ing the body we discovered an abscess, which seemed to have had its origin in the cellular membrane of the pelvis, near the neck of the bladder, which had burst into the neighbouring portion of the urethra, and which had also extended upwards on the left side, so that it could be traced as high as the mass of enlarged glands in the groin. The whole of the muscles surrounding the left hip-joint, were preternaturally soft and vascular, and so altered from their natural condition, that they could be lacerated by the slightest force. They also were to a considerable extent detached, or separated from each other, apparently in consequence of a serous fluid which had been effused between them, but of which nearly the whole had become absorbed. The capsular ligament and synovial membrane of the joint were of a red colour, and unusually vascular; and the cartilages covering the head of the femur and lining the acetabulum were also red and of a soft consistence, giving to the fingers a sensation somewhat resembling that which is produced by touching velvet." (p. 336-39.)

A very remarkable instance of ulceration of cartilage in an almost incredibly short space of time is mentioned by LAWRENCE (a). In a case of phlebitis, after bleeding, which came under his own care in St. Bartholomew's Hospital, the patient had pain in his knee, commencing on the fourth, and he died on the eighth day of the same month. "On examination after death I found the knee-joint filled with pus of a reddish colour, that is, with pus rendered red by the admixture of blood. The synovial membrane which had produced this pus was highly inflamed, but the articular cartilage of the femur and the corresponding articular surface of the tibia were completely destroyed, and this high degree of ulceration had been produced within the short period mentioned." (pp. 482, 3.)

He also mentions the following very curious circumstance:-"When necrosis attacks the shaft of a long bone, though it does not involve the ends, yet the mortification extends (or rather may extend?-J. F. S.) sufficiently to the extremities to excite inflammation and absorption of the cartilages, although the synovial membrane does not become involved." And he speaks of a case in which “the whole shaft of the thigh-bone had perished, and the cartilages were as completely removed as if they had been cut out by the knife." (p. 483.) This appears to me the condition, though much more advanced, to which KEY refers, when, having spoken of the vascular deposit on the synovial membrane that destroys cartilage, he proceeds:-"A membrane is sometimes seen in joints under different circumstances, and affords a contrast to the above, as well in structure as in office. I allude to that adventitious membrane that is formed from the edges of the synovial membrane, in consequence of inflammation of a joint, induced by a contiguous disease of bone, as necrosis. In this case the membrane is formed for the purpose of circumscribing the cavity of the joint, when the cartilage is destroyed by the extension of the disease. It possesses but little vascularity, is smooth on its surface, not being furnished with the villous texture necessary to the ulcerative function. The opposed cartilage, under these circumstances, appears entire, ulceration taking place only on the surface next to the bone, and the membrane has not any connexion with the surface of the cartilage." (pp. 226, 27.)

Although it appears that, under inflammation, either chronic or acute, the less or greater deposit of coagulable lymph from the synovial membrane, which becomes organized, absorbs or eats up the cartilage with which it is in contact, as has been so ably described by KEY just quoted, and often requires amputation of the limb to tranquillize the constitutional excitement of the patient, which, if continued, would wear out his powers and destroy him; yet is it not to be considered as always a destructive, but rather, as KEY (b) has very truly stated it to be, "a repairing process, established with a view to the ultimate anchylosis of the joint, and by an efficient provision to prevent an inflammatory process that would otherwise end in ulceration and suppuration. A membrane is gradually developed by the agency of which the cartilage is absorbed, and which afterwards becomes the medium of anchylosis; thus the destruction of the joint is often prevented." (p. 146.)

HENLE agrees with KEY as to the absence of vessels in cartilage, but he explains its wasting or ulceration as dependent on want of nutriment. The following are his observations on the subject:-"As cartilage has not vessels it is not subject to any disease which depends on unnatural movement of the blood, neither inflammation nor hypertrophy; for the same reason, as it needs no vessels, it is not so easily wasted by pressure as bone*** Cartilage only wastes when the current of blood into the tissue upon hich its nutrition depends is interrupted; the diseased cartilage, as for instance of inmed joints, therefore is destroyed as if by maceration, rough, then as it were eaten, I finally dissolved." (p. 809.)

