that degree, which the present
cultivated state of surgical science ought,
to afford.
  I am aware that the French surgeons
have extolled warm stupes, and, indeed,
they support their commendations on the
sol d basis of stubborn facts.  But it is to
be noticed that the mildness of white
swellings on thecontinent will not allow;
us to consider  them as a malady at all
like what we find them to be in this isl-
and, and consequently it would be ab-
surd to take French practice as a model
lor English practitioners.
   The only nu thod of treatment which
mv own persona1 experience enables me
strongly  to re commend,  consist's  in 
102        TREATMENT OF
  keeping np a discharge from the surface
  ofthe diseased  joint.   The opportuni-
  ties which I have had of observing the
  effects of blisters and caustic  issues, ra-
  ther incline me  to prefer the former to
  the latter.   I have seen  great good de-
  rived from both ; but more from blisters
  than from the other kind of issue. I litre
 are instances  in which  I. should  employ
■vesicating applications ; there are others
 in which I should prefer making an es-
 char with caubtic.   To  keep  a blister
 open a v, ry long lime with the savin cer-
 ate,  is  generally attended with  a good
 deal of rain to the patient and trouble to
 the sitrpeon.  The cut'wte  is  secreted
 so rani.'.lv on the surface of  the cutis
 fhat  it becomes  necessary to scrape the
 white matter  off the blistered surface
 very frequently, in order t> ketpit from
healing.   This operation always gives
infinite pain, vihich is the more distres-
sing, because it is to be so often rtiterat-
ed.
   V\ hen a blister is  preferred  it  is best
to apply a Targe one.  Some practition-
ers recommend blistering first  one side •
of the joint and  then the other, alter-
nately, for a considerable time.    Thus,
while one blister h healing another is 
          WHITE SWELLINGS.      108

* forming, and the method is said to be
 attended with  considerable success.  I
 cannot say that I have seen this plan fol-
 lowed upas it ought  to have been ; but
 irorn all I have setn and heard 1 am in-
 duced to entertain a very favorable o-
 pinion of such practice, and shall cer-
 tainly very soon  take an opportunity of
 giving it a fair trial.
   I have only to repeat that, in my opin-
 ion, a large blistered surface properly
 kepi open by mi ans ofthe savin  cerate,
 has Borne advantage, in pidm ofefficny,
 ova issues made with  caustic and kept
 open with peas or hiiirs.
   The plan of dressing blisters with the
 savin ointment was first introduced into
 practice by Mr. Crowtlur, and he is en-
 titled to the whole of th: honour attach-
 ed to  this improvement.   The  former
 m< thod of dressing  excoriated surfaces
 wuh  the ointment of cantharides was,
 oltcn  productive of very troublesome
 stranguaries and retentions ofurine,com-
 plaints which never  occur from the ex-
 ternal employment of savin.
   With  respect  to caustic issues, they
 are at first even more painful than blis-
 ters ; but they afterwards become more
 like indolent sores, and are more easily 
104        TREATMENT OF
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 mannerof making them and keep-
ing them open,  such circumstances be-
ing familiarly known to every novice at
all initiated  in the surgical profession*.
  It has been a disputed point,  whethe*
blisters and  issues produce benefit upon
the principal of  counter-irritation, or in
consequence ofthe discharge which they
occasion.   I am inclined to believe that
they act beneficially in both ways. Ku*
befacients are  certainly  efficacious in
exciting the action of  the absorbents^
and probably also in modifying the  ac-
tion of the vessels in diseased parts.
I have not mentioned them in this dis-
sertation because I am  decidedly of o-
pinion that,  whenever such, applications
might be, in some degree, serviceable in
cases of white swelling, a blister would
be  so in a still greater  degree. - Rube-
facients must obviously act  altogether
on  the principle of counter-irritation.
A blister operates in the same way, but
much more  powerfully ; and, if efficacy 
WHITE SWELLINGS.      105
 also result, and I firmly believe that it
 does-result, from maintaining a copious
 discharge from  the vicinity ot the dis-
 ease, vesicating applications must always
 be preferable to mere rubefacient ones,
   With regard  to constitutional reme-
 dies in  cases  of white swellings, little is
 to be said.   Many diseased joints are
 undoubtedly  connected 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 al-
 tering this kind of temperament.   It
 seems  rational, however, to combine
 such general remedies as have  been
 known to be serviceable in other strum-
 ous diseases with the local treatment al-
 ready noticed.   Hectic  symptoms are
 such as we commonly have to palliate in
 the  cases under consideration.  When
the stomach can bear bark this medicine
 should be given, conjoined with..the art
 amatic confection.  I have seen s^x  much
•comfort derived from the prudent ad-
ministration  of opium to patients afflict-
ed vtrth diseased joints  that I cannot
refrain  Jrom  strongly praising it, and;
declaring that theobjectipn made to its
 emphrymunt, on the  ground that  it in- 
:106      WHITE SWELLINGS.
■■ creases perspiration, seems to me ex-
 ceedingly frivolous when I call to mind
 the great good which this exctlltnt med-
 icine produces in keeping off a debilitat-
 ing dianhcea,  alleviating pain,  and pro-
 curing sleep.
    Nothing  is more serviceable in all
 cases of diseased joints, than keeping
 the morbid  parts perfectly motionless.
 Foolish attempts to walk requently frus-
 trate the most  scientific plan of treat-
 ment.   Some surgeons  are in the habit
 of confining  the diseased knee in splints,
 and impute a good deal of benefit to this
 plan.  I am very much incliindto think
wtdJ ofthe method ; but I t.-.n say noth-
ing particular  in its recommendation
from my own p-rsonal experience.  We
see thafone constant effect of disease in
the knee is to produce a contraction, or
permanently  hem  state of the articula-
tion.   This  might undoubtedly be pre-
vented  by  splints, arch  by altering the
positionVof the joint, as well ashy keep-
in;; it completely n.otionh-ss, some ben-
eficial change might also  be made in re-
gard to the malady itself.
   Here I %hail take the liberty of laying
before my readers four original cases off
diseased joints, which were matenallv 
     CASES OF WHITE  SWELLING. 107

benefited  by maintaining  a  discharge
from blisters or issues.
             CASE  III.

