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 is hot,
and 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.
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.
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 violent constitutional disturbance.
When suppuration has occurred, it will in many instances be prudent
to evacuate the matter by one or more incisions, in order to prevent
farther mischief, especially if the bursa, a superficial one, is in
the neighbourhood of a joint. After the matter has been evacuated, the
cavity gradually contracts, and ultimately the bursa is completely
obliterated. Diseased bursæ, near the surface, and unconnected with
important parts, have been dissected out. The operation is not often
necessary, and in some situations attended with considerable risk.
Tumours, solid or nearly so, arising from diseased bursa of long
standing, may sometimes require to be so treated.
OF COXALGIA, MORBUS COXARIUS, OR HIP-JOINT DISEASE.
This disease has been supposed to commence in the cartilages; it
appears, however, to originate indiscriminately in the cartilage and
the bone, as well as in the membrane lining the capsule and investing
the cartilage and the ligaments; but whether it begins in one or other
of these tissues, it soon, if neglected, involves them all. It affects
patients of all ages, though children under twelve are most generally
its victims; and in these it often makes considerable progress without
its existence being suspected. The patient is observed to be a little
lame, and to be awkward in the use of the affected limb, but he
experiences little or no pain in the first instance; and if he does,
it is of a dull kind, and generally referred to other parts. Thus, pain
in the knee is generally the prominent symptom of this affection, and
occasionally pain is also referred to the ankle, or to the sole of the
foot: careful study and considerable experience are here required, to
guard the young practitioner from error in diagnosis. Parts remote from
the seat of morbid action have often been made the subject of treatment
in this and other affections; the knee, in morbus coxarius, has been
leeched, poulticed, blistered, and burnt, and that, too, when this
joint was not at all altered in appearance, and showed no symptom of
disease.
Again, and particularly in adults, the limb is easy only in certain
positions, and cannot be moved without great suffering; pain is also
complained of in the groin, and often immediately behind the trochanter
major. If an examination is made when the patient is thus halting, and
even though he complains of no pain, the limb is found shrunk, wasted,
and lengthened. The elongation of the limb occurs mainly in consequence
of the inclination of the pelvis towards that side. When the disease
has made progress, it has been supposed that swelling of the apparatus
of the joint, and effusion into its cavity, might separate the head
of the bone from the acetabulum, when pressure from the trunk was not
applied. The lengthening is often great, and its extent and cause are
ascertained by accurate comparison of the two limbs, laid in contact
when the patient is in the recumbent posture.
[Illustration]
The degree of lengthening is here carefully represented from a recent
case. But occasionally, even in the first stage, before destructive
ulceration has set in, in consequence of the pain and spasms, the limb
becomes remarkably shortened and retracted. This also will be found, on
careful examination, to depend upon the relative positions of the two
ossa innominata.
When the patient stands, the affected limb is considerably advanced
before the other, on which the weight of the trunk is chiefly, or
entirely, supported; the knee is generally bent, and the toes only
rest on the ground. In the advanced stages of the disease, and when
there is reason to suppose that ulceration of the cartilages has set
in, the patient, during progression, moves the affected limb with the
hands grasped round the thigh, and in bed it is moved by the aid of the
sound one. The spine is frequently affected, becoming bent in different
directions, to preserve the equilibrium of the body; and a deformity of
the trunk to a certain degree occurs, which, however, may be in general
easily remedied. The nates are much altered; they become flattened,
and those parts which are naturally most prominent are reduced to the
level of the others; the usual niche between the buttock and thigh,
in the erect position, is effaced, and the upper part of the thigh
is often considerably swollen. The alteration is at once manifest on
contrasting the healthy with the diseased side. Even from the first,
locomotion is difficult: in the morning, the movements of the joint
are constrained and stiff; afterwards, however, the patient walks with
more ease, though still by very slight exertion the limb is speedily
tired, and he is unwilling to use it. Pain is produced by pressing on
the groin, or by tapping on the trochanter, and by pushing the head
of the femur forcibly against the acetabulum. The inguinal glands
occasionally become enlarged. As the disease advances, the lameness is
more apparent; pain is produced and increased by motion, and by any
attempt to stretch, and more especially to abduct the limb whilst in
the recumbent posture. The emaciation of the member becomes more and
more visible. The muscles, as it were, are paralysed from inaction and
pain, abscesses form, and the constitution then sympathises remarkably;
hectic fever supervenes, with its usual train of symptoms.
