before the joint exhibits symptoms of participating in the mischief. From this time the disease makes rapid progress: if suppuration takes place in the cavity of the joint, the synovial membrane ulcerates and allows the matter to burrow between the muscles of the limb: fistulous openings at length form, and tend in some measure to abate the patient's sufferings. The effect, however, on the constitution is such that amputation is usually resorted to for the preservation of life. Examination of the joint exhibits very different appearances from those which are observed in the chronic strumous disease of the bone; not in the cavity of the joint itself, for here the process of destruction is in some respects the same; but in the bone the affection is found to be altogether of a different character. The substance of the bone retains its firmness of texture; and when cut through shows no signs of disease except at one part of the cancelli. There a cavity is found containing one or more portions of detached bone, surrounded with pus; this cavity is found to communicate with the joint by a fistulous opening of small size, which may sometimes escape observation. The cancellated structure of the bone surrounding the cavity usually appears natural and sending forth vascular granulations. The cartilage covering the end of the bone is extensively ulcerated in some parts, whilst in others it appears to have undergone no change. The process of ulceration evidently begins on the outside of the joint, for the cartilage, when closely examined, appears to be undermined, and the surface towards the joint where this undermining process is going on seems quite sound. The synovial membrane shows signs of acute inflammation, and its cavity is found to communicate with one or more extensive collections of pus above and below the joint. This form of disease is in its nature analogous to necrosis of the shafts of the cylindrical bones." (p. 245-47.)

"In scrofulous disease of the cancellated texture of the heads of bone," says GOODSIR, "or in cases where the joint only is affected, but to the extent of total destruction of the cartilage over part or the whole of its extent, the latter is, during the progress of the ulceration, attacked from its attached surface. Nipple-shaped processes of vascular texture pass from the bone into the attached surface of the cartilage, the latter undergoing the change already described. The processes from the two surfaces may thus meet halfway in the substance of the cartilage, or they may pass from the attached, and project through a sound portion of the surface of the cartilage, like little vascular nipples or granulations. The cartilage may thus be riddled, or it may be broken up into scales of various size and thickness, or it may be undermined for a greater or less extent, or be thrown into the fluid of the cavity of the joint in small detached portions, or it may entirely disappear." (p. 19.)]

222. According to the stage of the disease, the joint ends are found on dissection in different conditions. They are soft, broken up, dusky red; their vessels much enlarged, and the cells of the bone are filled with reddish lymph. The cartilages are often still unchanged externally, but their inner surface is loosened from the destroyed bone. In the most advanced stage, both bone and cartilage are destroyed, the synovial membrane and ligaments disorganized, and the cavity of the joint filled with ichorous pus.

223. This disease is more rare in the hip and shoulder than in other joints, and most frequent in the spongy bones of the wrist and instep. It is more frequent in children and young persons than in adults. Its occasional cause may be external violence, but there is always dyscratic disease, and especially scrofula, in causal connexion with it.

[BRODIE says: :-"The scrofulous affection of the joints occurs frequently in children; it is rare after thirty years of age. Examples of it occur in almost every joint of the body; but the hip and shoulder appear less liable to it than many other articulations." (p. 248.) But KEY states:-"The bones in which he has observed this (the chronic) form of disease are the small bones of the carpus and the extremity of the femur; and, more frequently, the head of the tibia and the bones of the tarsus. Persons of all ages appear to be liable to it: I have witnessed it," he says, "in patients from the age of two years to fifty." (p. 244.)

BRODIE also further observes :-"As it depends on a certain morbid condition of the general system, it is not surprising that we should sometimes find it affecting several joints at the same time, nor that it show itself in different joints in succession, attacking a second joint after it has been cured in the first, or after the first has been removed by amputation. It is seldom met with, except in persons who have the marks of what is called a scrofulous diathesis; and in many cases it is either preceded, attended, or

followed, by some other scrofulous symptoms, such as enlargement of the scrofulous glands of the neck, and mesentery; or tubercles of the lungs. I have often been led to believe that the occurrence of this disease in the joint has suspended the progress of some other, and perhaps more serious, disease elsewhere." (pp. 249, 50.)

