a state of ill-nutrition; it follows from such credence that anything which draws largely on the sustaining power of the system, must of necessity be held to increase the nutritive fault. In watching cases of strumous joint-disease it is impossible to avoid being impressed with the relation between the demands on the system made by the original disease, and the establishment of fresh strumous phenomena in other, generally internal organs. As in an acute suppurative synovitis, purulent infection is to be dreaded,* so in rheumatic joint-disease we must expect a condition tending to atheromatous cachexia, and in strumous maladies, tuberculosis. The signs of an atheromatous condition are most obscure and difficult. I do not pretend either to be sure of them, or to describe them; but believe it possible to recognise a peculiar expression of face, a tinge of the conjunctivæ, a condition of bronchial membrane, an irritable form of fever, with rather hard sharp pulse, and dry furfuraceous skin, which would indicate approaching danger.

In a strumous form of malady, it is a condition of chronic hectic (the only term applicable that I can find) which is to be dreaded. A mere passive state of superabundant granulation, such as is described at p. 110, very rarely, if ever, induces such a condition; but a considerable amount of suppuration, or the peculiar nightly pains of joint-disease, is accompanied by an irritability which is always combined with defective nutrition, and by danger, therefore, of further strumous manifestation. The peculiar starting pains, upon which so much stress has been laid, very often affect the health in a strongly marked mode, and bring down the constitution in a manner more rapid than I have observed in any affection not produced by a morbid poison. Indeed, were it compatible with the plan of a work professing merely to be a matter-of-fact investigation into a surgical malady, a good deal of true, but rather vague writing might be expended on the "physiognomy of joint-disease." Every surgeon, however, dealing with far advanced and painful articular affections, recognises, consciously or unconsciously, certain changes of countenance, which warn him that the constitution is yielding to disease. If to such signs be added the daily increase in the irritative fever, and the exacerbation of the local malady, * Accompanied by deposits of pus in internal organs.

there will be sufficient grounds for drawing a legitimate conclusion. So much has been said, in previous chapters, of the different local conditions produced by articular disease, that little beyond a short summing up is necessary. Rheumatic synovitis, less commonly than the strumous, induces a state which requires removal for the sake of saving life. The nonsuppurative and non-degenerative quality of joint-disease, arising from or prolonged by that diathesis, has been discussed. The patient, who is affected by such malady, does not suffer from the wasting effects of large abscesses and drains upon the system; but, on the other hand, such maladies do not often tend to cure by obliteration of the cavity when the cartilages have nearly, or entirely, disappeared,+ but they produce very considerable pain and sleeplessness, thereby setting up an amount of irritative fever. This latter condition must be taken in connection with the difficulty of cure, and be weighed against the absence of physical drain caused by the malady, and the fact that throughout the disease exacerbations and ameliorations are to be expected.

The disease called chronic rheumatic arthritis, and which I have ventured to describe as a rheumatic osteitis, is of a character not sufficiently local to need consideration here.

Strumous inflammation, to which by far the larger number of joint-diseases requiring removal are due, attacks, as we have seen, primarily either the bone or the synovial membrane; by the time that the affection is so advanced that its removal comes at all into consideration the place of origin is unimportant as influencing that question alone. The local conditions, which promise still further impairment rather than improvement, are-plentiful degenerations among the new tissues; widespread abscess among surrounding parts; a certain suppurative tendency which must be described in the sequel. Many joints have been amputated, or excised, on account of sluggish strumous swelling, without abscess, or other wasting condition—such state as a local malady only, the general health being unaffected, does not, as we have seen, necessitate such interference. As long as the subsynovial tissues are granulating, the only fault

* A remarkable case of rheumatic synovitis was detailed, p. 177, showing that such a malady might advance to a point permitting dislocation without

production of abscess or other impoverishing process.

The nature of our present subject postulates far-advanced cases.

being want of development beyond the crude cell-formation, it is competent for treatment to produce an action that shall cause some further organization, and thereby improvement. When much of the tissue is degenerating and suppurating, and abscesses form at distances from the seat of injury (the deeper and the closer to the bone the worse is their prognostication), more particularly if fragments of bone come away with the pus, the state is such as may hardly get well without a severe trial to the constitution; but if the health continue firm, even these local evils should not make us despair, for it may happen that some sudden change in the circumstances-a dislocation, partial or total-causes a great amelioration in all the conditions, and the patient gets well with but little further difficulty. There is another condition, which appears to consist in osteal and periosteal irritation, produced by the presence of the diseased tissues. Such cases which begin in the synovial tissues are decidedly strumous, belonging to the form of that diathesis with fine connective tissues, and run their course more rapidly than the ordinary pulpy disease of synovial membrane. The new tissues are not long persistent: in from six to twelve weeks pus forms in and around the joint, and makes exit by tolerably straight simple passages; the cartilage disappears rather quickly, leaving generally the articular lamella attached; if a probe be passed into the sinus it finds bare bone all round; the cancelli inflame; their lining membrane does not granulate freely, but abscesses form among certain of the cavities and open into the joint by sharp-edged singular-looking holes in the otherwise even bonesurface. The periosteum becomes inflamed and swollen, generally suddenly; the patient complains of pain, and the surgeon finds a deep hard swelling beneath the muscles, equally diffused all round the bone. This tumefaction may subside and recur three or four times, but each time it does so it leaves more and more persistent enlargement behind it. At last, if operative interference be still postponed, abscesses form, both in and around the periosteum; caries (generally caries necrotica) commences in the end of the bone, and spreads even a long way from the original seat of disease. Such local disorder is

* The remarkable change for the better in general health, the sudden tendency of the abscesses to heal, and the remission of pain upon the occur

rence of dislocation, have been already noticed as showing the influence of interarticular pressure.

always accompanied by a corresponding fever and depression in health, so that in such cases the joint can hardly be saved.

