Elements of Surgery. Robert Liston

in grooves, corresponding to the motions of the articular surfaces; the subjacent bone becomes at length completely denuded, and soon presents a polished porcelain-like surface, which is so remarkable that it is commonly known under the name of porcellaneous deposit. It is obvious that, when the disease has proceeded thus far, the joint must become more or less deformed, and its motions considerably impeded. Accordingly, old men are often seen at work with much rigidity of the joints, particularly of the knee, which is frequently projected inwards, from absorption of the cartilage from the outer condyle of the femur and corresponding part of the tibia, with a thinning and degeneration of the inner-articular cartilage into a tissue resembling the cellular.

      The hard, polished, and ivory-like appearance of the articular surface, would lead us to suppose that it contained an unusual quantity of earthy matter, yet an analysis by Dr. Davy, here given, shows the contrary.

Composition of the Shaft.		Composition of the polished Articular Surface.
Phosphate of lime, &c.	58·8	Phosphate of lime	54·2
Animal matter	41·2	Animal matter	45·8
	——		——
	100·0		100·0

      In many instances where the disease is of long standing, a deposit of adventitious bone takes place around the articular surfaces, and this may occur to such an extent as to produce anchylosis of the joint, the articular extremities of the bone often presenting several irregular depressions, and becoming variously altered in shapes, as shown in the cuts, p. 86.

      It is curious that the atrophy of cartilage is generally seen in its early stage to attack the joints in pairs, and to occur also in corresponding parts of the articular surfaces; a fact which coincides with the disposition of caries to appear simultaneously or successively in corresponding molar teeth.

      Of the causes of the disease but little is known, although it is generally attributed, like some other obscure affections, to the effect of rheumatism. It often follows in old people upon long disuse and confinement of a limb to one position, as during the cure of fractures. A very valuable specimen was presented to me lately by my friend Mr. Busk, of the Dreadnought hospital ship. The elbow had been apparently subjected to great injury. The radius and ulna had been fractured: the former had united, whilst a false joint had been formed betwixt the portions of the ulna. There is profuse deposit of bone around the elbow-joint, which must have been quite stiff, or nearly so, as regarded flexion and extension; but the end of the radius and corresponding articulation of the humerus are beautifully polished. This polish is not unfrequently seen also upon disunited fractures, as in the neck of the femur. Atrophy of the cartilages has been seen where no rheumatism was ever known to have troubled the patients; and they are more generally disposed to ascribe it to the effect of incessant hard work. At all events it is comparatively rare among women, and in the upper ranks of society; and the wasting often presents very much the appearance which would result from the effects of attrition, as if the wear of the cartilage had not been supplied by a corresponding reproduction. It is probable, therefore, that the affection is attributable to defective nutrition, somewhat allied to certain changes in the cornea, which are known to proceed from this cause, and which are also unattended by inflammation or the formation of pus.

      The symptoms of the disease are generally obvious enough in the more advanced stages by the crackling which may be heard when the joint is moved; and in the early stage a grating may be felt by a careful manipulation.

SCROFULOUS DISEASE OF JOINTS.

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      Affections of the membranes, ligaments, and bones, often occur in persons of weak constitutions, and proceed very gradually. They have been all classed under the general term of white swelling. They most frequently present themselves without any assignable cause, or are attributed to the slightest injuries. The disease generally commences in the cancellated texture of the bones: these are soft and light, and contain in their cells a quantity of caseous or tubercular matter. The softness is attributable to an interstitial atrophy of the bony tissue, as well as to an alteration in the proportion of its constituents; the animal matter being in excess, with a corresponding deficiency of the phosphate of lime. There is an increased vascularity of the medullary membrane, and the cancellated texture contains thin brownish-looking fluid instead of marrow. In cases of disease which has commenced in the cancellated texture, there is hardly any pain at first, and the progress of the disease is remarkably insidious. When the lower extremity is affected, the child is observed to limp; the limb wastes; it appears to be longer, partly from atrophy of the muscles, partly from relaxation of the ligaments and effusion into the joint.

      The term white-swelling, which ought to be discarded from surgery, was at one time made to include all the different affections to which joints are liable in weak constitutions—thickening of the parts, with an external colourless swelling—collections of matter about articulations, with or without an external aperture—effusion of fluids into the cavities of joints, or into the bursæ—destruction of cartilage by ulceration, or in consequence of portions becoming dead—absorption, ulceration, caries, or intractable ulceration of the bone adjoining the articulation.

      Those under twenty years of age are most liable to chronic affections of the joints, and they occur very frequently in children. Great anxiety is often shown by friends of patients to account for chronic disease of a joint, so as to save their whole generation from the imputation of being tainted with scrofula. It is attributed, sometimes correctly enough, to some injury perhaps trifling; to a sprain, or twist, or squeeze from a tight shoe, or to a bruise from falling; and it is no doubt true, that young or old people of the most healthy constitutions, if thrown out of health from one cause, will present all the appearances of scrofula, and become affected with chronic diseases of the mucous membranes, glands, joints, or bones, from very slight existing causes.

      Such affections advance slowly; all the articulations are liable to them; but those which are most subject to the disease are the hip, knee, ankle, and elbow. Of these, the knee-joint is most frequently affected, probably from the greater extent of cancellated and articulating surface. In young persons of unhealthy constitutions, the joints not unfrequently become affected one after another, and superficial abscesses form, terminating in open sores. I was obliged to amputate the upper extremity of a young lady a few days ago, in which a metacarpal bone and its articulation, the entire chain of carpal bones, the wrist and elbow joints, were all thoroughly involved in disease.

NEURALGIC AFFECTIONS OF JOINTS.

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      The joints, like other parts of the body, are very often the seat of painful affections, without organic disease existing. These neuralgic affections are often connected with, or followed by, hysterical symptoms. They frequently also depend upon derangement of the digestive organs,—upon the lodgement of irritating matters, sordes, or worms in the intestinal tube; and when we reflect upon the extent of the lining membrane, the expansion of nervous filaments, and upon the sympathy which they hold with the whole system, we cannot be astonished at the circumstance. Many cases of supposed hip-disease in children, with the symptoms and some of the signs of it, have come under my notice, which have yielded at once to the expulsion of offending matters or worms. Some affections of joints seem to depend upon gouty diathesis; others are intermittent: at one time the joint complained of