[Illustration]
The circumstances attending the first stage of the disease in
childhood, in which the limb is lengthened, and there is no decrease,
but rather an enlargement of the parts composing the joint, have been
already described and illustrated. When, however, absorption occurs,
and the articulation begins to be destroyed, the second stage of the
disease commences, and the limb becomes then sensibly shortened; the
toes are turned inwards or outwards; in many cases there is every
appearance of dislocation of the thigh upward and backward; and in
others the limb is much bent, the toes only reaching the ground.
The ultimate position of the limb and degree of shortening will
depend much upon the extent to which the head and neck of the femur
is destroyed, upon the inclination of the pelvis, and also upon the
portion of the acetabulum which is most diseased. The joint becomes
tender, the slightest motion causing much pain, and the parts around
appear swollen. The patient retains the limb in the most comfortable
position, and it is generally bent upon the pelvis and inverted. This
may arise from relief being afforded when the psoas is relaxed, and
the pressure thus removed from the fore part of the joint. In many
cases matter forms behind, or rather below, the trochanter major, and
the collection often attains a large size. When the presence of matter
has been ascertained in this situation, it has been recommended that
an early opening should be made, on the supposition that the disease
arises from an acrimonious discharge into and round the joint, and
that, by the matter being allowed to escape, the cause of the disease
may be removed. The synovia has been compared by one old author to
bland oil, the vitiated secretion to oil of vitriol. Though the
principle is incorrect, still the rule of practice is important; for in
consequence of the long-continued presence of matter, accumulating in a
cavity which is not dilatable in proportion to the increase of purulent
secretion, the original affection will be much aggravated, and disease
induced in the neighbouring parts. But the existence of matter in the
joint could only be ascertained to exist in a very emaciated person.
[Illustration]
The formation of matter is preceded by great pain, and frequent
startings of the limb during sleep, accompanied with fever, and other
symptoms of severe constitutional disturbance. On the escape of matter
by the natural process from the capsule the painful feelings usually
subside. The abscess may appear, as already stated, near the trochanter
major, or in the back part of the thigh. Matter sometimes makes its way
into the pelvis, through a perforation in the acetabulum, thence it may
fall through the sacro-ischiatic notch into the thigh, and find its
way under the fascia, nearly to the knee; or again, it may present to
the side of the rectum, or even, as I have seen, burst into the bowel
and continue to be discharged thus for a long period. If the treatment
is neglected, abscess succeeds abscess; and in consequence of the
profuse discharge, which may be evacuated from one or many openings
round the joint, the patient is at length exhausted, and sinks. In
some instances the spontaneous cure by anchylosis occurs, as in the
instances from which these sketches are taken. In the one, the head and
neck of the bone had been almost entirely destroyed by ulceration,
before anchylosis had begun; in the other, the change is very slight,
but the head of the femur and os innominatum are inseparably united
by bone, and their cancellated texture runs into each other. Or when
the femur has been dislocated, which is a very rare occurrence, the
disease sometimes gradually abates, and a sort of new joint is formed;
the limb, after some time, may thus again become so far useful to the
patient.
