Elements of Surgery. Robert Liston

matter has formed and remained long within the cavity of the articulation, the synovial membrane and the ligaments become blended into one soft mass, the internal surface of which is lined with a thick coating of lymph, as in the case of common abscess. If purulent matter is effused externally, and communicate with the joint, the capsular ligament will be found to have ulcerated and given way at certain points, forming apertures, usually of small size, and with ragged margins.

      All these appearances may exist without disease of the cartilages

or extremities of the bones; but generally they are also affected at the same time. At first the surface of the cartilage is slightly irregular and rough, and the change is not observed, unless on minute inspection. Afterwards the surface is marked with small depressions, which may be numerous, and are surrounded with irregular and somewhat serrated margins. They gradually increase in depth and extent, and the subjacent bone is ultimately exposed at one or more points, as here shown. Often the greater part of the cartilage is removed by absorption; the bone is exposed, opened out in its texture, softened, of an irregular surface, and in some places excavated, containing a thin ichorous fluid; the process of ulceration has also extended to the osseous tissue. Sometimes scales of cartilage of considerable size are either completely detached, having become dead, and been thrown off by the natural process, and are found lying loose in the cavity of the articulation; or they are all but separated, adhering by one or more very slender attachments.

      The incipient stage of such disease may exist without the synovial membrane being much, if at all, affected; but when the ulceration has made farther progress, all the articulating apparatus is more or less diseased. It may be here remarked, that the synovial membrane may be affected for a long period, thickened portions may extend over the cartilages, and these may have lymph upon them and yet remain intact.

      The cure, resorted to by nature, and in which she may be much assisted by the surgeon, is Anchylosis, ligamentous or osseous. New bone is deposited in the neighbourhood of the disease, and the ulcers become, as it were, cicatrised; the articulating extremities of the bones are joined to each other by a firm osseous matter, either universally disposed or consisting of processes extended between the bones at various points: or again, in consequence of the effusion of lymph into the cellular tissue, and the consequent thickening and induration of that and of the fibrous tissue exterior to the joint, this connecting medium is so strengthened and concentrated as to retain the articulating surfaces in exact apposition; from one, and usually from both, of these changes, the joint is securely fixed and rendered immovable, or nearly so. In complete anchylosis, the cancellous texture of the two bones, after some time, becomes perfectly continuous, so that they in fact constitute but one bone, as seen in cut, p. 84. A very perfect specimen of anchylosed knee joint is also delineated in the cut above. But even after this happens, the disease is still apt to recur from slight causes, the bony or ligamentous union being disturbed or destroyed, and the original disease attacking the parts with fresh activity; abscesses form,—may be extensive both in size and number,—and thereby the health is again undermined. So that the patient, after undergoing much suffering and risk, preserves, perhaps only for a few years, a limb which is almost useless to him, and which must be removed at last. In other cases, the union is permanent, the disease does not return; by care and time the limb is brought into the most convenient position, and proves of considerable service.

      The joints are often affected by rheumatic and gouty inflammation; and there are three species of disease, tolerably distinct in their pathological characters, generally attributed to these causes. In one there is a deposit of chalky-looking matter, composed chiefly of super-lithate of soda, on the articular surfaces of the synovial membrane and cartilage, but most abundantly in the cellular tissue outside the joint, an affection in which the cartilage is seldom known to ulcerate. In the second, the cartilages are atrophied, as if

worn away by attrition, the articular surfaces of the bone being much modified in shape, more or less denuded of cartilage, and remarkably polished and hard, so as to have been compared to porcelain, as will be described in another section. In the third, the fibrous tissue in the neighbourhood of a joint is primarily affected, the synovial membrane and cartilages not becoming involved till the disease is much advanced. It is not uncommon in the elbow of middle-aged persons who have been much exposed to the atmospherical vicissitudes, and is sometimes attributed to the effect of mercury or syphilis. The periosteum around the articular ends of the bones becomes swelled and painful; the affection is very slow in its progress; abundant deposition of adventitious bone takes place, often in short spiculæ, gradually encroaching around the joint, which ultimately becomes involved. A good specimen is here given. The disease was of twelve months’ duration, and was attributable to rheumatic inflammation supervening upon sprain. The affection involves extensively all the bones composing the articulation.

      Although wounds penetrating the larger joints are attended with danger, the synovial membranes are possessed of considerable powers of reparation, and often heal readily after severe injuries. An occasional result of inflammation is adhesion between the layers of the membrane, but this is by no means so frequent as in the serous tissues. The reparative power of cartilage is so low that the best termination that can be expected from the ordinary forms of ulceration, is union between the abraded surfaces. In experiments which have been made on the lower animals, portions of cartilage which had been removed from their joints were never reproduced, but the functions of the part were soon restored by the cut surface becoming smooth. In like manner there is occasionally to be seen in museums a circumscribed indentation in human articular cartilage, as if it had been destroyed by a small ulcer in this situation, which had cicatrized without any reproduction of the destroyed tissue.

ON HYPERTROPHY AND ATROPHY OF THE ARTICULAR CARTILAGES, WITH EBURNATION OF THE SURFACES OF THE BONES.

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      It has been already observed (at page 68), that the cartilages are occasionally swelled and softened in cases of chronic inflammation; and it now remains to notice instances in which they become hypertrophied or atrophied, apparently without inflammatory action. Although these affections are not likely to come often under the treatment of the surgeon in civil life, yet they are of much importance to the naval or military practitioner, since an accurate knowledge of them will lead him to institute a careful inquiry when a man complains of inability to sustain the fatigue of marching with the burden of a heavy knapsack; and they are of considerable interest in a physiological point of view, because they tend to show the inherent vitality of cartilage, and that it is liable to serious organic changes quite independently of diseased action in the surrounding tissues.

      Some examples of hypertrophy of cartilage, principally affecting that of the patella, have been described by Mr. Gulliver, and figured in the third fasciculus of drawings from the Army Anatomical Museum. In these the cartilage is swelled so as to form a ridge across the articular surface of the bone, the hypertrophied part being perfectly smooth, except where its continuity is interrupted by irregular fissures, as if the perpendicular cartilaginous fibres were split into bundles of variable size and shape. These cases occurred in young and middle-aged men who died of pulmonary consumption; and it is probable that the disease would be more frequently found, if it were more frequently looked for, since it does not seem to have been accompanied by any change in the surrounding parts, and would perhaps only be indicated by weakness of a joint rendering it unfit for severe work.

      The atrophy, or absorption of cartilage, is so frequently seen in the joints of old subjects, that some authors have been disposed to regard it rather as a physiological than a pathological condition. It is, however, unquestionably a disease; and in the drawings above mentioned, are some specimens of it from a soldier under the middle age. The cartilage seems in the first instance to be opened out in its texture, and numerous little villous processes appear on its surface, often as if its fibres were enlarged after absorption of the substance which connected them. The thinning sometimes takes