number of these contained oil-globules; the number of free oil-globules was very striking; this was clearly proved by the addition of liquor potassæ and sulphuric æther.

Cartilages. Section showed the corpuscles to be large and the cells therein remarkably evident; the hyaline substance was, in parts, plainly striated. In order to get a part clear for the use of a Valentin's knife, the bone was sawn through again at one corner, leaving the cartilage; and on breaking this and separating the fragments, a thin, tough film was drawn from the free surface like a fine transparent membrane; placed under the microscope this showed some large cartilage cells more thinly scattered than usual, since there was a hyaline part which was finely mottled, granular and studded with oil-molecules. I found that I could, in all parts of this case, produce a similar membrane-like beard.

With a sharp Valentin's knife some very thin sections were made, one or two of which preserved the outer edge; there is here and there a mark of separation between this margin (0·02 of a line thick) and the rest of the cartilage; sometimes an actual separation, sometimes no line whatever, but in all parts continuity of structure and continuity of cell-alteration may be traced between one portion and the other; this outer portion would, in a short time, have been shed in fragments into the joint-cavity.

CASE XXXV.-Daniel Hogan, aged 30, a dark-complexioned man, rather above middle height, young-looking, a machineman at a printer's, came to me 20th March, 1860, with a bad elbow.

About fifteen years ago he twisted the left arm in some game; it was painful, and in a few days swelled; he went to King's-College, they applied blisters and iodine, the swelling at the inner side increased and it was lanced; some pus flowed. Before the skin was well, however, he went to Mr. Verral, who put on a splint; and then to St.-Bartholomew's under Mr. Skey, who leeched it, and in about a fortnight lanced an abscess which appeared at inner side of upper 3rd of forearm. All this took place in about a year or eighteen months; motion of the arm was painful, but I cannot make out whether or not the inflammation was in the joint; at all events, he got so well that for the last fifteen years he has been machineman at a large printing-office, having frequently to lift heavy weights, as a form full of type, and, owing to a smash of the right hand, has used the left one most. Five months ago he had a swelling form at inner side, just below elbow, which got rapidly bigger, and in three weeks became very painful; he went to a medical man in the Waterloo-Bridge Road, who lanced it; the pain was a heavy and bursting pain. A month ago starting pains

came on.

20th March. The elbow-joint is much swollen; the swelling conceals the shape of the bones, is rounded and shapeless; the arm above thin; the tumefaction is evidently in and around the joint; it presents a false sense of fluctuation, which is characteristic of strumous synovitis; the skin is red at inner side and below elbow, where there is an opening discharging pus; a probe passed into it entered the joint, but did not come in contact with bare bone; he cannot bear the slightest movement

or pressure of articular surfaces together. A gutta percha splint was applied on the outside of the arm bent at more than a right angle; codliver oil and quinine administered internally.

12th April.-Drawing made from elbow.

14th.-There has been nothing of importance; the arm has increased in size, and the starting pains have become more marked; these pains prevent his sleeping at night; his looks have become worn and haggard; a part near the inner condyle fluctuates so distinctly that I puncture it; no pus escapes; I put my little finger in the wound, feel soft jelly tissue all round; a portion of this is extracted, examined beneath the microscope, nearly all the cells are found crowded with oil-globules; there are a great many free ones lying among the cells; to this formation is doubtless owing the fluc

tuation. It was explained to him that hardly the faintest hope existed of saving the joint, and he was advised to permit its removal: he wished to postpone this. With a view of trying to prevent the starting pain the joint was tightly strapped.

16th. He had, after being strapped, a couple of the starting pains, but has had none since; has slept very well. He tells me to-day, for the first time, that for about a month past, whenever he has leant in a certain way upon the elbow, he has had a peculiar sensation, as though one bone slipped or glided over the other out of place.

30th. He has continued to be free from the starting pains and his looks have very much improved; the elbow is reduced in size and harder, but the last few days he complains of pain over the outer condyle; an abscess, very superficial but of large extent, was found; the skin was discoloured and evidently separated from the subjacent tissues for some distance; it was freely incised; bled smartly, to stop which pressure was applied.

2nd May. The part of skin which was previously blue and discoloured has ulcerated; the sore is oval, about an inch and a quarter long by three quarters broad; the upper arm is swollen; strapping applied more tightly. I learnt, in the earlier part of the case, that this man was able to live pretty well, having, it appeared, saved a little money, but it is now exhausted; he is evidently badly fed.

