ration have been referred to the head of True or Permanent and Complete ANKYLOSIS.

It still remains to be determined what are the circumstances which distinguish true, complete, and permanent Ankylosis, and those which form the characters of spurious and temporary Ankylosis. The name is entirely symptomatic and semiographical, and has been used to denominate different forms and degrees of immovable or imperfectly movable joint, with little or no regard to the internal pathological conditions with which the external state is associated. This careless and irregular mode of using the term is so generally manifest in the writings of surgeons, that it does not require any specific proof; but if such proof were wanted, the reader has only to turn to the Pathologie Chirurgicale of Lassus,* in order to see in how vague and indefinite a manner it is possible to speak of this lesion.

This writer, in other points a very sensible and intelligent surgeon, gives, in the thirty-eighth section of his first volume, on Rheumatism, the following explanations, which may be regarded as indicating the state of surgical opinions in the end of the eighteenth and beginning of the nineteenth century.

According to this author, those who have long and habitually, as it were, suffered under rheumatic pains in the loins, sometimes lose the faculty of keeping themselves erect and raising themselves, in consequence of mutual Ankylosis of several vertebræ. This is observed, he adds, in most men who work in a stooping attitude, exposing themselves to cold, to rain, to all the atmospheric variations; or there follows a sort of atony, a feebleness, a species of palsy of the lower extremities.

Next he states, that if this inflammation,-the rheumatic, with fever, acute pain, and sleeplessness,-attack the ligaments, the membranes, the periosteum of the lumbar vertebræ, it terminates, when entirely neglected, towards the twentieth or thirtieth day, in abscess, without change of colour in the skin, with evident fluctuation in the groin, at the lateral part of the vertebræ, or towards the ischiatic tuberosity, an abscess necessarily mortal, and which is the result of caries of the bodies of one or more vertebræ. This shows the vague manner in which the word rheumatism is used. It is obvious that the author is here describing lumbar abscess from disease of the vertebræ; a malady which has rarely any connection with Ankylosis, unless it were to be healed either by art or spontaneously, when two or more of the diseased vertebræ may after a long time be consolidated in one mass, with spinal deformity.

Again he states that rheumatism of the neck becoming chronic, causes in children and in adults, the head to be obliquely reversed

* Pathologie Chirurgicale, par M. Lassus. Nouvelle Edition. Tome Premier A Paris, 1809. P. 227.

upon the shoulder of the diseased side, with slow deformity, and sometimes true Ankylosis of some of these vertebrae with each other. The disease in this instance he pronounces to be incurable, because it is no longer possible to raise the head erect, since the vertebræ possess in this instance no movement. He allows it to be curable only when the head can be kept in its natural erect position by mechanical means.

If this is to be styled rheumatism, it is a rare form of it, and is rather to be regarded as one of the effects of that disease. We have seen the following take place in adults, after an attack of what was called rheumatism of the cervical region. The neck and head became stiff and incapable of motion, while the individual could neither turn the head without turning the person, unless to a very limited extent; nor could he bend the head forwards upon the chest. This appeared to be the effect of thickening of the whole cervical fascia; and probably the diseased state had extended to the periosteum of the vertebræ, and some of their articulations. But it was impossible to ascertain whether there was adhesion of these vertebræ by their articulations or not. This, nevertheless, may be regarded as an example of Ankylosis succeeding rheumatism.

Lassus next specifies, under this enumeration, inflammation and suppuration of the mastoid cells as an effect of rheumatic inflammation, fixed on the tendinous and aponeurotic portion of the sterno-mastoid muscle and the periosteum covering the mastoid process. It is more probable, that the disease, in this instance, arose first in the membrane lining the mastoid cells.

As another instance of the effects of rheumatic inflammation, he adduces the usual changes which take place in disease of the hip-joint. (Morbus Coxarius).