BRODIE's last observation is, I am convinced, exceedingly correct, if, as I presume, he means some modification of scrofulous disease in other parts of the body. I am certain that I have, again and again, seen persons, whose appearance betokened incipient phthisis, recover, and become stout and healthy; as if the disease had proceeded to its crisis in the joint, and, on the removal of which by amputation, all the constitutional disturbance ceased.-J. F. 8.

BRODIE considers that "the scrofulous disease is more likely to be confounded with ulceration of the articular cartilages than with any other. There is, in many respects, a correspondence in their symptoms. There are, however, certain points of difference, and I believe that this difference will be found in general sufficient to enable the practitioner, who is careful and minute in his observations, to make a correct diagnosis; at least, in those cases in which the local disease is not so far advanced, and in which it has not so much affected the general constitution as to make the diagnosis of no importance. (p. 250.) The principal difference which is to be observed between the symptoms which have been just described, and those which are met with, where ulceration of the cartilages occurs as a primary affection, is in the degree of pain which the patient endures, and which is much less in the cases of the former (the scrofulous disease) than in those of the latter description. It may, indeed, be matter of surprise that, in cases of this scrofulous affection, the sufferings of the patient should be so little as they are found to be in proportion to the quantity of local mischief. For the most part, the pain which he experiences is not a subject of serious complaint, except at the time when an abscess is just presenting itself underneath the skin, and then it is immediately relieved by the abscess bursting. There is never that severe pain which exhausts the powers and the spirits of the patient in cases of ulceration of the cartilage, except in a very few instances, and in the most advanced stage of the disease, when a portion of the ulcerated bone has died, and, having exfoliated so as to lie loose in the cavity of the joint, irritates the parts with which it is in contact, and thus becomes a source of constant torment. There are other circumstances, besides the less degree of pain, which, although not in themselves sufficient, it is useful to take into the account in forming our diagnosis, such as the general aspect and constitution of the patient, and his having manifested a disposition to other scrofulous symptoms; the very tedious progress of the disease; and the circumstance of the suppuration not being in general confined to a single collection of matter, but producing a succession of abscesses." (pp. 255, 6.)]

224. The prognosis and treatment are the same, as already stated, in inflammation and ulceration of cartilage.

[OF THE FAVOURABLE CONSEQUENCES OF ULCERAtion of the

CARTILAGES.

224.* The termination of ulceration of the articular cartilages from whatever cause, although generally destroying the patient by wearing out his constitutional powers, unless prevented by the removal of the limb, is neither always fatal, nor does the joint or its motions even seem to be always destroyed. When the destruction of cartilage has a favourable issue it terminates in one of two ways. In the first, the cartilage is replaced by a layer of ivory-like bone, and the motions of the joint continue; this especially happens in disease of the hip-joint. In the second, the opposed ends of the bones are united either by a ligamento-fibrous structure, which permits a slightly yielding motion of the joint, or by bone which precludes any motion, and thus are produced the two forms of anchylosis, viz., the soft and the hard. Whether the one kind passes into the other, I can not positively state, though I think I have seen, in more than one instance, part of the connecting medium ligamento-fibrous and part bony.

I. Of the ivory-like covering of the joint surfaces of bones. This condition has been by some anatomists thought to be merely a natural process, the common consequence of age, by which the cartilage thick in youth is gradually thinned in adult age, and

finally in advanced life completely removed, bone being stated to be constantly deposited in its place till the whole surface of the joint is thus covered. I think, however, I shall be able to show that this is an erroneous statement, as at the very onset it would appear unlikely that more earthy matter should be deposited, under natural circumstances, upon the ends of bones, so as to give those parts an ivory-like character, whilst on every other part of the same organs less earth is deposited, and even the fibrous mould in which it is lodged becomes thinner and thinner in age.