(a) Lectures on Surgery; in Lancet, 1829-30, vol. ii.

(b) Med.-Chir. Trans., vol. xix.

Of Ulceration of Cartilage. This, the more rare mode in which destruction of cartilage is effected, really occurs in the cartilage itself, and is described by KEY (a) as "an action altogether different from absorption, and analogous to the softening of the intervertebral substance," in other words, "the result of disorganization of texture." (p. 135.) But before stating his opinions on this subject it will be advisable to mention his views on ulcerations in general, for the better comprehension of their application to cartilage. "Ulceration is a process analagous to the softening attending suppuration; it is a degeneration of tissue, a change in the affinities existing between its component parts, by which it becomes changed from a solid texture to a fluid inorganic mass. It differs from gangrene in being a vital action; while gangrene, by at once producing death in a part, prevents any such change taking place. In gangrene the supply of blood to the part altogether ceases, while the integrity of tissue is preserved; under ulceration the circulation in the vessels continues during the action, and the part still belongs to the living mass, and remains under the influence of vital action until its separation is completed." (pp. 137, 38.)

** *

"Ulceration of cartilage," says KEY, " is effected in the same manner as an ulcer in soft parts; it is a destructive action that sooner or later is followed by suppuration of the joint. It commences in the structure of the cartilage itself, which, no longer under the influence of those forces that unite its integral parts, breaks up, and becomes converted into a purulent mass, which, mixing with the synovia of the joint, irritates the synovial membrane to inflammation, and ultimately to suppuration and ulceration. Ulceration of cartilage, however, as a primary disease, is a much less frequent occurrence than absorption through the intervention of membrane. I do not remember," says KEY, "to have examined a joint, that had been the subject of ordinary chronic inflammation, in which this membrane was not more or less developed. Nor have I seen an instance of chronic inflammation, in the early stage of strumous disease, in which degeneration or ulceration of the cartilage existed as the primary action. Chronic inflammation, however, after existing for many months or years in strumous subjects, may, and often does, become acute, and ulceration sometimes, in such cases, supersedes the absorbing process, and abscess rapidly forms. * Nature endeavours, so long as she can, to remove the cartilage by absorption, in order to prevent the necessity of suppuration; for primary ulceration of cartilage leads to the formation of abscess. The breaking up of the tissue of the cartilage is equivalent to the suppurative process in softer tissues; it creates a product that must be got rid of; the synovial membrane is irritated, and ulceration with abscess is the result. In absorption of the cartilage through the intervention of the membrane, suppuration is not a necessary attendant, and we sometimes find the whole process completed without abscess. But where the membrane is wanting, the process is analogous to the degeneration of soft parts, and is sooner or later followed by suppuration. *** The diseases in which the texture of the cartilage primarily undergoes ulceration are, for the most part, acute from their commencement. The inflammation that follows wounds of joints often leads to the rapid ulceration of the cartilage, and to burrowing abscess. In these cases, the cartilage is found often to be extensively destroyed, and the bone laid bare, without any appearance of a membrane for the purpose of absorption. The remaining cartilage sometimes exhibits different stages of approaching disorganization; in some parts retaining its natural form, consistence, and appearance; in others being soft and spongy, or even pulpy; and in those parts most advanced towards ulceration, the fibre of the cartilage can be seen to separate, and flakes here and there appeared to be almost detached. *** The chronic inflammation of the synovial membrane, attended with absorption of the cartilage, not unfrequently becomes acute from accidental causes, and, leading to ulceration, quickly disorganises the joint. Both ulceration and absorption may here be seen to operate. In some parts may be seen the membrane adhering to the cartilage or to the denuded bone, in various degrees of activity or vascularity, according as its office is completed or in progress; and in others a total loss of the cartilage may be observed, without the development of a membrane. It is not unusual for one half of a knee-joint to be losing its cartilage by absorption, while, by a process of inflammation subsequently excited, the other is in a state of active ulceration. On one side the cartilage is furnished with the absorbing membrane, which sometimes spreads over the whole of that side of the cavity, and protects it from the devastating process of ulceration that is at work on the other side of the joint, which is filled with pus and the remains of the disorganised cartilage. In persons who have become extremely irritable and weak, the ulcerative process is so determined, that the membrane itself is sometimes found in a state of ulceration." (p. 146-50.)]