Lastly, he states that it is common for rheumatism, which has been long fixed upon the knee-joint, the elbow-joint, or the shoulder-joint, to produce there a white soft oedematous swelling, with little pain, void of fluctuation, capable of solution, when it consists only in simple serous infiltration of the subcutaneous cellular tissue, but incapable of resolution when this tissue is distended and thickened by an accumulation of albuminous, gelatinous, yellowish fluid. The tumour in this stage being no longer oedematous, forms that incurable disease known under the name of false Ankylosis, Fungus, and White Swelling of the joint*

This is a strange association. White Swelling, which is used to designate four or five different morbid states, is the same as spurious Ankylosis. The truth is now known to be, that Ankylosis, in different stages and degrees, sometimes false and incomplete, sometimes true and perfect, may be the effect of several of Pathologie Chirurgicale, Tome i., p. 229.

*

those disorders which were formerly collected under the general name of White Swelling.

Such are the varied sources and determining causes of Ankylosis according to Lassus; independent of this, that he allows it to be the effect of abscess within the cavity of the joints (Inflammation of the Synovial Membrane), and of the abscesses which may be formed in the cellular tissue around the articular capsules, either in consequence of Synovitis, or from wounds, injuries, and other disorders around the articular tissues. This Ankylosis he allows to be frequent after such affections in the elbow-joint and in the wrist.

Ankylosis is defined by Monteggia to be that state of a joint naturally movable, in which the motion of the articulating bones is impeded. This impeded motion may be frequently the consequence of various diseases of the joints, and also the consequence of dislocations, and of fractures in the vicinity of the articulation. This defect of movement, he adds, acquires the name of Ankylosis only in case that it forms the principal character or remnant of the disease. If the immobility depends on an actual disease still present, on the cessation of which it may be supposed that the natural mobility could be restored, then the state deserves not the name of Ankylosis, as is exemplified in the case of a joint being incapable of movement in consequence of inflammation or any other spastic or painful disease, in consequence of palsy, unreduced luxation, and similar causes.

The movement of a joint may be either entirely and permanently impeded; and then the Ankylosis is called true or perfect; or the motion may be merely more difficult and more limited than natural, and its complete restoration may still be hoped for; and in this case it is denominated false or imperfect Ankylosis.

The proximate causes of Ankylosis, Monteggia represents to be retraction of the muscles; retraction of the ligaments; adhesion of the latter and of the tendons surrounding the articulation, and of the bones themselves together; or the changed figure of the articulating surfaces by enlargement of the bones, hard tophaceous concretions, excrescences and other inequalities, in consequence of which the one cannot glide upon the other in natural movements; and in like manner extensive cicatrices of the integuments and cellular membrane, conditions consequent on wounds, gangrene, or burns.

Retraction of the muscles is the result of irritation communicated to these muscles by the articular disease, in consequence of which they are placed in a state of permanent contraction; or it may be the consequence of their being left for a long time immovable in the same position. In eircumstances of this kind, for the most part the member remains ankylosed in the state of flexion, because the flexor muscles in general preponderate in

energy over the extensor muscles, excepting those of the foot, in which the extensors are strongest. Indeed, in many diseases, and especially in chronic ulcers of the legs, as also in consequence of the long inaction produced by fractures or luxations, the foot alone remains extended to excess, in consequence of which patients, on first rsing from bed and attempting to walk, are unable to place the foot flat on the ground, and can only touch the ground with the inferior extremity of the metatarsus and the toes, while the heel is elevated. Monteggia adds, that he knew different diseased states, from chronic ulcers in the leg, which had left after them this species of incurable Ankylosis, though these patients had no disease in the articulation of the foot; and hence it is necessary to take particular care against this in the instance of long continued ulcers and wounds in the legs. He states further, that ladies, who in former times wore very highheeled shoes, ended at length in acquiring some degree of this deformity; and that the proof of this was found in the fact, that upon dissecting the foot, a part of the superior convexity of the astragalus was observed to be drawn downwards and forwards, out of the articular notch of the tibia.