"The removal of the cartilage from the heads of bones in old people,” observes KEY, "proceeds so slowly that it is difficult to say, on the examination of a joint, whether the action has ceased, or is still in a state of progress. The form of disease to which I allude is attended with a good deal of stiffening of the joint, accompanied by what are termed rheumatic pains. The place of the cartilage is often supplied by a bony deposit, resembling ivory in texture as well as appearance." (p. 242.) ToYNBEE says: The articular cartilage is gradually being converted into bone during the whole of life; thus it is thicker in young than in adult subjects; and, as Sir B. BRODIE informs me, it is much thinner in old age than in the adult: in fact, it is not very rare to find that the articular cartilage of the head of the os femoris in very old persons has completely disappeared, a change which is probably to be attributed to its entire ossification." (p. 167.)

That this is merely a natural process as might be inferred from TOYNBEE's observation cannot be admitted; were it so, the disappearance of the cartilage and the ivory-like covering of the joint-end of bones would be much more frequent than it is. It is quite true that the cartilages of elderly people are much thinner than those of young persons; but this does not depend on their conversion into bone, for the shell of bone in the aged is commonly as much attenuated in comparison. It ought also to be commonly happening in all joints, which is far from the case, as it is but rarely found except in the hip-joint. For these reasons I think BRODIE's opinion is correct, that "it is probable in these cases the original disease had been ulceration of the cartilages." And especially as he mentions what appears to me to be the two stages of this ivory-like appearance, the first being that which he speaks of as having "many times in dissection observed a portion of cartilage of a joint wanting, and in its place a thin layer of hard, semi-transparent substance, of a gray colour, and presenting an irregular granulated substance;" and the second, that in which "no remains of cartilage were found on the bones of one hip; but, in its place, a crust of bony matter was formed, of a compact texture, of a white colour, smooth, and having an appearance not very unlike that of marble." (pp. 204, 5.) The difference of the two appearances seems to me easily explained by the continual motions in the joint wearing down the irregular granulated surface till the white, smooth, marblelike condition is produced. That it is also a consequence of absorption of the cartilage I think is further proved by the expansion of the articular surfaces, which is very often noticed in the hip-joint under this form of disease, both the head of the thigh-bone and its socket being also flattened; which flattening and spreading of ball and socket, or of hinge-joints, very frequently occurs with ulceration of cartilage without any ivory-like deposit, and as commonly when soft anchylosis exists. This then is the first and most favourable result of ulceration of cartilage, in which the motions of the joint are not materially impaired.

II. Of Anchylosis." This is an union of bone with bone," says JOHN HUNTER (a), "which ought not to be united, and is of two kinds, one by soft parts, the other by bone. In inflammations of joints we often have adhesions by a soft medium. Very considerable inflammation is necessary to produce anchylosis in joints, and much time is necessary for their perfection, as we see in white swellings. The adhesions are sometimes partial, sometimes universal. The soft is from two modes, viz., adhesion and granulation. The soft only can take place where there is naturally no intermediate substance, and the joint is surrounded by capsular ligament. Bony anchylosis I shall divide into five kinds, four of which are in the surrounding parts by ossific inflammation, the other by an entirely new substance between the extremities of a bone." (p. 521.) With the first four kinds we have at present nothing to do, but the fifth kind is the immediate object of our attention, viz.,

Anchylosis effected "by the whole substance of the articulation."

This is of two kinds, and these are the only ones which can admit of the soft anchylosis. It is somewhat similar to the union which takes place in soft parts; it arises from two causes, 1st, from inflammation of the parts themselves; 2ndly, from the inflammation of the surrounding parts, the parts themselves partaking of it.

From the first cause, or inflammation of the parts themselves, arises" suppuration in

(a) Lectures on Surgery, PALMER'S Edition.

VOL. I.

R

joints producing anchylosis. This is of two kinds," says HUNTER, "viz., the truly inflammatory, and the scrofulous; the former we shall now treat of.