(a) Med.-Chir. Trans., vol xix.

217. On examination of the joint after death, produced by other diseases, it has been found, if the disease were still in its commencement, that the cartilage, at one or more places, was loosened into a fibrous mass, and ulcerated; at a later period there was great destruction of the cartilage, the joint was filled with ichor, the synovial membrane and other parts of the joint disorganized.

Many will not allow the possibility of primary affections of the cartilage, as the cartilages of a movable joint must be considered as lifeless parts, which cannot take on inflammation, do not feel the effect of irritants, and, in affections of the synovial membrane or of the bony tissue beneath it, only suffer destruction and exfoliation. SCHUMER (α) has, in his experiments on animals, observed the same results as DÖRNER and others had previously, that the joint-cartilages, laid bare, injured, and even exposed to the air, never showed any trace of inflammation, which appeared only in the bony epiphyses and synovial membrane. GENDRIN (b) supports this opinion especially on the ground of the cartilage not being covered with synovial membrane; an assertion which though also put forth by others is contradicted by observation. J. B. MARC (c).

According to BRODIE's and my own observations, I must consider the disease here described as different from common inflammation of the synovial membrane and of the spongy ends of bones, even although perhaps it does not always arise as a primary affection of the cartilage, but is caused by partial inflammation of the synovial membrane, and of the spongy bony tissue beneath the cartilage. MECKEL (d) also supposes that the cartilage in different diseases of the joints may redden, swell, soften, and loosen up, but with this peculiarity, that suppuration is not necessarily connected with their ulceration.

[Sufficient has been already said in the last paragraph to prove, as seems to me, the truth of WILSON's and KEY'S notion of the deposit of a new and vascular substance upon the synovial membrane being the usual cause of ulceration of cartilage, and that the cause is not in the cartilage itself. It will not, therefore, require again to be adverted to further than to observe that it is quite distinct from the "loosening of the cartilage into a fibrous mass," spoken of in the present paragraph.

This form BRODIE speaks of thus:-"We find occasionally some portion of the cartilage covering bone, altered from its natural organization, converted into a number of ligamentous fibres, each of which is connected by one extremity to the bone, while the other is towards the cavity of the joint" (p. 113); and as he soon after mentions in the dissection of one such case, "having no lateral connexion with each other" (p. 119); producing the "brush-like projections of the cartilage and synovial membrane," as MAYO calls them (e). This "conversion of the cartilage into soft fibrous structure," BRODIE says, "I am disposed to believe is the frequent, though not constant, forerunner of ulceration. In a woman who died a week after a severe contusion of the hip, the cartilage of the hip was found in some parts entirely absorbed, in others having a fibrous appearance, similar to what has been described. And I have noticed the same circumstances in other cases sometimes connected with, and sometimes independent of local injury." (p. 121.) Here, then, is a morbid alteration of structure, the occurrence of which seems to indicate that there must be such a vascular apparatus entering into the formation of cartilages as enables new materials to be deposited and old materials to be absorbed, and without which morbid alterations of structure do not take place in other parts of the body.” (p. 113.) BRODIE (ƒ) further observes :-" The degeneration of the cartilage into a fibrous structure is no uncommon circumstance; and I suspect that it is one cause of the crackling of the joints, which is not uncommonly met with in persons somewhat advanced in life. I have no doubt that it often exists where it is never followed by ulceration; but I am also well assured that, in many other instances, it precedes, and, in fact, forms, the first stage of the disease." (p. 339.) In regard to this "degeneration of the cartilage of a joint into a fibrous structure," which KEY holds as a distinct form, and describes as the third mode of ulceration of cartilage, he says:-“ As far as my observations have enabled me to judge, it is a disease of a peculiar character, and differing in many respects from the ordinary affection of joints that end in the destruction of the cartilage. I have had but few opportunities of verifying by dissection the

(a) Diss. de Cartilaginum Articulorum ex Morbis Mutatione. Groning. 1836. 8vo.