   Hannah Hussey, when  eleven years
 of ag•-, and a month after rdie had recov-
 ered from the smallpox, was attacked
 with pain and swelling ofthe right knee.
 Various lotions and phsurs were m.-de
 use of, but without  any good t ffect, the
 disease still continuing to increase.   In
 the month of July, 1803, two years after
 the patient  first complained,  the whole
joint had become prodigiously swodrn
 under the inert treatment and ev« n neg-
 lectful plan  which had hitherto been a-
 dopud.
   At this  time the  integuments were
 hot and tender to the touch ; a fluctua-
 tion was perceptible in the anterior part
 ofthe tumour,  and  the condyh s of the
 ft rriur communicated  a deceitful sensa-
 tion, when handl-rd, as if-th-  y wire re-
 ally very much enlarg. d.  On  moving
 the joint a gmtuig noise could be heard,
 and'considerable pain w.is experiment
 under the knee pan, and in the centre of 
108            CASES OF
the articulation.  The patient's health
was also much impaired.
   Leeches were applied to  the joint,
and the saturnine  lotion  was  contin-
ually made use of.   The leeches were
repeated three times, and at the  expira-
tion of a wee!:, the heat, acute pain, and
tension had  considerably  abated.  A
blister was now put on each  side ofthe
joint, and dressed with the savin cerate.
Tonic medicines were, at the same time,
internally administered.
   A copious discharge was in this man-
ner kept up  for three months,  during',
which time all the •ymptoms gradually
diminished.
   As there was some difficulty in keep-,
ing up  a sufficient discharge from the
blistered surfaces, in consequence of in-
attention on  the part of  the parent and
her friends, the blisters were now allowed
to heal, and issues were made with caus-
tic in  their stead.   A discharge was
continually kept  up  from  these tor five
months.                       .     . T
   At the end of this time the pain in the
articulation  was entirely removed ;  the
whole collection of fluid in the capsular
ligament absorbed ; and the girl's health
perfectly restored. 
          WHITE SWELLINGS.      109

   She was able to walk a considerable
 distance without  much inconvenience,
 though the joint was still somewhat en-
 larged.
   In this amended state she continued
 for three  months, w'hen her health be-
 gan to decline again ; fluid was accum-
 ulating in the joint ; and  the  pain was
 returning.  Blisters and the savin cer-
 ate were once more employed, 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 wa3 con-
"fined in  as straight a position as possible
 by means of a1 Splint;"  Sufficient  atten-
 tion, however, was not paid to this  meth-
 od, ahd  a degree of  contraction took
 place.                 ....
  ' The  joint now  remains somewhat
 larger, less flexible,-and strong, than the
' other ; but the pain rs entirely removed,
• the morbid affection has ceased, and the
 event' ofthe case may be deemed a very
 successful one.       '  *" 
110
             CASE  IV.

  Elizabeth Goddard, fourteen years of
age, applied for surgical assistance on
account of pain and tnlargtuuit of ihe
unkle-joirt.  The  complaint had exist-
ed, in a slighter degree, for three years,
and had originates m  consequence of an
external injury.  Vaiious applications
had been made use of without benefit.
  rI he articulation was now very iv uoh
swollen, particularly about the internal
maleolus.  The [ uiint was equally in-
capable of using her ankle, and bearing
any weight upr.n it.
  As there was no appearance of active
inflammation a blister was immediately
applied to each side of the joint, and af-
terwards dressed  with the savin cerate.
A copious discharge was thus maintain-
ed for five months.  Very soon after the
application of the  blisters a material
change for the better look plac<,  and
when the excoriated surfaces wcic heal-
ed the fulness and pain of the joint had
subsided, and scarcely the smallest de-
gree of enlargement could be perceived. 
   CASES OF WHITE SWELLINGS.  Ill

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 enlarge-
ment of his left  knee.   The  disorder
had existed five weeks, and was attend-
ed with a degree of pain and heat in the
articulation.
   Some purging medicine was prescrib-
ed for him, and he was directed to apply
lintn^ wet  with the saturnine lotion, to
the affected knee.   No  more was seen
of the patient for nine months, during
which tune he had been under the care
of different medical men without obtain-
ing any benefit whatever.
  On his second application the tume-
faction of the articulation was much in-
creased ;  the pain,  heat,  and tension
Were very considerable ; and a sensation
was  communicated on feeling the con-
dyles of the os femoris, just  as if they
Were  actually enlarged.
   Leeches and the saturnine lotion were
made use of, till  the knee  became in a 
 112           CASES  OF

 more quiet state, and  then a copious
 discharge was kept Up on each side of
 the articulation, with very  little inter-
 mission for a year and a half.  The dis-
 charge was obtained, partly by means of
 blisters and partly by means of caustic
 issues.
   Though this treatment   diminished
 the swelling around the-joint,*as well as
 the quantity of fluid in the capsular lig-
 ament, yet the pain in the articulation,
 after having been at  first relieved^re-
 turned, and continued in so  great a de-
 gree that the patient could  not bear to
 stand on the leg, nor suffer the slightest
 motion of the km e.   For  a long time
 he was also under the necessity of taking
 opium  at night.
  Besides the above remedies, campho-
 rated meicurial ointment was well rub-
 bed  into the knee, and mercury was in-
 ternally exhibited, so as to affect the sys-
 tem.   A lair trial was  also given to the
 muriate of lime,  which  is  sometimes
serviceable in scrophulous  diseases cf
the bones.  This case,  however, was
probably not of a scrophulous nature;
for it had originated in aman thirty-six
years of age, in consequence of external
violence, and in a constitution in which 
-WHITE SWELLINGS.      113
there were no veatiges of a scrophulous
habit.   In  the  present  instance there-
fore, as might be expected, neither mer-
cury nor the muriate of lime proved of
any utility.
   In December, 1805, he wat admitted
into one ofthe* London hospitals, where
he remained ten weeks without deriving
the least benefit from the various appli-
cations which were tried.
   Latterly he  has declined doing any
■thing for his complaint. Great pain is
still experienced  in  the affected joint,
and some enlargement ofthe part is
still manifest.  There is a degree  of  '
moveablcaess in the articulation; but all
motion is attended with a grating nais©*.
and considerable  pain.  The leg and
thigh are both very much  emaciated^
and this circumstance, as I have statt d
in a foregoing.chapter, always ma-2*1 <\f
joint seem more enlarged than is rt \.ty
the case.   As  his general  heilV doji
not materially suffer, he seems  negligent
of the local disease.   He continues to
enjoy some  share of  locoiootfon, by
transmitting the  weight of hia bodyto
the ground, by means of a strong forked ,
stick, which is made fast to tlue.hip*  and
supports the leg and fofllV 
   114'           CASES  OF

     In'this  case  we must allow that the
   progress ol 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 th^y diminished the thickening of
   tin soft parts around the  articulation in
   a very considerable degree.


                CASE VI.

     William Paley,raged forty, and a ro-
   bust man,  was  seized  three, years ago"
   with an affection of his right knee.  The'
   complaint  had  been coming  on  about
   three weeks before he applied for advice.
   The joint was now considerably swollen,
\  and iff ei  d with severe pain, extending
 .. all over the  articulation.   There was'
   Jhkrwise a good deal of ft ver.
   *> Leecfu s andthe saturnine lotion were
   ap^li d'to  the joint,  and purgative, ftb-
   rifu£;-, and opiate medicines  were pre-
   scribed.   At the expiration of ten days-
   the lebiite symptoms  had abated ; but
   the state o/f the joint was scarcely alter-
   ed, and, as the pam continued to be ex-
   cessive,  emollient  fomentations  and
   poultices were  used as topical applies- 
         ~WHITE  SWELLINGS.       115

