The common tartar-emetic ointment produces slowly a pustular eruption. The combination we have mentioned is more speedy in its operation, occasions more general inflammation of the cutis, and gives rise to an eruption more vesicular than pustular.* Stimulating plasters are considered by our author as less convenient than stimulating liniments. They seem to be adapted to an ulterior stage of the complaint, when the patient is beginning to exercise the joint. Issues and setons may be of some service in chronic cases, but they are more serviceable when the cartilage has become ulcerated.

A great deal may be effected by rest, and by those means which tend to produce it. In the early stage of the inflammation the patient's sensations warn him to abstain from motion. But exercise at a later period is productive of less immediate inconvenience, and the patient will not submit to very rigid confinement, which, indeed, would be injurious to the health. Under these circumstances the surgeon must resort to bandages or splints. On this head we may extract Mr. Brodie's sentiments.

"If the disease be far advanced, and there is danger of the cartilages being ulcerated, he will find it prudent to restrain the motions of the joint altogether, by the application of pasteboard splints, confined by a roller, or even by circular stripes of adhesive plaster on their outside. In other cases, the bandages, &c. recommended by Mr. Scott, in his ingenious work on the diseases of the joints, will be productive of the best results. There is a bandage which is very well suited to cases of this kind, which, in one part of its circumference is composed of a stiff leather, elsewhere of an elastic material, and secured by a lace or buckles, so that it admits of being secured with any degree of tightness. If the seat of the disease be in the knee, there may be a single piece of leather adapted to the shape of the posterior part of the limb; if it be in the elbow there may be a double piece of leather, one on each side, and thus the construction of it may be varied so as to adapt it to any of the other articulations. In some instances much support may be wanted, and the leather should be stiff and unyielding extending a considerable way above and below the joint. In others, where little support is necessary, the leather may be more pliant, and it should not extend beyond the immediate neighbourhood of the part affected. Such a bandage is worn with the greatest comfort, and it fully answers the intended purpose. As it may be removed or applied by the patient's own hands, the use of it is quite compatible with that of the stimulating liniments which I have formerly mentioned." 37.

Mr. Brodie has not touched on an interesting subject of inquiry-the action of different modes of cutaneous irritation on various conditions of internal morbid action.

↑ "A very convenient mode of applying bandages in these cases is as follows; -Let it be supposed that the disease is in the knee. Circular stripes of leather with the emplastrum plumbi are to be applied round the joint, and extending some way above and below it; care being taken that a space is left for the patella; on which there ought to be as little pressure as possible. Over this a calico roller (four or five yards for an adult) may be applied, and over this again a few circular stripes of linen, spread with adhesive plaster, with another calico roller over the whole. A bandage of this kind carefully adjusted may not require to be changed for six or eight weeks, and is very convenient to the patient."

"Bandages of this kind are made by Shoolbred, and Co. in Jermyn Street, and by Sparkes, in Old Bond Street."

Such is the treatment, on general principles, of acute and of chronic synovial inflammation. But Mr. Brodie alluded to those forms of the disease which are dependent on, or connected with rheumatism, syphilis, and gout. In these complaints particular remedies appear to display some peculiar influence.

In rheumatic inflammation we are accustomed to employ opium, diaphoretics, colchicum, and mercury. The indications for each particular medicine it would now be out of place to enter on. With regard to colchicum and mercury, Mr. Brodie expresses the following opinions.

"I have found reason to believe that the colchicum is to be preferred, where several joints are affected, and where the synovial membranes, which constitute the bursæ mucosa and sheaths of the tendons, participate in the disease. In such cases, the wine of the root of colchicum may be administered in doses varying from 15 to 30 minims, three times daily, or, in some instances, the acetous extract of colchicum may be given in alterative doses of 2 or 3 grains every night. On the other hand, mercury is preferable where only one or two joints are affected at a time; but where there has been a manifest translation of the disease, either from some internal organ, or from one joint to another. The form of mercury most generally useful under these circumstances, is that of calomel combined with opium, and it should be administered in such doses as to affect the gums, or to produce some other indication of its action on the general system." 29.

In the cases, apparently allied to gout, where the patient complains of an excruciating grinding pain, or feels as if the joint were torn open, the relief from colchicum is even more remarkable than in cases of rheumatism.

Where synovial inflammation is plainly connected with syphilis, mercury is beneficial; where it coexists with disease of the bone or periosteum, and forms one of the class of cachectic symptoms, sarsaparilla is required.