"If the inflammation be carried on, an abscess is formed in the cavity as in any other part; and the suppuration is more universal in the cavity than in other parts, being diffused through the whole. This continues to approach nearer and nearer the external surface, and either breaks or may be opened. So far as they are connected with bone, they are similar to compound fractures, but the suppuration is slow, and takes place with difficulty, and then generally falls into the natural scrofulous disposition, which renders it tedious. The suppuration is then imperfect, appearing to partake of both the adhesive and suppurative. The ulcerative disposition is slow in bringing the matter to the skin, which arises from the indolence of the prior suppurative disposition and inflammation. The ulcerative inflammation sometimes goes on, so as entirely to alter the joint, that is, the receiving cavity becomes larger and the received part less; this is often the case in the hip-joint. These cases then become very tedious, and generally very uncertain in their cure. Before they are opened they are generally become so indolent that opening has very little effect, and often, when scrofulous, such a disagreeable inflammation comes on as to destroy the patient, and therefore amputation had better be performed at once, if this disagreeable inflammation does not take place immediately after opening; yet a fistulous opening is generally the consequence.

"Soft anchylosis from granulations.-A joint so healed has no cavity left; the surfaces uniting. A joint coming to suppuration from not being resolved in the first mode, but forming granulations, is more tedious than in the soft parts, and the powers of restoration in them are very weak.

"Bony anchylosis takes place when the granulations ossify, so that the two bones are united into one, exactly similar to a compound fracture. But when the suppuration is healthy the joints sometimes recover; in such cases the matter is sooner discharged, and the parts are more disposed to return into their original state." (pp. 522, 23.)

Such is JOHN HUNTER'S account of this important process, to which, however, some exceptions must be made. He seems to wish it inferred, that anchylosis generally results from suppuration of joints, for he has elsewhere observed, that "Nature is very little disposed to take on adhesive inflammation, because the necessary consequence would be loss of motion in a part originally intended for motion." (p. 519.) And that granulations as the consequence of suppuration produce anchylosis either soft or bony. I am not, however, disposed to assent generally to these statements, though I would not deny their occurrence as exceptions.

In the first place, as regards the frequency of Soft Anchylosis from granulations following suppuration, I feel assured, from frequent observation, that soft anchylosis is produced by the adventitious membrane poured out during inflammation of the synovial membrane, which, as KEY (a) says, "produces ulceration of the contiguous cartilage," (p. 224,) and, "when the cartilage has been wholly absorbed, and the ulcerative process has been checked by the inflammation being arrested, serves another purpose: it becomes the medium of union between opposed surfaces of bone, or the means of anchylosis. Long after all inflammation has subsided, one of the condyles of the femur is often found adhering to the tibia by means of this membrane, which appears white and ligamentous, a layer of cartilage often remaining between the membrane and the bones, as if the process of ulceration had been arrested." (p. 226.) And I believe, most commonly, when the soft anchylosis so originating is completed, that no suppuration in the joint takes place, and that, when it does happen, it results from recent inflammatory action assuming the suppurative character, and set up by external violence, which, destroying the cartilage down to the surface of the bones, these also ulcerate; and then, if there be sufficient constitutional power, the bones produce the granulations, and these inosculating, union of the opposed surfaces is produced, as seen in MAYO's case below, (p. 246,) and as in compound fracture, by deposit of earthy matter in the granulations, and thus bony anchylosis is brought about. I think this will be shown to be a correct view of the subject on examination of the cases which will be presently mentioned. Hip disease, which is also almost invariably attended with suppuration, and more or less complete destruction of the cartilage, and even of the head of the thigh-bone and its socket, seems to me a further proof of the opinion I have advanced, as at that joint soft anchylosis is very rare; whilst, on the contrary, bony anchylosis, if the patient's strength enable him to battle out the disease, is almost the constant favourable issue of the contest.