tions.   This plan was certainly produc-
tive of infinite relief.
   A'mc-nth elapsed before the joint be-
came sufficiently quiet to warrant the
•topical employment ot stimidMits.   "i he
articulation was  preatly  tnlarged, and
handling it  cm a ted  uneasiness ;  but rvs
the heat and pain were now dimished,  I
■applied a blister to each side of tlu joint.
A- soon as the cuticle was n moved the
excoriated surfaces wee dressed two or
time times  with  the savin cerate.  This
produced so much  irritation that the
former.symptoms returned,  isnd it was
necessary to have recourse again to the
emollient plan of treatment, till the in-
flammation, &c. had abated.
.   The blisters were once more appl'n d ;
the same consequences ensin d, and tiie
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 caus-
tic on each sid.- of the part, and k< pto-
pen bv means of beans.   The strictest
quietude was  enjoined,  and  the Peru-
vian bark administered.
   As the discharge oontinuf.d,  so did
the disease  gradually subside ; and as
the patient was  sensible of the benefit 
11-6"            CAsISs or
which he reaped from the mode of treat-
ment, 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 incon-
venience-  However, there is still sortie
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 per-
petual bli«ters cannot always be employ-
ed, on accountof the excessive irritation
which they sometimes produce through-
out the joint; and that, under such cir-
cumstances, caustic issues may be ad-
vantageously 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 scrophulous  ; for these lath:*
are  naturally  very chronic affections,
and bear the stimulating effect of a blis-
tered surface without the  production of
a gen ral irritation through the diseased
joints.  But  this>  observation  applies
only  to cases which are  not in an iro.
flammatory state, or (in  other words,) 
WHITE SWELLINGS.       117
which are unattended with heat ofthe
skin, throbbing pain, &c.
  I need scarcely notice that the last
case was undoubtedly not of a scrophu-
lous nature : the disease began1 at too
advanced a period of life, and the pain,
instead of affecting one  particular part
of the joint, was general and diffused. 
116
      i   ,    CHAP.  V.
• i J  if   lO  .                      ' >
 Treatment ofthe White Swejling condud-
 ..,■•■;           ed.
Jit:' 'I f'-                ,        .
   WHILE  the  patient's  constitution
 continues  equal to sustain the irritation
of a scrophulous or other invettrate dis-
ease of the knee-joint, no humane prac-
titioner would  ever think of proposing
amputation of the limb, hewever diffi-
cult,  or impossible he  might hitherto
find it to cure  the malady, or even re-
tard its progress.   Such smddt n altera-
tions for the better do sometimes suc-
ceed a long duration of intractable dis-
order in a joint, that  no nan can pro-
nounce with certainty that every chance
of preserving the limb  is at an end.
   The state of the gem-rat  health, and
not of the local disease, is the only thing
that can  form  a solid reason for the re-
moval ofthe affected member.   When
the strength of the system  has be< n al-
most exhausted by the severe effects of
the local malady on the  constitution, I
see no rational alternative.  A  longer
attempt to preserve the limb would only 
          WHITE SWELLINGS.       119

 plunge the patient  into so feeble a con-
 dition, that no mortal effort,  no human
 skill, nor science, could again recai the
 sad,  though  consolatory dilemma, of
 losing the limb for the sake of preserv-
 ing life.
  .What  man of common  understand-
 ing, aware of the severe nature of hectic- '
 al symptoms, after they have" lasted a,
 considerable time,  can feel  a want'of
 decision in these cases ?  What reason-
 able being can  suppose  that  a speedy
 dissolution will not result from the total
 loss of appetite, rest, and strength, pro-
 fuse night sweats, and as profuse purg-
 ings, which foil, as  Mr. Pott very  ahlv
 describes, all the efforts of  medicine,
 and bring the patient to the brink of de-
 struction  .'*
  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 consideration, alone,- he should
 presume to advise the use of the knife,
 he is guilty of the  most culpable igno-
 rance.   I a^ain rep at  (for T think it a
 subject of the highest cons-:iquence,) that

  • Chirurgical Works, vol. iii.  Remarks on Am-
putation, p.  371.  Edit. :?8j. 
180.       TREATMENT OX
the debilitated state of the constitution,
the impaired state of the health, is the
only thing which, can ever urge the per*
formance  of  amputation in  cases of
white swellings.  If.the strength is still
remaining, though  the  diseased joint
may  he  immensely  enlarged ;   nay,
though it may.he  surrounded with aV
scessea ;  the operation of removing the
limb is not indicated ;  and that man e-.
vinces.a very mistaken judgment,  who
recommends, under such circumstances,
the employment of. the  knife.   As I
have already said, while the.constitution
show* itself, equal  to the.struggle, it is
impossible to. 'prognosticate  with cer-
tainty  that n white swelling,  however
bad it may be at present,  will not have
such a termination as shall enable the
patient to preserve  his.limb.
   Doctor. Jeffrey, 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 sub*
ject ofthe excision of  carious joints, as
an operation to supercede the removal
ofthe  whole!limb.*-

  • Cases of the Excision of Carious  Joints, by
H. Parke, SurgcQR in the Liverpool HotpiiaL; and
P. F. Kloreau, m.' D. dc I'ecole de Paiis :  vrii^i
Observations by J. Jcjfray. iBoC. 
         WHITE SWELLINGS.       121

   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
disease, humanity dictates the propriety
of persevering in an attempt to save the
affected limb.   Indeed I would repro-
bate any man who should inculcate the
premature practice of a severe operation,
as being either defective in professional
judgment,  or destitute of a proper re-
gard for his fellow-creatures.
   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 ofthe 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 ?
           F 
122        EXCISION OF

  1 cannot admit that the extirpation of   |
the whole of so  large an articulation as
the knee, can be compared with the oper-
ation of amputation,in pointoi simplicity
andsafety. Hovvever,itisnoton thediffi-
culty ofpractisingthe former that I would
found my objections ; for I believe that
any man,  possessing a tolerable knowl-
edge of the anatomy  of the leg, might   '
contrive to achieve the business.
  The grounds on which I shall at pres-
ent 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 op-
eration was performed on the 2d of Ju-
ly, 1781, and that  it was February 28th
cf the  following year before all  the sub-
sequent abscesses and  sores were per-
fectly  healed.   This space  of  time  is
very nearly eight months !   Mr. Parke
describes the patient as a strong robust
sailor ; and gives us no further particu-
lars concerning the state of his constitu-
tion, at the time of the operation, than
that his health was declining.   I enter-
tain little  doubt that if the excision  of 
          CARIOUS JOINTS.       125

the knee had been performed in that
state of the health in which amputation
becomes truly indispensable,  this man
would not have survived the operation.
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 consequent to so severe an op-
eration ; and, after three months confine-
ment, 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 I  The young man
in the mean  time  was attacked with an
epidemic dysentery, which carried him
off.
  2.   Even  supposing the excision of
the knee-joint  to be followed with all
possible success, is  the advantage  of
having a mutilated, shortened, stiff limb,
in lieu of an artrkcial leg, sufficiently
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
against any branch of practice ; but par-
ticularly so when the method is, in some 
 124        EXCISION 01

 degn e, supported on the basis of fact,
 and the recommendations of very respec-
 table characters.   I profess myself to
 be a sincere adn inr,and a warm,though
 feeble, patron of all rational innovations
 and improvements, and it would be with
 heart-felt pleasure that I should foresee
 any likelihood of  the present proposal
 becoming n ally  beneficial  to mankind.
 The esteem in which I hold my profes-
 sion will  always render me anxious for
 ks cultivation.   But the  very  same
 principles which would urge me to extol
 certain introductions into practice, will
 always force me to condemn others, of
 which I cannot  form so propitious an
 Opinion.
   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 circum-
 stances, forming a stronger recommen-
 dation of the practice.  But I am afraid
 that the events of such examples will al-
 ways  be  considered rather as escapes
 than scientific cures ; a.s instances rather
 to be remembered than imitated.
   I shall  say nothing concerning the ex-
 tirpation  of other articulations,  except
, that the operation in the  elbow would 
CARIOUS JOINTS.        125
not be so formidable 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 swellings ofthe knee. 
 
