than another, from the fluid or the addition of solid matter being
accumulated where the least resistance is afforded; but the slighter
inequalities are generally filled up by œdema of the cellular
texture. As the disease proceeds, matter forms in the joint, and
is often attended with great pain and fever; or the pus is effused
into the bursæ, into the surrounding cellular tissue, or into the
filamentous tissue amongst the tendinous sheaths of the muscles in the
neighbourhood; being allowed to remain without an outlet, it at length
communicates with the cavity of the joint. Portions of the cartilages
are absorbed, though this, as already noticed, may occur at the very
commencement of the disease; the subjacent bone becomes affected by
ulceration, or perhaps its vitality is partially destroyed. When
matter has accumulated, a portion of the capsular ligament generally
ulcerates, the pus escapes, and is ultimately discharged externally.
When the disease begins with swelling, which is of a chronic character,
and produces but little inconvenience, and when the more urgent
symptoms supervene after the swelling has continued for a considerable
time, there is every reason to suppose that the disease has originated
in the synovial membrane, or perhaps in the osseous cancelli, and
this is generally met with in poorly fed and strumous subjects. But
when the first symptoms have been pain and stiffness of the joint,
without change of its appearance, and when the swelling has occurred
after these symptoms have been of some duration, then it is probable
that the cartilages are the primary seat of mischief. For the most
part, however, the symptoms have a general resemblance in most chronic
affections of the joints, and all the apparatus is sooner or later
involved. When the cartilage has been extensively absorbed, a grating
sensation is felt in moving the articular surfaces of the bones upon
each other. In consequence, also, of the softening and disorganisation
of the lateral and other ligaments, the affected articulation at length
becomes unnaturally loose, which is owing in some measure, also, to the
muscles being wasted and paralysed from pain and disuse. At an earlier
stage of the disease, the joint may be rigid from deposition of lymph
into the contiguous cellular tissue, and contraction of the muscles.
Purulent matter not unfrequently collects in the substance of the
bones, which in all cases ultimately become softened in a remarkable
manner. In many subjects, without actual disease of the osseous
tissue, the heads of the bones are so altered in consistence, are so
deficient of earthy matter, as to be easily cut with a knife. It has
been a matter of dispute, whether, in this affection, the articulating
extremities of the bones are enlarged or not; and the supposition that
they are always more or less increased in size, or hypertrophied, has
arisen from the extensive effusion and indurated state of the soft
parts being mistaken for this enlargement. In the first stages of the
disease, they are seldom, if ever, enlarged; but when ulceration of the
bone has occurred, new osseous matter is deposited to a greater or less
degree in the neighbourhood of the ulcer,—an attempt by nature towards
a cure, but too often an ineffectual one. The bones, in strumous
subjects, are often much enlarged, from collection of purulent matter
in their substance giving rise to a sort of spina ventosa. I removed
the upper extremity of a boy lately on account of extensive disease
about the elbow. The ulna to near the wrist was swollen enormously by
purulent collections in its medullary canal. In cases when the whole
of the articulating extremity of the bone is not enlarged, still that
portion which is more immediately concerned in the articulation is
often considerably expanded.
Frequently when the knee is the seat of the disease, the lymphatic
glands in the groin are enlarged; and when the elbow or wrist joints
are affected, there is often a similar enlargement of the glands in
the axilla: such glandular tumours have not rarely been confounded
with those accompanying malignant disease, and measures which were
absolutely necessary for the salvation of the patient, have thus been
delayed or neglected.
When the disease is extensive, and has endured for a considerable
period, hectic fever supervenes, and is aggravated after the abscesses
give way. The patient becomes much weakened and emaciated, and loses
his appetite; the pulse is rapid, with night sweats, diarrhœa, &c.;
and from a continuation of the hectic cause, the life is endangered.
In some cases, however, the health is restored, and the disease abates
spontaneously; in others, the disease is arrested, and a complete
cure accomplished, by the careful employment of such means as will be
afterwards mentioned.
The appearances produced by inflammation and consequent disease of
the synovial membrane, are the following. In the first stage, the
internal surface of the capsular ligament, and the rest of the synovial
membrane, is found of a red hue, its formerly colourless vessels being
now made apparent, from enlargement and consequent injection with a
greater quantity of red blood; and the serum within the cavity of the
joint is more abundant than in the natural state. When the disease
has been of longer continuance, the membrane is found considerably
thickened, its usual smooth glossy surface is destroyed, it is
irregularly flocculent, and frequently of a light yellow colour.
The interarticular adipose tissue also seems to be increased in volume,
from being infiltrated with a serous fluid, by the discharge of which
the diseased bloodvessels may have attempted to relieve themselves.
When the inflammation has been intense, or of long duration, lymph
is secreted, and deposited on the external surface of the membrane,
forming an intimate union between it and the ligaments, and producing
thickening of the external apparatus. Or the lymph is also effused on
the inner surface of the membrane, to which it adheres and becomes
organised; this is generally accompanied by the formation of purulent
matter; the organised effusion is often so extensive as to conceal
almost the whole of the synovial membrane, excepting portions of its
delicate reflexions which invest the articulating cartilages. By the
lymphatic deposit, to a less degree, the folds also of the synovial
membrane adhere to each other, whereby the motion is still farther
impeded, and the pain, when attempted, increased. Occasionally the
synovial membrane is found enormously thickened, much softened in
texture, and of a brown hue, when the disease has been of a very
chronic character. Along with these appearances, serum is generally
found effused, in a greater or less quantity, into the cellular tissue
exterior to the ligamentous covering. In cases in which the 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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
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 place in patches,
occasionally 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.
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.