KEY states, that "the formation of the vascular membrane frequently takes place without suppuration, as may be seen in strumous joints that have been the subject of chronic inflammation for years, without abscess having formed; and the inflammation

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

is sometimes confined to one side of the joint. Such joints are sometimes seized with an acute attack of inflammation of that part which had been previously healthy; suppuration rapidly ensues, under which the failing of the patient's health and powers demand amputation of the limb for the preservation of life. The two sides of the joint present different appearances: one shows no recent signs of inflammation; the ends of the bones are partially, perhaps wholly, deprived of their cartilage, or the cartilaginous surface is ulcerated only to a certain depth; between the bones is seen the membrane adhering to the cartilage, white, possessing scarcely a trace of vascularity, and merely serving to connect the ends of the bones by means of what is termed ligamentous anchylosis. The other side of the joint is full of pus; every tissue in a state of active inflammation; the cartilage removed by a rapid process of ulceration, in which the bone is probably found to have taken an active part; and the ends of the bone are seen covered with vascular fungous granulations, from which pus is abundantly secreted." (pp. 227, 28.) With the correctness of these remarks I fully concur, and the following instances well support them, excepting that, in the first, the pus had been discharged, and, in the second, ulceration had occurred without suppuration.

CASE 1.-B. S., aged nine years, a fair-haired strumous boy, became my patient in June, 1840. Five years ago he was attacked with swelling and lameness of the left knee, without any known cause; he was put under medical treatment, and afterwards was admitted into the hospital, from which, about four years since, he was discharged; and it may be presumed all active disease had ceased, as his mother was told that the knee, which had become much bent, with the heel much raised from the ground, would be restored, as his health recovered. No such improvement, however, has taken place, and he has since gone about constantly on a crutch. Being a very active boy, he has frequently got falls, and hurt his knee; which, however, in the course of a few days have been recovered from. Within the last two months he has fallen twice, but has not got well as previously; and though during the day his knee has been little painful, yet at night it has become so much so as to prevent his sleeping.

The leg is now bent nearly at a right angle with the thigh; it can be bent a little more, but not straightened; the great toe only touches the ground, but he cannot bear upon it. The knee is rather larger than natural, especially the inner condyle; and both condyles project a little over the front of the head of the shin-bone. There is a little fulness above the knee-cap, as if the joint were distended; but there is little tenderness, and gentle motion does not cause pain.

During a month nothing was done except keeping quiet; and it was observed that, if he did not move about during the day, he had not any pain at night. The joint then seeming to be perfectly free from irritation, I thought it advisable to attempt straightening the leg, sufficient to bring the foot down and render the limb useful. A hinge-splint, adapted to the bent state of the limb, was, therefore, adjusted to the back of the leg and thigh, which it was purposed slowly to extend by a screw, the two ends of which were affixed to the two portions of the splint. This practice was continued for some weeks without benefit; but swelling coming on, attended with pain and tenderness, it was discontinued, and amputation successfully performed in the September following.

On examination, the whole joint was found largely covered with fat; and immediately above the knee-cap an abscess, about the size of a shilling, communicating with the joint below the front of the outer condyle by a narrow passage an inch long, lined with adhesive matter, but not containing pus. There is not any dislocation, but mere bending of the leg upon the thigh-bone. The cavity of the joint was destroyed, and the opposed bony surfaces united with fibrous matter, but some of the cartilage still remained."

CASE 2.-J. P., aged nineteen years, a dark-haired scrofulous lad, came under my care in November 1839. Eight years ago, whilst running, he felt a sudden snap in his left knee-joint, and almost immediately a swelling appeared above the base of the kneecap, rather larger than a pigeon's egg, but unattended with pain. This on the following morning had subsided, but another swelling presented itself on the inside of the ham, which was at once blistered by his medical attendant. On the next day he was attacked with bilious fever, which confined him to bed fifteen weeks, and reduced him very much; but during this time he did not suffer any pain or inconvenience in his knee. Soon after getting about, the knee began to swell and to become stiff, but unaccompanied with pain, and not preventing his walking. Leeches were once applied, and an evaporation lotion used, but nothing more done; and at the end of a twelvemonth, the knee having become fixed in a straight position, he was told he had a white-swelling, and the removal of the limb advised, to which, however, he would not submit. His health continued improving, and he walked about with the aid of a stick, without pain, or further inconvenience than a little halting, as late as July last, when he took a walk of fourteen miles