PART III.
DISEASE OF THE IIIP-JOINTc
             CHAP. I.

     Description of the Complaint.

  IT is far  from  my intention in the
subsequent columns to take a view of
the whole of this interesting subject. If
I succeed in  tracing  the  characteristic
features of the present disease, explain-
ing 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 use-
ful or original matter.   In performing
this  task I  shall  aim at adopting the
same  simplicity of style, which  it has
been my wish to diffuse throughout the 
128          DISEASE OF
 preceding pages.   To such  readers as
 may admire a more ornamented  and
 florid production  I can  only say with
 Celsus,  " morbi non eloquentia, sed rem-
 ediis curantur"   Prsef. lib. i.
   The first proposition  with which I
 shall commence is that  the  complaint
 commonly  called  the "disease ofthe
 hip-joint,"  is  very analogous in its na-
 ture to the white  swelling of other ar-
 ticulations.  Like the  latter malady it
 probably has its varieties, some of which
 are undoubtedly connected  with scro-
 phula, 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
 ofthe joints which  is commonly consid-
 ered  to  be  connected with a strumous
 constitution.  It has been  stated that if
 a person live to the age of five and twen-
ty, perfectly free from all scrophulous
symptoms, the hazard  of his ever be-
coming afterwards  afflicted with a true 
THE  HIP JOINT.        t2t>
scrophulous complaint,  may be regard-
ed as almost past.   Hence all morbid
affections of the joints, first  occuring
after this period of life,  and under such
circumstances, I think, may  be justly
deemed  to  have no connection  with
scrophula.
  Disease of the hip-joint is most  com-
monly met with  in  children  under the
age of fourteen ; in this respect it is very
analogous to  the  true white  swelling.
But no age is exempt from the malady j
so that though children form a large
proportion  of those subjects  who are
afflicted, yet the number of adults, and
even of old persons, is much more con-
siderable in a  given number of these
cases than we find to occur in  the same
number of cases in which the knee is
diseased.  This is my reason for think-
ing that there are more hip cases uncon-
nected with scrophula, than there are ex-
amples of white swellings being similar-
ly circumstanced.  Of course  I  apply
the observation only to a definite num-
ber of cases of each disease  ; for the
much more frequent occurrence of mor-
bid knees,  ankles,  wrists, and elbows,
than of diseased hips, weuld destroy the 
ISO
DISEASE OF
accuracy of the remark, if taken in  a
general sense.
  The approach ofthe hip disease is far
more insidious than that of the white
swelling.   The latter is generally pre-
ceded by severe pains, while the only
forerunner ofthe former is frequently a
slight weakness and limping of the af-
fected limb.   This state  is too often
overlooked, and when noticed by men
little  versed in the profession is com-
monly treated on principles the most re-
pugnant to surgical science.  Embroca-
tions are  generally prescribed, without
any injunction to keep the limb in a quiet
state.  The  application is also often
made to the knee,  or other part ofthe
extremity ; for as there is frequently an
uneasiness  about that joint, when the
hip is affected, and as no pain whatever
is sometimes mentioned, as occurring
in the latter situation, till a more advanc-
ed period ofthe  malady,  it is not un-
common to see careless practitioners di-
recting their remedies to some situation
very different from that of the disease.
While such applications as stimulating
■ -liniments are directed^ the shrewd ob-
server may remark  that  the error is a
 fortunate one, and that it is better to ap- 
THE  HIP JOINT.
131
ply nothing than what is ot an irritating
nature.   I coincide most sincerely with
this sentiment; but how shall we excuse
such supine neglect, such  guilty igno-
rance,  when we are informed that this
incipient period of the complaint is the
only one in which a favorable prognosis
might be made ! for mere rest and re-
peated topical  bleeding will now have
more effect, in the course of a fortnight,
than large painful issues will afterwards
generally have  in  the long space of a
twelve month.
   The first diagnostic symptoms of dis-
ease in the hip-joint, if we merely look
for them in the situation of that articu-
lation, are not particularly conspicuous.
It is true that a fixed pain behind the
trochanter major,  in  some instances,
very soon excites the attention of the
most careless surgeon to the seat of the
morbid  ahection.   But mere pain in a
joint, quite free  from visible  enlarge-
ment, and external change of colour, is
generally disregarded  as a complaint of
no importance in young subjects/and as
a mere rheumatic or  gouty affection in
adults.  Ev« n when the pain begins to
be severe, it is commonly not confined
to the seat of the disease j but shoou 
152          DISEASE  OF
 downward in the  course  of the vastus
 externus muscle to the knee,  and along
 the outer part ofthe fibula to the maleo-
 lus externus.  I have often found that
 patients refer most of theirpainful sen-
 sations to the groin.   In short, there is
 no particular symptom, occurring in the
 precise situation of the morbid affection,
 so as to form an infallible pathognomon-
 ic mark of its existence.   But still  the
 characters ofthe disease are very strong,
 when  examined  by a surgeon who  has
 paid attention to the subject.
   Almost as early as  the least limping
 can be perceived, some diminution in
 the circumference  of  the leg and thigh
 has actually taken place, as may be easi-
 ly found by an accurate measurement.
   The hip-joint is  deeply situated, so
 that its accidents and diseases cannot be
 examined as readily as those of  many
 other articulations.  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 ofthe
 femoral artery,soon after it has descend-
ed  below the brim of the  pelvis.  At
this spot the surgeon may apply pressure
to the front cf this large  articulation, 
THE HIP JOINT.
1 <" n
loo
and if it be diseased considerable pain
will be the consequence of the experi-
ment.
  The limping gait denotes that  some-
thing is wrong in the limb ; and  if this
symptom  cannot  be attributed to some
affection ofthe vertebrae, or some  recent
accident ; also if it be conjoined with
the above mentioned emaciation  ofthe
affected member, and exasperation  of
pain on pressing che front of the acetab-
ulum ;  then the evidence of disease in
the hip becomes more  and more con-
vincing.   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  completely
discriminating this complaint from the
feebleness of the limb arising from a
disorder in the hip-joint.
  Another remarkable  symptom is the
elongation of the limb in the incipient
stage of the  hip disease.   Mr. Ford*
has very ably pointed outthe right meth-
od of discovering the circumstance, by
comparing the condyles of the os femo-