(b) Histoire Anatomique des Inflammations. Paris, 1836. 2 vols. 8vo.

(c) Essai sur les Synoviales, Paris, 1834, p. 13.
Above cited, par. 2.

(e) Med.-Chir. Trans, vol. xix. p. 49.
(f) Additional Notes.

existence of this disease. BRODIE has described it, and appears to regard it as a not uncommon occurrence; in one instance he found it combined with disease of the intervertebral substance. Of three cases that have come under my notice, two have occurred in subjects brought into the dissecting-room, and the history of which I was unacquainted with; the other case was that of a gentleman who was labouring under stone in the bladder, and suddenly experienced a severe attack of pain about the head of the fibula and the bursæ at the back part of the head of the tibia. The pain was accompanied with considerable fever, and slight swelling of the parts in which he complained of the pain. On the third day the pain shifted from the fibula to the knee-joint, which swelled, as if from an effusion of synovial fluid. The suffering now became excessive, and the fever assumed a typhoid character. At the end of ten days from the commencement of the attack he died. The bladder presented less evidence of the inflammatory action than might have been expected from the intensity of his sufferings. The knee-joint was distended with a thin opaque synovial secretion, of a somewhat purulent character; the surface of the synovial membrane presented here and there patches of more than ordinary vascularity. The cartilaginous surfaces of the bones were entire, with the exception of a small spot on the end of the femur, which appeared ragged and irregularly broken up into a fibrous mass." (pp. 241, 2.)]

218. This disease shows itself in every age, but especially in children; more frequently in the hip and shoulder than in other joints. Its causes

are external injury, but especially dyscratic diseases.

["The ulceration of the articular cartilages may," according to BRODIE, “occur at any period of life, but it is most frequent in those who have passed the age of puberty, and who are under thirty-five years of age. We meet with it, however, some times in young children, and at other times in old persons." (p. 151.)]

219. The prognosis is always unfavourable, as the disease is often mistaken at its commencement, and speedy destruction of the parts of the joint is produced.

220. In severe irritation of the joint, leeches, cupping, even blood-letting, warm baths, and so on, must be employed at the onset. If the inflammation be thereby diminished, or if the disease has originally taken an insidious course, derivative remedies, and, among these, issues especially and the actual cautery are to be employed. The action of these remedies is often very rapid; the suppuration must, however, be kept up from the surface for a long time, and the joint kept perfectly at rest. Sometimes improvement quickly takes place; but the attacks recur, in which case, probably, suppuration has already taken place in the joint. When abscesses are formed, they must be treated as already directed, and especially the general diseased condition of the body somehow connected with the disease of the joint, properly attended to.

D. OF THE INFLAMMATION OF THE JOINT-ENDS OF BONES.

221. The inflammation, in these cases, (Inflammatio Processuum Articulorum, Lat.; Entzündung der Gelenk-Enden der Knocken, Germ. ; Inflammation des Extrémités Articulaires des Os, Fr.,) begins in the very vascular spongy part of the joint-end of the bone, and is at first accompanied with little pain, which comes on imperceptibly. After a lapse of time of uncertain length, there appears an elastic, irregularly spreading swelling of the outermost parts of the joint, the form of which depends on the expanded joint processes: the swelling is larger when the joint is in action, and smaller when it is at rest. The motions of the joint are little interfered with. After a shorter or longer time, increased pain comes on, the external skin becomes dusky red, and finally breaks; ill-conditioned pus is discharged, and caries is felt on using a probe. So often as some

wounds close, others break out, and hectic fever threatens to exhaust the patient.