This preponderance of the extensor muscles of the foot over the flexors, nevertheless, he allows, is verified only in the instance of adults, probably because the extensor muscles are greatly strengthened by standing and walking upon the legs; while in new-born children, who have not yet practised this exercise, the action of the flexor muscles is wont to prevail, so that in them the feet are much expanded, showing that the dorsum of the feet is so much raised towards the tibia, as these parts may easily be touched, which cannot take place in adults.

In order to remedy the species of Ankylosis arising from contraction of the muscles, Monteggia recommends that they should be gradually forced to movements, and sometimes by the continued action of lacs and other mechanical means, and with the prolonged use of emollient and resolvent agents, such as warm baths of water, of decoction of bran, or broth of tripe, or of sheephead, long inunctions with olive oil, the use of the volatile liniment, camphorated soap, or mercurial liniment; sulphurous baths, douches, and sulphurous mud baths; artificial douches, with a solution of sal-ammoniac; or vapour baths, which should be directed in greater amount and strength upon the part by means of a tube, or still better with the Eolipyle. Greatly commended also, as very suitable, are certain volatile fumigations, made with salammoniac and salt of tartar, mixed together in vessels of water, conducting the vapours thereof to the affected part by means of a funnel. For this immobility also, arising from retraction of muscles, Latta particularly recommends electricity, by causing the shocks to pass through the whole length of the muscle.

The remedies now specified, he further recommends for the other forms of Ankylosis, namely, that from rigidity or persistent swelling of the ligaments, in consequence of long rest or of inflammation. To the propriety of this advice we may afterwards advert.

With regard to the selection of remedies in Ankylosis, it will be important, he says, to remember, that where there are simple rigidity and immobility, simple emollients and the vapour of warm water alone will suit; and that the animal fats and oils are preferred by Benjamin Bell to the vegetable oils, because this surgeon thought that the former penetrate and combine better with the animal textures, by reason of their analogy of substance. Wherever, then, there is any swelling to be resolved, there is an indication for the use of remedies, something stimulating, introduced principally in a mild aqueous or oily vehicle.

The following remark deserves attention, and is given in the words of the author.

"507. It is nevertheless to be observed, that when an immovable articulation is the seat of considerable swelling, the character of some other disease which produces the swelling may prevail, and the name of Ankylosis, which refers to the simple isolated defect of immobility, may not be applicable. And although in practice, and even in some books, the name of Ankylosis is occasionally employed to designate an articular disease, yet this is an abuse of language not to be imitated."

This is indeed the conclusion at which every intelligent surgeon must arrive. The name has been employed so loosely and generally, to express every form and degree of immobility of the joints, whatever might be the pathological cause, that it has become altogether useless, when any inquiry is made, or when facts are given, illustrating the method or methods of treatment which have been attended with success; in short, when any attempt is made to form an estimate of the comparative merits of different therapeutic methods.

"Adhesion of the ligaments, of the tendons, and of the bones, follows as an effect of inflammation, or from condensation of the nutrient fluids which are exuded, and which, in consequence of rest, are transformed into cellular filaments, shreds; not from any inspissation of the synovia, as was formerly believed. Perhaps,

* Instituzione Chirurgiche di G. B. Monteggia. Edizione secunda. Vol. v. Milano, 1814. Capo xxvii., p. 249. It may here be mentioned, that Monteggia gives, on the subject of ankylosis, two articles, one in the second volume, chapter xviii, under the head of Diseases of the Articulations, parag. 798-809 inclusive (p. 342–346); and the other in the fifth volume, in a separate chapter by itself. Both articles are very similar, in many respects verbally the same; but the latter, in volume fifth, is the most ample, and appears to have been composed after the author had thought that the first was less complete and satisfactory. The passage now quoted is not in the first article; but all the important matters of the first are included in the second.