  * Observations on the Disease of the Hip-Joint,
&c p. 12. 
 134         DISEASE OF

 nis, 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 accu-
 rately explained.  It is  a fact that the
 limb not unfrequently 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 ofthe
 os femoris or acetabulum,  it  will thrust
 the head of the bone downwards and
 lengthen the limb."   The error of this
 explanation is easily  exposed  by stating,
 that the diameter of the acetabulum it-
 self is not  so great  as the lengthening
 ofthe limb, and that it  is almost com-
 pletely  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 inconsiderable.   No  relaxation
 of ligaments,  if ever there were such a
 state, could account for the fact j for in
the  most healthy condition of the hip-
* Dissertation on Ischias, &c. p. 17. 
\
           THE HIP  JOINT.        135

joint no ligaments, (if Ave except that
which  completes the  bony  deficiency
at the lower and inner  part  of the ace-
tabulum,)  are concerned  in preventing
the os  femoris from descending down-
ward.    The  ligamentum teres  resists
the dislocation of the head of  the bone
upward, but not downward. The orbic-
ular 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
increasing the  strength  of  the  artic-
ulation.   I  am very  much   disposed
to believe that, in the very early stage of
the hip disease, the cartilage  and liga-
ment 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 it frequently does, in
cases of diseased hip-joints.  The bone

  * Mr.  Ford has given an account of  the morbid
appearances found  in a recent case, and attended
with elongation of the limb.  It does not appear
thatin this instance there was a destrsction of the
ligament and  cartilage completing  the lower and
front part of the acetabulum.  How the limb could
be elongated while the  heat of the bone was in
its socket, 1 am at a los» to conjitftuic. 
136         DISEASE OF

is certainly not pushed out of the coty-
loid cavity in a lateral direction, for if
it were so, the muscles would draw the
bone upward and shorten  the limb, as
we find  actually occurs as soon as the
upper and posterior part ofthe acetabu-
lum and the ligamentum teres are so de-
stroyed that they make no resistance to
this'kind of dislocation.   Mr. Ford  is
entitled  to  the merit of  having first
pointed out to surgeons, " the alteration
"with respect  to  the natural fulness
" and convexity of the nates, that part
" appearing flattened which is usually
«» most prominent."   The gluteus mag-
nus becomt s emaciated, and its edge no
longer forms so bold  aline as it natural-
ly does at the upper and back part ofthe
thigh, in the sound  state  of the limb.
This is  one very  strong feature ofthe
early state of the disease, 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 mal idy in its incipient state, yet
the former joint may  be  bent  and ex-
terded without any increase ofuneasi-
ititss j but the thigh bone cannot be mov- 
           THE HIP JOINT.       137

ed without augmenting the sufferings of
the afflicted.
  Patients with diseased hips soon get
into the habit  of  bearing the weight of
the body chiefly on the other extremity,
so that they btnd  the thigh ofthe affect-
ed 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 ofthe 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 gen-
erally find the health little disturbed.
  The malady is usually not  very pain-
ful to the touch, except the pressure be
applied to the front of the joint, the part
which is undoubtedly the most superfi-
cial. 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, exceedingly painful
when handled, and in which the integu-
ments are even tinged with the light pink
blush.   I have generally observed the
 complaint to  assume this appearance in
 patients who  have been guilty of impru-
 dent exercise, and in the children ofthe
            f 2 
138         DISEASE  OF
 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 suppuration.
   The symptoms which are the forerun-
 ners ofthe formation ofthe pus are dif-
 ferent in differ«nt cases.  This variety
 depends upon the presence of acute, or
 only chronic inflammation.  When the
 former occurs, the parts surrounding
 the joint become tense and extremely
 painful, the skin i s even reddish, and the
 patient experiences an attack of sympa-
 thetic inflammatory 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 re-
 markable an  increase of pain in the ar-
ticulation  previously to the occurrence
of suppuration.  Mr.  Phillot, surgeon
to the Bath General Hospital, says that
startings and catchings during sleep are,
in this stage ofthe  disease, among the
most certain signs of the  formation of 
           THE HIP JOINT.       139

matter.*  When the  pus forms in this
chronic manner, it does not make its
way to the surface ofthe body so quick-
ly as when the abscess has been the im-
mediate result of active  inflammation
attacking  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 shorten-
ed,  and this  circumstance, when the re-
traction is very considerable, arises from
nothing less than an  actual dislocation
ofthe  head  ofthe thigh bone, in conse-
quence of the destruction of the cartil-
ages, ligaments, and articular  cavity.
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 fol-
lows without any occurrence of abscesses.

  •  See a note, p. 9, of Falconer's DiwciUtion- on
the  Ischias, 
140         DISEASE OF "
   Sometimes patients are seriously de-
 jected by hectic symptoms  before mat-
 ter forms.  In the suppurative stage of
 the malady these effects on the constitu-
 tion  always become worse.   The  pa-
 tient loses • his appetite,  cannot sleep at
 night, has a small frequent  pulse, col-
 liquative sweats, and often a very obsti-
 nate and debilitating diarrhoea.
   The  openings through which such
 abscesses as 1 have described are dis-
 charged, continue, in most instances, to
 emit an  unhealthy kind of matter for a
 long  time after  their first  formation.
 They become, in fact,  the  terminations
 of sinuses leading to the morbid joint.
   When disease in the hip-joint follows
 external violence, the advances  ofthe
 malady are somewhat different from the
 above description.    The  symptoms
 which precede the affection are a violent
 pain at the instant of the  accident, and
 an inability to move the limb.   Howev-
 er, this privation of the faculty of mov-
 ing the member is not so complete as
when the neck ofthe os femoris is frac-
tured ; because the superior part of this
bone,  and the articular cavity,  which
have suffered no alteration, form a suffi-
cient fulcrum to enable  the muscle to 
           THE  HIP JOINT.       141

act on the thigh.  The injury is very
soon followed by more or less swelling,
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 altered.   But afterwards the thigh
becomes gradually shorter, and the foot
turned  inward.   The  patient cannot
move without  experiencing the  most
acute pain. An abscess commonly forms
at the upper and middle part of the thigh,
and, if no amendment take place, hec-
tic  disorders sooner  or  later occasion
»he  patient's dissolution.
  To illustrate the progress of the dis-
ease when it  is  die consequence of ex-
ternjl violence, and  to  point out the
ravages which it produces in the parts
affected, I have inserted the  following
interesting case, which  is the abstract
of am  related  by  M.  Sabatier in the
Mem. de TAcad, de Chirurgie.
             CASE VII.