[Illustration]
In many cases, the appearance which the various parts of the diseased
joint present, are similar to those which have been already described
when treating of affections of the joints generally. Frequently,
however, the osseous tissue in this situation is much more extensively
affected. Often the whole cartilage on the head of the femur is
completely removed, exposing the bone in an ulcerated condition; and
when the system has long borne up under the disease, the greater
portion of the head, neck, and even of the trochanter, is destroyed,
the extremity of the bone being completely altered in form, and
composed of a loose and spongy structure. A similar disorganisation
occurs in the acetabulum; the mucous gland is destroyed, the cartilage
is often wholly removed, and the margins of the acetabulum absorbed,
a large and flat ulcerated depression merely being left for the
reception of the diseased femur; in other instances the margins
remain unaffected, whilst the ulceration proceeds in the centre, and
the cavity is thereby much deepened. Not unfrequently the ulceration
proceeds farther, and an aperture is formed in the acetabulum, so that
matter accumulates within the pelvis. The opening is sometimes so large
that the femur is protruded through it. When matter has formed in the
soft parts round the joint, portions of the bones of the pelvis, in
contact with the pus, are ulcerated to a greater or less extent, and
sometimes these ulcers are surrounded by deposits of new bony matter.
From such changes in the osseous parts of the articulation the limb
is shortened, sometimes to a great degree, though no dislocation has
occurred. Indeed, dislocation is by no means so frequent a cause of the
shortening as is generally believed.
If the head of the femur has been dislocated, and if the disease in
the joint has afterwards subsided, the acetabulum is found to be much
contracted, with its margins smooth and little elevated, and, if
the patient survive for a number of years, it will be almost wholly
obliterated. But a portion of the dorsum of the ilium, upward and
backward, which is the most frequent dislocation in this disease, is
gradually absorbed, so as to form a sort of glenoid cavity for the
reception of the femur, the extremity of which becomes more solid in
texture, and more smooth on its articular surface. The remaining neck
of the bone is in the sketch here given turned forwards, and must
have given rise to great eversion of the toes. I have seen one other
specimen of this form of luxation. The limb is generally, however,
inverted; and what remains of the head of the bone consequently points
backwards. The consecutive luxation occasionally, also, though rarely,
takes place upon the pubis. Whilst a depression is thus formed, new
bone is sometimes deposited round its margins, whereby the cavity is
increased in depth, so as to resemble somewhat the original acetabulum,
the new deposit having become smooth and of a regular form.
[Illustration]
ON CERTAIN ALTERATIONS OF FORM IN THE HEAD AND NECK OF THE THIGH BONE.
[Illustration]
When treating of atrophy of the articular cartilages, it was observed
that, in the latter stages of the disease, the subjacent bone was
liable to become denuded, and its articular extremity more or less
deformed. Now one of the most interesting of these changes occurs in
the head of the thigh bone, which becomes polished on its surface,
flattened and expanded, with a corresponding alteration in the
acetabulum. In other cases the head of the thigh bone is somewhat
elongated, and the acetabulum becomes deepened in proportion, by a
deposition of new bone around its margin, as shown in the preceding
page, frequently to such an extent as to render the removal of the
head of the bone, even after the removal of all the soft parts by
maceration, almost impossible without fracture of the edge of the
socket. The head of the bone may also become still further misshapen,
and anchylosis result; while in some instances the new bony matter
presents in the form of nodosities, sometimes projecting towards the
cavity of the articulation. This cut represents a section of the
upper end of the femur of a labouring man, aged 49, who had fallen on
the trochanter ten years before death, and became gradually lame in
consequence, with shortening of the limb and anchylosis of the joint,
although he had never been confined more than a day or two on account
of the injury.
[Illustration]
[Illustration]
But there is another affection in which the femur may be shortened in a
comparatively brief space of time from absorption of the intra-capsular
portion of its neck, generally succeeding to a fall on the trochanter,
and sometimes occurring in young and middle-aged subjects. In treating
of fractures of the cervix femoris, it will be observed that retraction
of the limb is occasionally delayed for a while: hence the importance
of an accurate knowledge of those cases in which shortening of the
neck of the thigh bone may succeed to an injury short of fracture. The
deficiency of accurate anatomical details concerning such cases led to
a doubt as to their existence; but this question has been completely
put at rest since the history and dissection of two unequivocal
examples by Mr. Gulliver; and the annexed cut represents the changes
of form in the head of the bone, the shortening of the neck and
comparative length of the femora, in a young man from whom these bones
were obtained, and who walked about as many others have done, during
the progress of the disease.