9th. The upper arm is swollen, with deep, hard tumefaction; again examined the limb carefully and passed a probe along sinus at inside arm; it struck bare bone, or rather seemed to pass into a chasm, with bare, rough, not crumbly bone, on every side. It was now pointed out to him that he had better make up his mind to the operation and come into the house for that purpose; to all this he agreed, but he could not be taken in; the following week the strapping was discontinued, but the starting pains recurred with so much violence that his health began to suffer, and it was reapplied.

22nd. He came into the house, under my care, by the kind courtesy of Mr. Canton, and on the

26th.-I excised the joint.*

Examination of Joint.-The synovial membrane was lined, and the subsynovial tissues thickened by remarkably soft, yellowish jelly; on neither humerus, ulna, nor radius was there the slightest trace of cartilage; the cancelli upon the first and last of these bones lay bare, except that a soft, pulpy tissue seemed to grow out of them. The cancelli of the humerus were not bare, but a hole, about the size of the bulb of an ordinary probe, in the centre of the surface, led to a cavity in the bone that was filled with pus.

The man has done extremely well.

For the rest of this case see Excision.

CHAPTER VI.

CHRONIC RHEUMATIC SYNOVITIS.

PATHOLOGY.

THIS disease is less common than the strumous malady; it seldom commences in a chronic form, but is usually the residue of an acute synovitis, either brought on by accident or by acute rheumatism. There is no doubt of the inflammatory nature of this disease. Pains were taken to show, at perhaps too great a length, that the joint affection in acute rheumatism is an inflammatory disease (see Chapter III.); because if the acute malady be not inflammation, still less can the chronic disease be of such nature. But as it is proved that acute rheumatism really produces joint inflammation, so is it unnecessary to go further to show the nature of the chronic attack. Whatever may have been the origin of the primary acute disease, whether it have arisen from accident, exposure, or rheumatic fever, it will, on subsidence, have left behind it much the same condition of parts. The synovial membrane and subsynovial tissues will be thickened and the cavity will contain an abnormal quantity of fluid. If the constitution be healthy, these relics of the malady should gradually disappear; but a constitutional evil is likely to prolong their existence. We have seen that after a slight injury a synovitis may arise, which, as it falls into a more and more chronic stage, may become endued with marked strumous characters; the diathesis prolonging the inflammation and impressing its own character of non-development upon the products.* In the same way, if the diathesis be rheumatic instead of strumous, an acute or subacute inflammation may be prolonged into chronic rheumatic synovitis, the products of the inflammation receiving the stamp of the constitution. The histories of the two forms of inflammation are, however, generally different Let it, however, be remembered that strumous synovitis begins often as a chronic disease.

because the strumous frequently begins as a chronic malady, running a tolerably even course from end to end. The rheumatic disease very rarely begins otherwise than after an acute attack; it is subject to frequent remissions and exacerbations; each of the former following, rest and treatment, each relapse being generally preceded by some imprudence, over exercise or exposure to cold.

*

The first acute and each subsequent attack of inflammation consists, as all inflammations of connective tissues do consist,* of plentiful granulation, i.e. growth of cells. In the rheumatic inflammations the tendency of this growth is always fibrinogenous -organizing; hence the inflammatory product, or thickening, instead of remaining in the soft gelatinous stage of fungoid granulation, becomes a tough firm membrane. Thus the tissue never reaches a rank luxuriousness of growth, since most of the cells, instead of generating new cells, become transformed into fibres, and those fibres contract. The inner surface of the synovial membrane is therefore hard; presents long rounded undulations, which run in a direction round the joint, and are separated often by rather deep but narrow fissures; the colour of the tissue is of a light red-brown, about the hue of calf leather. The section is evidently fibrous, an appearance more easily visible when the tissue, which is tough, be torn, not cut. This material occupies the place of the synovial membrane, that fine fabric having disappeared in the much coarser substance, which is formed around it and on its surface. The growth may be of variable thickness in different cases, indeed in different parts of the same case. Thus at the knee it will be usually pretty well developed on each side of the ligamentum patellæ, will be thinner at the back, but in the subcrureal sac is formed into a dense hard cushion, which not uncommonly almost fills up that space, and sometimes does so altogether.

If a thin section of the material be made, and it be placed, without much disturbance and no tearing, under the microscope, it will appear at first sight to consist entirely of cells, fusiform, oval, and round, very closely packed together; a more minute examination will show that the oval and round cells are, except

* See previous Chapter, and my pa- | Joints,' in Beale's Archives, November,. per 'On Granulation as it Affects the 1859.