  A boy, about fourteen years of age,
had for two years a considerable abscess
at the anterior and superior part of the
right thigh.   The extremity on this side 
142         DISEASE OF
was about three finger-breadths shorter
thnn the other, and the toes were turn-
ed  inward.   An  cedematous swelling
occupied the lumber region and the sit-
uation ofthe glutei muscles, and extend-
ed down the  thigh  even  to  the knee.
There was a good deal  of pain all round
the abscess, .and  particularly in the
groin, where the glands were swollen
and hard.
  The boy had fallen on his knee on the
15th.of Jure, and afterwards experienc-
ed such pain,  shooting from that joint
to the top of the thigh, that he was oblig-
ed to  remain in bed four days.   The
pains being abated, he got  up and at-
tempted to take his usual exercise again;
but he found  that he could not support
himself,  and was necessitated to make
use of crutches until the 3d of January
following.  In the meantime the ingui-
nal glands became  considerably enlarg-
ed.   'I his  symptom was somewhat re-
lieved by emollient and resolvent impli-
cations.  The pain, however, continued
to increase daily ; the difficulty of walk-
ing, even v;ith crutches, became greater
and greater ; and the thigh began to be
shorter than the other. 
THE  HIP JOINT.       143
  An empirical practitioner, who was
consulted* pronounced that the thigh
was  dislocated, and that it was proper
to reduce it.   Such attempts as he pro-
posed with this view were put in execu-
tion.  Sometime 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 began to manifest itself about
the middle of February.
  The contents of this abscess were af-
terwards  let out through  a small punc-
ture, by a regular surgeon.   The quality
ofthe matter was fetid, and the quantity
three pints.   The  immediate  conse-
quences ofthe operation were success-
ful beyond expectation.  The tumefac-
tion of the thigh decreased; the inguinal
glands became smaller ; the pains were
not so acute  as  before ; and almost all
febrile disturbance  disappeared.  Such
symptoms, however, 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 (Edematous ery- 
144         DISEASE OF
sipelas, and  the  patient at length died
five months  and  a half after the opera-
tion.
   On  dissection  several  collections of
pus were  discovered,  some among the
glutei muscles, and others on the exter-
nal surface of the os  ilium,  and in the
situation of the cotyloid cavity.   The
»uscles  on  the anterior  and superior
part of the thigh  were  covered with a
large quantity of matter, similar to what
was discharged from the principal ab-
scess.  The  latter collection extended
even into the hip-joint.   The femur
was drawn  upward above four finger-
breadths on the  external surface of the  .
os ilium.   The  cartilage  which covers
the head ofthe former bone was entire-
ly destroyed ; and this part ofthe bone
was altered,  and marked with deep ex-
cavations in  consequence of caries.  In
this case the acetabulum was totally de-
stroyed, so that the femur had been lux-
ated, because the brim of the articular
cavity having been tffactd, the htnd of
the bone was obliged to obe} the action
ofthe  muscles.  All  the outer ruilVice
ofthe os ilium, rn vhich the head of the
thigh bene had glided, was affected with
a kind of carious disten per, aLcl frarj-
it -nis tf it easily crumlUd off. 
           THE  HIP JOINT.       145

  No elongation ofthe limb is recorded
in this case ;  but, in all probability, this
circumstance occurred in the early stage
ofthe disease, before a regular surgeon
was consulted.
   But to return to the description  of
 the interesting  malady now under con-
 sideration.   It  is observed by Dr. Fal-
 coner that the tuberosity of the ischium
 is, in many instances, lower on  the af-
 fected side than on the other.  To con-
 firm this circumstance he  mentions the
 pelvis of a person who died in the Bath
 General Hospital.   In  this specimen,
 which Was preserved there many years,
 the fact was  demonstrable.  If this al-
 teration  were  eviclent in the bones of
 the skeleton, the circumstance must a-
 ri ,e from a permanent  distortion ofthe
 pelvis, and cannot be the mere tempora-
 ry effect of any particular posture ofthe
 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 merits at-
 tention.
  With respect to the morbid anatomy
ofthe disease in its incipient state .little is
              G 
146         DISEASE OF
known. Two dissections related by Mr.
Ford are, I belie ve, the only ont s throw-
ing light  on this  point.  In one there
was a tea-spoonful of matter in the cavi-
ty of the  hip-joint.   The head of  the
thigh bone  was a little inflamed,  the
capsular ligament a little thickened, and
the ligamentum tt res united in its natu-
ral way with the acetabulum.   The car-
tilage lining the  cotyloid cavity was
eroded in  one  place  with  a small aper-
ture, through which  a probe  might be
passed  underneath the cartilage,  into
the internal surface of  the os  pubis, on
one side, and, on the other, into the os
ischii; the opposite or extonal part ofthe
os innominatum  showing more appear*
ance of disease than the cotyloid cavity.
In the other case the disease  was more
advanced.  These examples are import-
ant, inasmuch as they prove that the hip
complaint primarily  affects  the  cartil-
ages, 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
ofthe os  ischium, os ilium,  and os pu-
bis, forming the acetabulum, togfther
with the investing cartilage and syrovial
gland,  are  destroyed.  The cartilage 
           THE HIP JOINT.       14/

covering the head of the os femoris, the
ligamentum teres,  and capsule ofthe
joint, suff. r the same  fat;; and caries
frequently affects not only the  adjacent
parts of the ossu innominata,  but also
the head and neck of the femur.  I be-
lieve,however, that the bones  of  the
pelvis alwavs suff r more than  the thigh
bone.   The  malady  may even have
made such ravages as to have complete-
ly destroyed the brim of the acetabulum,
and dislocated the head of the os femo-
ris ; and yet the substance ofthe latter'
part may be free  from  all distemper.
The following tact illustrates the veraci-
ty of this remaik.


            CASE VIII.

   A subject was brought to the dissect-
ing room at St. Bartholomew's Hospital,
and  it was noticed by  the g> ntlemen
present that there was  great retraction
of one  ofthe lower extremities,  owing
to some morbid affection about the hip-
jpint.   On cutting  into the parts a Vi ry
large abscess was found  on the dorsum
ofthe  ilium,  and,  in  the  midst of the
matter, the head of the thigh  bone was 
1-48
DISEASE OF
found lodged on  the iUuim   The coty-
loid (Cavity  was  completely  destroyed
by disease, together, with alL the liga-
ments and cartilages.  The head of the
femur was quite perfect, and free from
tlae slightest mark of caries, though. it»
cartilage  was  slightlyjerodtd in a few
places.
  The  preparation showing this fact \*
preserved 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 ossainnominata
are g> nerally more affected  than the fe-
mur, is very important, I thought the
insertion of this interesting and striking
example  would be better than an) lmg
reasoning on the matter.*
   Sometimes, however, the head an J
neck  of  the thigh are  completely de-
stroyed by the  same  morbid  proc ss,.

  * Mr.  Ford sa.y», " In every case of'disease of
the hip-joint,  which has terminated fatally, I have
remarked that the o» innominaturn  ha« been af-
fected by the caries in a moie extensive dtfgiee than
the thighbone itself."  P. 107.
  The knowledge ofthe circumstance it extremely
important,  because it displays the absurdity of at-
tempting amputation tss these cases. 
TUP  HIP JOINT.       149
 vhichannihilatestheacetabulum. There
 is a specimen  of this fact  in the above
 n entioned museum, and Mr. Ford has
 given, in his valuable work, an engrav-
 ing illustrative of such a case.
   I have  only to say on the subject of
 the remote causes of the hip  disease,
 that they  are  very  imperfectly -known.
 External  violence is undoubted ry otic,
 a.nd the testimony of numerous  respect*
 ablewriters confrrmschat lying down on
 the damp ground in summer time, and
 indeed all kind of exposure to damp and
 cold, are  frequently conducive to the
 origin of the  malady.   Fortius reason
 the lower orders of society are rather
 more subject  to the affliction than t>h«
 higher.  The  particularities, however,
 in the affected joint, or in the constitu-
 tion, which cause the  disease  to  take
 place in some persons, and not in others,
 though  similarly circumstanced in life,
 «re, perhaps, beyond the reach of human
investigation.   A scrophulous  habit  is
 certainly one predisposing circumstance;
hut the  disease often  takes place with-
out any suspicion  of scrophula,  and
without any apparent cause whateTcr. 
150
             CHAP. II.

 Treatment  of the Disease of the Hip-
                Joint.