["There is another malady," says BRODIE, "which affects the joints, having all the character of scrofula, generally occurring in persons who have a scrofulous appearance, and usually preceded by, or combined with, scrofulous symptoms. In this disease of the joints, the cancellous structure of the bone is the part primarily affected; in consequence of which ulceration takes place in the cartilages covering their articulating surfaces. The cartilages being ulcerated, the subsequent progress of the disease is, in many respects, the same as where this ulceration takes place in the first instance." (p. 226.) The morbid affection appears to have its origin in the bones, which become preternaturally vascular, and containing a less than usual quantity of earthy matter; while at first a transparent fluid, and afterwards a yellow cheesy substance, is deposited in their cancelli. From the diseased bone we see, in some instances, vessels carrying red blood extend into the cartilage. The cartilage afterwards ulcerates in spots, the ulceration beginning on that surface which is connected to the bone. The ulceration of the cartilage often proceeds very slowly. I have known a knee amputated on account of this disease, in which the cartilage was absorbed for not more than the extent of a sixpence. Occasionally a portion of the carious bone dies and exfoliates. As the caries of the bones advances inflammation takes place of the cellular membrane, external to the joint. Serum, and afterwards coagulable lymph, is effused, and hence arises a puffy and elastic swelling in the early, and an oedematous swelling in the advanced, stage of the disease. Abscess having formed in the joint, makes its way by ulceration through the ligaments and synovial membrane, and afterwards bursts externally, having caused the formation of numerous and circuitous sinuses in the neighbouring soft parts. In one case, thin layers of cartilage were found lying on the ulcerated surface of bone, apparently unconnected with it. In some instances, in the advanced stages of this disease, we find nearly the whole of the cartilage forming an exfoliation instead of being ulcerated. This scrofulous affection attacks those bones, or portions of bones, which have a spongy texture, as the extremities of the cylindrical bones, and the bones of the carpus and tarsus, and hence the joints become affected from their contiguity to the parts which are the original seat of the disease. Sometimes, however, we may trace the effects of these morbid changes even in the shaft of a cylindrical bone; so that we see the femur or tibia converted in its middle into a thin shell of earthy matter, enclosing a medullary canal of unusual magnitude. It has been remarked by a modern author (a), that in the last stage of this disease the bones not only lose the preternatural vascularity which they possessed at an early period, but even become less vascular than healthy bone. I believe the observation to be correct; and this diminution of the number of vessels, and, consequently, of the supply of blood, is probably (as this author has suggested) the proximate cause of those exfoliations which sometimes occur where the disease has existed for a considerable length of time, especially in the smaller bones." (p. 245–48.)

Upon this condition, his "last form, in which ulceration (or rather absorption) of cartilage takes place," KEY (b) observes:-"There are two forms of disease in bone under which this secondary absorption of cartilage takes place; the one is of a chronic nature; the other assumes an acute form; but in the process of ulceration the same passive condition of the cartilage may be observed as in that which commences within the cavity of the joint.

The chronic form is that in which a strumous action takes place in the cancellated structure," (pp. 243, 44,) and is that just described. "I apprehend," says KEY," that most pathologists will concur in the probability of the loss of the cartilage being effected by means of the vascular granulations that spring up from the cancelli, and appear to form a continuous structure with the surface of the cartilage. In making a transverse section of the joint, under these circumstances, there is no trace to be seen of increased vascularity in the cartilage, nor in the synovial membrane, until the action is far advanced, that can lead us to suppose that the cartilage was ulcerated by any other agent than the vascular tissue of the bone.

The acute form of the disease differs from the former in the comparative suddenness of the attack, as well as in the appearance which the bone presents. The former is like all strumous affections, slow in its progress, and at first marked by little or no pain in the part. Months often elapse before the symptoms become severe, and the constitution much affected. But in the acute form of disease attacking the spongy extremities of bones, the pain is often severe in the beginning, the limb at that part tender when pressed, and the constitution a good deal disturbed. A few weeks only elapse (b) Med.-Chir. Trans., vol. xviii.

(a) LLOYD on Scrofula, p. 123.