In cases of the peculiar chronic disease occurring in persons of a gouty habit, and invading many joints in succession, it is necessary to pay attention to the general health, to regulate the diet and amount of exercise, and to keep the bowels gently open by mild aperient medicines. It has appeared to Mr. Brodie that patients have derived benefit from the use of acetous extract of colchicum, exhibited at intervals of six or eight weeks, for 10 or 12 successive nights, in small or alterative doses and still more from the long-continued use of alkalies. The carbonate of potash usually agrees with the stomach better than the pure potash. Ten or fifteen grains may be given twice daily, in the middle of the day and evening, and continued, with occasional brief intermissions, for many months.

The treatment of the stiffness which occasionally continues after the inflammation of the joint has subsided, is the only point which remains to be considered. If its mobility is only in a slight degree impaired, we may safely leave its restoration to nature. But if there be much stiffness and thickening of the soft parts, repeated blisters, or the moxa, may be serviceable. At a still later period, friction will be useful, but it ought to be employed with caution. Whenever we discover the slightest indication of return of inflammatory action, blood should be taken from the part, and the friction should not be resumed for some time. When friction can be used with safety, it should be continued for two or three hours daily, and during a considerable period of time. The douche is productive of much the same

consequences, and applicable under much the same circumstances as the remedy last-mentioned. Whenever friction is useful the vapour-bath is useful also, in combination with shampooing and with passive motion. All these remedies require both time and patience. Where complete anchylosis has occurred no method will effect the recovery of motion in the joint.

Mr. Brodie relates three cases illustrative of the ordinary characters and progress of inflammation of the synovial membrane. These we may omit. But the case which follows displays a peculiar feature-the sudden diminution of swelling in the knee, and supervention of affection of the head.

Case. A young gentleman, aged about 13, was seized in July, 1817, with inflammation of the synovial membrane of one knee. Under proper treatment the inflammatory action subsided, but left a thickened state of the synovial membrane, the joint admitting only of a limited degree of motion. He was directed to employ friction with a stimulating liniment. About the middle of November the swelling became suddenly reduced and almost wholly disappeared, but on the same day he complained of acute pain in the forehead. This went off in a few hours, but for several days it returned periodically in the form of a nocturnal paroxysm, of great severity, though of only a few minutes' duration. With active treatment the pain ceased in the course of about a week, but he was then seized with somnolency, which was soon followed by strabismus, partial blindness, and almost total cessation of speech; after remaining in this state for about a week he died.

The next case is intended to illustrate a circumstance that occasionally presents itself—a sensation, on examination of the swollen joint, as of a number of small loose substances, of a soft consistence, within the cavity of the joint, and just perceptible to the touch. Mr. Brodie suspects these loose substances to be portions of coagulated lymph, which had been effused on the inner surface of the synovial membrane, and had afterwards become detached; similar to those which are sometimes formed in the cavity of an inflamed bursa mucosa. This idea, however, has not been confirmed by dissection.

In the next case, a sensation was given to the hand, on examining the knee-joint, as of some soft loose substance formed within the joint; and a crepitus was distinguished on moving the patella from one side to the other. Under the treatment resorted to, the loose substance became no longer perceptible, and the crepitus could scarcely be distinguished. Mr. Brodie supposes that this kind of crepitus, differing from that occasioned by ulceration of the cartilage and exposure of the bones, is produced by an effusion of coagulated lymph, or an altered secretion of synovia.

In the next case inflammation of the synovial membrane of the hip ended in dislocation of the head of the femur on the dorsum of the ilium.

Mr. Brodie next proceeds to an interesting form of synovial inflammation, that connected with inflammation and discharge from the urethra or the conjunctiva. From those cases it results that the affection may commence with inflammation of the urethra, or with conjunctivitis, or with synovial inflammation. This variety is well illustrated in one of the cases related by our author.