   BY referring to the writings of Hip-
pocrates, Celsus, Cselius, Aurelianus,
&c. we shall  discover  that our forefa-
thers are indisputably entitled to the
honour of having employed every tffica-
cious plan, even now known to- the mod-
erns, of treating the disorder of the hip-
joint.   Forming an eschar, and keeping
the sore  open ; topical  bleedings;  fo-
mentations ; cupping ; &c. were all prac-
tised  by the ancients.  1 he 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
utdity of  this rrmtdy in the incipient
state ofthe hip disease.  Dr.  Falconer
has givt-n a  table of the state ofthe pa-
ti»n s at their discharge, who were ad-
mitted  into  the Bath Hospital  for hip
cases, from  May 1, 1785, to April 7,
1801.   The number  amounts to five 
       TREATMENT OF THE, &C.    151

 hundred and fifty-six, of which one hun-
 dred and three werc cured, one hundred
 and sixty-eight were much better, one
 hundr. d and eleven were better, thirty-
 three were no  better, one  hundred and
 twenty-two were improper objects, the
 disease bring too far advanced, thirteen
 were discharged for irregularity, and
 six dead.   Now from the  numerous
 cases of this disease which I have seen
 I have not the  smallest  hesitation in as-
 serting that the success at Bath far ex-
 ceeds any  thing  ever met  with in this
 metropolis.  It is to be obs. rved, how-
 ever, that Drs. Charlton,  Oliver,   Fal-
 coner, and other advocates for the  Bath
 water, agree th;>t  its util'ty  as  an exter-
 nal application, in thebe cases, is limited
 to that incipient state ofthe disease, un-
 accompanied either with hectic fever or
 suppuration; and  that  as  soon as one,
 or both  the tatter circumstances occur,
 the application  then becomes injurious,
 and ill deserw s the name of a renaedy.
 Patients, in order to derive benefit from
 the  water, are placed in a warm bath for
 filteen to twenty-five minutes, two or
three times a week.
  When we consider the nature of the
disease of the  hip-joint, and reflect on 
152      TREATMENT OF THE

its deep situation ; when we recal to
mind the disteniepered state  soon pro-
duced in the cartilages, ligaments, and
bones ofthe articulation ; we can hardly
believe that the mere  external  use of
any remedy, like Bath water, can have
such powerful influence over the disease
as we might be led  to  suppose from a
perusal of  Dr. Falconer's   pamphlet.
For my own part I regard the  subject m
a different point of view. I doubt wheth-
er all the numerous instances adduced
in support  of  the practice,  were really
and truly cases of the hipdisease.  Many
of them might have bien merely  rheu-
matic affections.  My suspicions orig-
inate  in consequence of Dr. Falconer's
admission,  that  cases attended with
hectic  fever or suppuration  are  never
benefited by the 3ame treatment;  in con-
sequence  of the facility of  mistaking
other maladies for incipient  hip cases ;
and in consequence  of  the table,  deliv-
ered by Dr. Falconer, being taken from
a register ofthe hospital ; a thing very
likely to be drawn up in a careless man-
ner.   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 
    DISEASE OF THE* HIP  JOINT.  1*3

author of  the  pamphlet on fn4s  sub-
ject.  I am entirely of opinion with Nlr.
Ford,  that any kind of warm  bat/hhig
would have been productive o'f the same
benefit.  I cannot say that it has occur-
red to me to see much of the >practioe
of placing  patients,  afflicted with  the
hip disease, in  the  warm bath  ;  but I
have  repeatedly seen fomentations em-
ployed.  The  latter applications  un-
doubtedly relieve  pain ;  and  in early
cases are very proper to be tried in con-
junction with topical bleeding.   I can,
however,  impute tothem no efficacy in
producing any  permanent  amendment
in the disease.   Topical  bleeding with
leeches, and cupping the circumference!
ofthe affected joint, provided the case is
attended with  symptoms denoting in-
flammation of the joint, are the measures
which  I  shall  confidently recommend.
The fomentations  may  be applied two
or three times a day for half an hour ;
but, as great utility does, in my opinion,
originate  from cold saturnine  applica-
tions to  the  part, I recommend them
to be used during the remainder ofthe
day.
  This plan of treatment, I think, ought
never to be employed, unless there are 
154   TREATMENT OF THE, &C.
manifest marks of active inflammation
in the'joint; for, when no such state ex-
ists, the method can only be considered
as preventing the employment of a more
beneficial plan, and therefore is liable to
severe reprobation.
   As faras morbid anatomy can inform
us the hip  disease consists  in the same
alteration of the bones,  ligaments, and
cartilages, as we find  exir.ts  in the gen-
erality of white swellings.    As  faras
my experience extends   both diseases
ought to be treated on the same princi-
ples.   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.   Tht bene-
fits resulting from both applications are
to be imputed partly to the counter-irri-
tation, and partly  to  the  discharge
which they occasion. 
155
             CASE IX.

Shewing the  Efficacy of a Caustic Issue
  in an Example ofthe Hip Disease in a
  recent State.

  G.H., a boyelewn years of age,with-
out anv assignable  cause b.gan to ex-
perience a weakness andlameness in the
left lower extremity, 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 be-
came pale and wan in the countenance.
V\ hen surgical advice was first r« quest-
ed 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 n<>t<seem so prominent as
in the natural state; and the whole limb
Was palpably  more  emaciated than the
other.  The. knee-joint could be bent
and extended without causing the least
uneasiness; but the thigh bone could
not  be  moved  without exciting severe
pain. 
156   TREATMENT Off  THE, &C.

  Sept. 19th, 1805.   An issue about as
large'as a half-crown was made in the
hollow just behind the trochanter major.
About eight days afterwards the slough
was  detached,  and as many bneans as
would conveniently lie  in th« cavity of
the sore were placed there.
  The lad began to b^ materially better
at the end of the following month, ;he
could then move the jxaint without pain,
and tfoere  were  no sensations-of nervous
irritation shooting down the extremity.
  About the middle of November he
was able to walk tolerably well without
crutches.   The issue was kept open for
six month-s, at  the end of which time
the emaciation  of the limb  had quits
disappeared, «nd there was almost 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 heal-*
ed, and the boy to go to sea  ; a life for
which he  had a strong inclination.   No
medicines  were  administered  during
the whole of the treatment. 
15-7
             CASE X.