There is in all diseases so close a relationship between local manifestation and constitutional condition that it is barely possible, and certainly not judicious, to consider the former without reference to the latter. In a few cases of even very far advanced joint-disease the constitution will remain so little affected that the surgeon may rightly postpone operative interference, hoping that yet a change for the better will, as sometimes occurs, set in. On the other hand, when the general health is plainly suffering, when a strumous patient manifests even the first signs of hectic, there should be no hesitation, because this state is one which especially favours, or causes tuberculization of internal organs.

B.-On Amputation and Excision performed for the Removal of Diseased Joints, and the Causes of Preference for one or the other. It is not very many years since that, whenever it was deemed necessary to remove a diseased joint, the limb was amputated; but, about a century ago, a change in this respect began, and the possibility of removing the diseased portion, without sacrificing the entire limb, came into consideration. The first notice of any case of removing a portion, or the whole, of a diseased joint that I can anywhere find is reported by John Daniel Schlichting, M.D., in 1742; the surgeon who performed the operation, and whose name the Doctor does not think it worth while to give, extracted the head of the thigh-bone in a case of hip-joint disease.† It is probable, however, that the head was separated at the epiphysis, as no mention of the use of a saw is made. No deduction is drawn as to the repetition of this operation on the same or other joints.

In 1768, Mr. White, of Manchester, removed the head of the humerus for caries;‡ subsequently four inches of the end of the

p. 274. Here follows a rough diagram of the head and neck of a thigh bone which gives no further information about the case.

*The shoulder and hip must be ex- raro deligat, atque sex septimanarum cepted. curriculo consolidat, ut puellam postThe case is thus reported under modum libere liceat manca inseperit." the title "Coxæ articuli suppuratio cum-Philosophical Transactions, vol. xlii. secessione coxæ femoris solidata.- Anno 1730.-Puella rustica, ætat. 14 annorum, coxæ articulus tumescit, dolet, suppuratur, perumpitur. Chirurgus dilatat foramen naturâ factum, extrahit totum ossis femoris caput. Subjecit posthac in ulceris cavitatum Myrrhæ tincturam porro fuscum Ung. fel W. stringat eam, denique arcto vinculo

Phil. Trans., 1769, vol. lix. p. 39, and 'Cases in Surgery, p. 57. I put this case before another, because it was first published.

humerus exfoliated, yet there was only an inch of shortening, which Mr. White attributed to the weight of the limb dragging it down, as "it was only suspended by a common sling, and the patient not at all confined to his bed."

In January, 1774, Mr. Bent, of Newcastle, published* the case of a woman from whom, in 1771, he had removed the head of the humerus for caries. The patient walked away from the surgeon's house to her lodgings, and appears to have worn no apparatus except a sling.

In October, 1778, Mr. Orred, of Chester, read before the Royal Society † a case in which he had removed the carious head of a humerus with success.

6

These are the first recorded cases of resection of the joint extremities of bones, or decapitatio ossium, that I can anywhere find. M. Velpeau, indeed, in his Médecine Opératoire,' vol. ii., p. 703, remarks, that in 1740 Thomas of Pezenas had successfully extracted the head of the humerus. Guthrie ‡ relates this case. The surgeon had enlarged the opening into an abscess; two or three days afterwards the necrosed end of the bone presented at the wound. About that time several French surgeons § make mention of extracting the splinters of the caput humeri, shattered by musket balls; but such operation is merely removal of splinters through a wound already existing, and does not therefore come into our subject. We may claim for England the first idea of the operation for removing the heads of bone; but the reader will observe, that the cases above given are not excisions of joints, for only one of the bones entering into the articulation was sawn through, and only one of the joint-surfaces removed: the cases belong to the category of partial resections, or, more definitely, to decapitations of bone (Decapitatio ossium).

We may also claim for England the first total resection of a joint, or removal of all the bones entering into its composition. The first published case belongs to Mr. Park, of Liverpool, and the operation was on the knee-joint. It was performed on the 2nd July, 1781, and was, as all the world knows, perfectly successful, the man afterwards following his occupation as a sailor. It appears that Mr. Filkin, of Northwick, had actually

* Phil. Trans., vol. lxiv., p. 353. + Phil. Trans., vol. lxiv., p. 6. On Gun-shot Wounds, p. 473.

§ Boucher, Observations sur les plaies d'Armes-à-feu.' Mémoires de l'Académie de Chirurgie, t. ii. MDCCLXIX. p. 287.