"One gentleman (at the time when these notes were taken) had as many as nine attacks of this complaint. The first took place when he was under twenty years of age, and the others at various intervals in the course of the next twenty years. In one of them the first symptom was inflammation of the urethra, attended with a discharge of pus, although, from particular circumstances, he could not believe that he had been exposed to the risk of infection. This was followed by purulent ophthalmia, and that by inflammation of the synovial membranes. In three of the attacks, a purulent ophthalmia was the first symptom; which was followed by inflammation and discharge from the urethra; and then the synovial membranes became affected; and in the other four attacks, the affection of the synovial membranes took place without any preceding inflammation either of the eye or urethra. The disease was not confined to the synovial membranes of the joints, but those of the bursæ mucosa were inflamed also. In some of the attacks, the muscles of the abdomen were painful and tender, and subject to spasmodic contractions; and there was an occasional impediment to breathing, which seemed to arise from a similar affection of the diaphragm. The acute form of the disease, in this case, lasted from six weeks to three months, but nearly a year generally elapsed before the use of the limb was perfectly restored. He had an attack in July, 1817; and in the beginning of May, 1818, while he was still lame, he was seized with a very violent inflammation of the sclerotic coat and iris of one eye, which was subdued by very copious bloodletting, and the exhibition of mercury. He had another attack of the disorder in 1820, and in the Winter of 1822 he became affected with an inflammation of the iris and sclerotic coat of the other eye, which was also relieved by bloodletting and the use of mercury." 57.

Mr. Brodie concludes this chapter by the narration of two cases, one tending to display the good effects of colchicum, the other those of calomel and opium. In the former the patient complained of the sensation of the joint being torn open.

II.

ON ULCERATION OF THE SYNOVIAL MEMBRANE.

When an abscess has formed in a joint, an ulcerated opening takes place in the synovial membrane, through which the matter is discharged. But Mr. Brodie has only seen two cases in which the ulceration occurred as a primary affection.

Case 1. A young lady, æt. 9, fell and wrenched her hip. She walked out on that day, and in the evening she went to a dance, where she was seized with a rigor, and was carried home and put to bed. Next morning she was much indisposed, and complained of pain in the thigh and knee. On the following day she had pain in the hip, and was very feverish. These symptoms continued; she became delirious; and she died just a week from the time of the accident. The only lesion discovered on dissection was the collection of about half an ounce of dark coloured pus in the cavity of the hip-joint, the synovial membrane of which, reflected over the neck of the femur, was destroyed by ulceration for about the extent of a shilling.

Case 2. A middle aged man, who had met with a contusion of one shoulder, was admitted into St. George's Hospital. He complained of pain and tenderness in the shoulder, and a very slight swelling was perceptible. He had fever of a typhoid character. He died in a few days. Half an

ounce of thin pus was discovered in the joint. The synovial membrane bore marks of general inflammation, and in one spot, where it was reflected over the neck of the os brachii, it was destroyed by ulceration for about the extent of a sixpence.

III. ON A MORbid Change of Structure of THE SYNOVIAL Membrane.

This disease consists in a morbid alteration of structure, which takes place in the synovial membranes of joints, and which, as far as Mr. Brodie has seen, is peculiar to these parts. He has never known an instance in the serous membranes, nor even in the synovial membranes of the bursæ and tendinous sheaths.

Mr. Brodie relates eight cases, in order to display the pathological condition which constitutes this affection, and the manner in which the tissue is invaded by it.

It is evident that the morbid action originates in the synovial membrane, which loses its natural organisation, and becomes converted into a thick pulpy substance, of a light brown, and sometimes of a reddish-brown colour, intersected by white membranous lines. As the disease advances, it involves all the parts of which the joint is composed, producing ulceration of the cartilages, caries of the bones, wasting of the ligaments, and abscesses. in different places.

We will introduce the notes of the dissection of the joint in three cases, in proof of the correctness of this summary.

Case 1. In a diseased knee sent to Mr. Brodie by the late Mr. Horn, the joint contained about four ounces of a pale yellow fluid, having flakes of coagulated lymph floating in it. The synovial membrane, where it formed the loose folds extending from one bone to the other, and where it was reflected over the bones themselves, the crucial ligaments, and the fatty substance of the joint, had completely lost its natural appearance. It was converted into a pulpy substance, in most parts about a quarter, but in some parts, nearly half an inch in thickness, of a light brown colour, intersected by white membranous lines, and with red spots formed by small vessels injected with their own blood. The synovial membrane on the edge of the cartilaginous surfaces had undergone a similar change of structure, but only for a small extent. The semilunar cartilages were entire, but in a great measure concealed by the pulpy substance projecting over them. The cartilages covering the bones, in a few places were in a state of incipient ulceration.

In another case the affection of the synovial membrane was more extensive, but the ulceration of the cartilage was so slight that it might not have been noticed on a superficial examination. These cases therefore shew that alteration of the structure of the synovial membrane is the primary, ulceration of the cartilage a subsequent condition.

Case 2. The ligaments of the diseased joint were perfectly natural. The whole synovial membrane, except where it was reflected over the cartilages, was converted into a pulpy, elastic substance, of a brown colour, intersected by white membranous lines, in some places half an inch in thickness, in