Terminating m dislocation ofthe Os Fe-
  moris ; the disease stopped;  and. thet
  Patient recovered*

  Mr. W. Si H—, a-gentleman twenty-
eight  years  of  age,  was seized, whilst
Walking on the 13(tb of April, 1803, with
so violent a pain  in the  groin that he
reached home wiO* difficulty.
  In  the preceding. October he- had  a
swelling of  the inguinal glands* uncon-
nected with  any venereal causes.   This
complaint ended in  an abscess, which
burst, and the aperture had closed short-
ly before the  present  attack.   A few
years  before he had  a similar swelling
in the axilla.  The pain in the hip con-
tinued 60 violent as  to  confine  him to
bed.  The limb was much,lengthened
at this period.  Leeches,  form ivtations,
and poultices,  had  bctn  employed at
first, and an issue afterwards made be-
hind the trochanter.
  When Mr. ----was consulted, pres-
sure on the trochanter gave great pain.
The patient kept his bed.   The issue 
 158'    TREATMENT OF  THE

 Was allowed to heal.  Leeches were re-
 peatedly applied to  the  itont  of the
jomt;   When moderate pressure could
 be borne without much inconvenience,
 a large blister was placed on the front of
 the htp.anddressr'd with ct rat. sabin.; hut
 so much pain and irritation ensued that
 the excoriated part was allowed to heal.
   Soon afterwards the patient was at-
 tacked with violent pain  in  the  joint,
 and spasm ofthe muscles,  during which
 state the slightest motion  could not be
 endured.  An abscess formed and burst
in front ofthe trochanter.   The patient
experienced afterwards some  respite ;
but the  fits of pain and spasm recurred
with increased  violence, and when they
 ceased, ^about the middle  of August) it
was manifest that the limb bad become
dislocated ; for it-was three inches short-
er than the opposite one.  The patient
now became easy.  A large issue was
made behind the trochanter, and it dis-
charged  copiously.   The  gentleman
completely  regained  his health and
spirits.   The dislocation ofthe bone oc-
casioned a great swelling of the  hip, and
thrrewerea strongly marked depression
and vacancy in  th, groin.   In October
the limb was  only  two inches shorter 
    DISEASE 0E THE HIP JOINT. 153 *

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 country,
and returned to town the following June.
His health  had been constantly good,
and the limb free from complaints, the
issue continuing open.   He has never
attempted  to move the  affected joint,
nor to  walk without crutches.
             CASE XI.

Terminating in the dislocation of the Os
  Femoris, and, probably. Anchylosis.

  M. H—, aged fourteen, was admitted
into St. Bartholomew's Hospital, afflict-
ed with a disease of the hip-joint.  The
case had advanced to a suppurative stage
before any issue was made.   An eschar
about as largr as a half-crown was at last
formed, and the issue was dressed with
beans.   Some amendment took place
soon after, and the  matter beneath  the
skin was certainly less in  quantity than
it was at first.  The girl's health, which
w s at first in a very bad state,  wa6 also
improved.   Symptoms of  active  in* 
 t60     TREATMENT OF THE

 {{animation unfortunately came on ; the
 abscess become very large, and the sur-
 geon 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-
 times worse.  The limb, some time be-
 fore she  was discharged,  had become
 three or four inches shorter than the op-
 posite 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 itused
 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
 succeeds  disease in  the hip we may b«
 sure that either the neck of the thigh
 bone is destroyed, and  the main portion
 ofthe  bono drawn upwards,  while  its
 head remains in the acetabulum, if it be
 not also entirely  annihilated by the mor-
 bid affection ; or  that  the  head of the
 bone is dislocated in consequence of the
 destruction of the brim of the acetabu-
lum and articular ligaments.   If a  case
xvere to occur in  which the  limb was 
    DISEASE OF TWE HIP JOINT.  161

considerably shortened,  and the toes
turned outward, I should conclude that
the head of the os femoris was separated
from the rest of the bone, and that the
muscles had rotated the limb outward.
But when the toes are turned inward,
q« all the great muscles of the  thigh.
have a propensity to twist the os femoris
outward, we may conclude that this po-
sition of the limb  is mechanically pre-
vented from taking  place, by the head
of the thigh bone  being'situated back-
ward on the dorsum of the ilium.


             CASE  XII.

Showing  a curkus Plan  of Treatment
   adopted in a Case of diseased Hip, arid
  followed by  effects wluch few waukl
   expert.

   A very respectable gentleman, resid-
 ing io the west of England, had a disease
of the hip-joint. Suppuration took place
 in the part  affected, and the matter was
 discharged by spontaneous  external o-
 pening«.    Very extensive  sinuses  re-
 mained,  which discharged largely. His
            g  2 
162'    treatment or the*
health of course became materially im-
paired.  Tworespectable practitioners,
a physician and surgeon, attended the
g ntleman.   After the patient had been
under their  care  a  considerable time,
things still remainingin nearly the same
state,  another medical  man was called
in to a consultation.   The latter boldly
undertook to effct a cure.  He injected
the  sinuses  with  oil  of  turpentine.
Healthy  inflammation  was  produced,
Without any considerable constitutional
disturbance.  The sinuses closed, and
the joint anchylosed.   The patient is
now well, having only a stiff joint.
  The gentleman who favored me with
this interesting article, is a very respect-
able surgeon, and a  man endowed with
talents far above those  of the ordinary
stamp.   He very ingeniously states that
the stimulus  of turpentine  is of a very
peculiar  nature :  when applied  to the
raw surface of a burn  or  scald it gives
no pain, and the surface of a chronic ab-
scess cannot  be in a more irritable state.
  I make no  comment on  the case ; but
the fact seems to  me  highly deserving
of a place in the records of surgery. 
     • ISEASE OF THE HIP  JOINT.  16S

   As I have not taken  any notice of
diseased xt rtebrse in the present disser-
tation, and it is an affection so very an-
alogous to  disorders of  the  knee and
hip, already treated of,  I think u may
be proper to conclude these observations
with a case which I have lately attended,
and indeed visit now whenever occasion
requires my presence.


            CASE  XIII.

Shewing the efficacy of Issues in Cases of
         diseased Vertebra:.

  Miss E----, a little girl, ten years of
age, living in PrinceVstret-t, Soho, was
brought to my house for advice respt ct-
ing a weakness of the  lower  limbs.  I
begged to examine the back,  and lound
that three  or four of the spinous pi -
cesses of  the middle dorsal  vertebrae
projected in a very preternatural degree.
The child was losing its health very f'st,
and appeared to be very wtak.  Its »y-
petite was  impaired, ard it  could not
Bleep at night.   Very severe affections
ofthe stomach,  resembling heartburn,
also frequently occurred,  but  a little 
164?     TREATMENT OF  THE

peppermint water regularly relieved this
complaint.
  I formed two issues with caustic (the
kali purum) on each side ofthe projec-
tion  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 con-
stitutional complaints had taken a very
favourable turn.   The friends, who are
very reputable people in business, in-
formed me that  a few hours  after the
eschars had been made the child became
more full of spirit, ate better, and look-
ed better  than it had  done for  many
months before.  In  the  course of  a
Week,  even before the sloughs came  a-
way, the child  could walk  without ex-
periencing half the weakness it did pre-
viously.  This is  one of the most con-
vincing cases, which have ever occurred
to me,  that issues produce their  good
effects  by counter-irritation, as Well ashy
the discharge which they Occasion.  In
this  instance most sr-prising amend-
ment took place before the eschars came
away, or a drop of pus had been secreted.
   The little girl has now had a discharge
kept up from the part  for nearly six 
    DISEASE  OF THE HIP JOINT.  165

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  caustic  issues in cases of disease
ofthe vertebrae, I always feel how much
we ought to honour the memory ofthe
late Mr. Pott, through whose transcend-
ent abilities this and  many branches of
surgery were  brought  into a very im-
proved state.

  * A few weeks after both  issues had been heal-
ed the child's mother  thoaght there  was a degree
of weakness returning in the legs.  This apprehen-
sion of a relapse has, however, now quite subsid-
ed ; for a (hort residence at  Margate, which I re-
comTiended, has made  the limbs completely recov-
erttuir proper strength.
THE END.
    ' i.
   s. 
 
M^d.Hist,
   wz
  3L10

  1311
c'}