Elements of Surgery. Robert Liston

somewhat swollen; at another cold, and bluish on the surface. In these affections of joints the pain, indeed, is seldom constant: the patient’s rest is not broken; there are none of the violent spasms during sleep, which attend upon certain alterations of structure. The pain is equally complained of when the part is touched with the utmost gentleness, or when a thorough and searching examination is made, when the joint is freely moved, and the articulating surfaces of the bones are forcibly squeezed against each other. The pinching of the skin causes pain. There is seldom throbbing, or heat, or swelling; though, after long continuance of the diseased state, these may supervene to a slight extent. The pain complained of is seldom referred to one point, but to a large extent of the limb; and if the attention is diverted, the examination may be carried to any extent, without complaint being made.

      Sir B. Brodie, who has done a great service to the profession by directing attention to these nervous affections in his excellent work, and in his lectures, notices that the knee, when the seat of pain, is generally kept in the extended position, and this is very different from what has been stated to be the position of one affected by organic disease. The tumefaction following upon local treatment, and especially when leeching and counter-irritants have been employed, is sometimes, as he remarks, very perplexing.

      This class of diseases generally affects females of delicate organisation about the age of puberty, and in whom the menstruation is irregular. Males in delicate health are also subject to similar affections.

ON GROWTHS FROM THE SYNOVIAL MEMBRANE, AND LOOSE SUBSTANCES IN THE JOINTS.

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      The synovial membrane is sometimes studded on its inner aspect with loose fleshy or semicartilaginous substances projecting into the cavity of the joint. The entire surface of the membrane is occasionally covered with these bodies, which are of a white or yellowish colour, and very variable in size and shape; the smallest presenting the form of villi not much larger than those of the jejunum, the largest having somewhat the magnitude and appearance of the appendices epiploicæ of the large intestine, while many of an intermediate size approach in appearance to a lemon-seed. In some instances the membrane is only partially pervaded by them, and they are not unfrequently arranged like a fringe around the edge of the articular surfaces. They are generally very smooth on the surface, which appears to be perfectly continuous, if not identical, with the synovial membrane. Their attachment is frequently broad, and occasionally very narrow and pedunculated, often merely filamentous, so that a little further thinning of the part, or slight force acting on the body, would remove it from the capsule, and throw it loose into the cavity of the articulation. The disease has been most frequently seen in the knee, and sometimes in the elbow.

      The affection is obscure in its nature; it is slow in its progress; the joint is the seat of pain after and during exercise, probably from the morbid processes interfering with the motions of the articular surfaces. As the disease advances, the joint becomes swelled and elastic, unattended generally by ulceration of the tissues within or around it. In examining the part, when the articular surfaces are moved on each other, it will be found that their motion is more or less interfered with; and considerable irregularity in their action may be felt by the hand placed firmly on the joint during the procedure.

      Loose bodies may be found in the articulations, particularly in the knee and elbow, under the circumstances just described; but we often find others of a different structure loose within the capsule, which may be throughout smooth and apparently healthy. These bodies are extremely variable in size, generally rounded or oval, with a polished surface; many of the smallest present the character of fibro-cartilage or cartilage; the larger are often more or less modulated, very firm and gristly, and sometimes contain a considerable nucleus of bony matter. The articular ends of the bones are occasionally more or less misshapen by the formation around them of knobs of adventitious osseous substance.

      The disease is common in the knee; and patients frequently go about for years, who will tell you that they have something rolling within the joint, which will often be found on examination to be actually the case. It is obvious that loose bodies in the joint must prove an obstacle to easy progression; and the smaller ones seem to be particularly so, probably from becoming easily entangled by different parts of the articular apparatus.

      However difficult it may be to account for the cause of these formations, the means by which they may get within the articulation seems obvious enough. If a small knob of coagulated lymph should form on the inner aspect of the membrane, the point of attachment, as has already been noticed, might gradually become narrower, from the motions of the joint or other causes, till the connection were severed. But there is reason to believe that many of the substances found loose in the joints are formed altogether in the cellular tissue without the capsule; for it is difficult to conceive that they can increase in size, or take on the ossific action in their centre, by an act of independent vitality, after they have been separated from the surrounding parts. Accordingly, dissection has occasionally disclosed loose bodies within the knee-joint, and others of just the same structure outside the synovial membrane, which was however protruded by their pressure, and appeared to connect some of them by a pedicle only, ready to break and allow the foreign body, with its covering of the membrane, to fall into the cavity of the articulation.

AFFECTIONS OF SYNOVIAL POUCHES OR BURSÆ.

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      Bursæ are lined by a membrane, greatly resembling the synovial in appearance, function, and disease. They are frequently the seat of inflammation of an acute character; but in most instances the action is of short duration, and generally terminates in an increase and accumulation of the secreted fluid. The attendant pain is very severe, and much increased by any motion of the neighbouring parts.

      Occasionally a portion of the cellular substance, which is exposed to pressure of motion, as over a prominent portion of bone, assumes the appearance of a bursa, secretes a similar fluid, and is similarly affected in consequence of inflammation. These adventitious bursæ are met with in various situations. Bunion is a good example of such a bursa thickened from long-continued pressure. They are seen on the outer ankles of tailors, on the shins of boot-closers, on the forehead, point of the elbow, &c.

      Disease of the bursæ may occur from external injury, and they often become affected subsequently to disease of the neighbouring joint. If the action is violent, lymph is effused on the inner surface, or external to its cavity, causing considerable thickening. The sac is thus sometimes all but obliterated. Tumours, originally housemaid’s knee, aggravated by continued pressure, are met with over the ligament of the patella in almost a solid state. Occasionally the action terminates in suppuration, pus being effused to a greater or less extent into the cavity; and if allowed to remain or accumulate, the abscess extends, and frequently communicates with the neighbouring joint, which may not have been previously diseased. In chronic cases of enlarged bursæ, especially of the bursal thecæ of the tendons of the wrist or ankle, we not unfrequently meet with loose cartilaginous bodies of various sizes, and of a flattened oval form, floating in the accumulated fluid. These have been also supposed to be formed by portions of lymph which have been deposited on the surface, condensed in structure, and afterwards become detached.

      When inflammatory action has commenced in a bursa, it must be subdued by copious topical bleeding, along with the exhibition of purgatives; in most cases general bloodletting will not be required. After the inflammation has subsided, the parts remain swollen, from the effusion either of serum or lymph; stimulating applications may then be employed with advantage. In general, the ammoniacal plaster, or the brushing over the surface with tincture of iodine will answer. Blisters are sometimes employed with the same view. In obstinate cases, when the tumour is of no large size, a seton may be passed, retained till suppuration has taken place, and gradually withdrawn. Great risk attends interference with bursæ of large size near joints or cysts containing serous or glairy fluid in any situation. Even trifling punctures into such have been sometimes followed by inflammation of the inner secreting surface and