formation of ossific growths between and upon the articular surfaces, and by alteration in the shape of the articular surfaces themselves, more or less immobility. Slight increase of synovial secretion is followed in the later stages of the affection by exostotic growths, which, encroaching on the articulation, seriously impair its motion. As Dr. Robert Adams, of Dublin, has shewn in his valuable work,* true bony anchylosis is an exceedingly rare result of this disease; but articular rigidity, or false anchylosis, is not an unusual consequence.

Scrofulous synovitis is the result of a morbid condition of the system, occasioned by insufficient nourishment and exposure to cold, or by want of pure air and sunlight; or it is hereditary, or it results as a sequel of measles, smallpox, scarlet fever, or other exhausting malady. Such a condition of the system generally being developed, scrofulous synovitis may be set up by a kick or a sprain or a fall, or, apparently, without a local cause.

It is true, that, in children, scrofulous disease of the joints usually commences in the articular extremity of the bone, and thence invades the soft structures of the joint. Within the last year, however, I have seen

A Treatise on Rheumatic Gout,' 1857.

at least half-a-dozen cases, where, in scrofulous children, inflammation commenced in the synovial membrane. One of these is remarkable for the very early age at which the child was attacked, namely, when it was twenty-three months old. I am at present watching this case, together with Mr. De Berdt Hovell. In this instance, false anchylosis of the hip joint, without the formation of abscess, took place.

Morbid

Scrofulous disease of the joints is a very common form of disease, and among children it is that affection which is usually met with. action commences, as has been said, in the cancellous structure of the articular extremity of the bone, and anchylosis may take place without the formation of abscess. Such a course, however, in this form of disease is rare. When the disease terminates without suppuration being established, motion may not unfrequently be restored; and even this has been known to take place when a portion of cartilage has been removed. Not uncommonly, the course of this affection is as follows:Slight pain and swelling at first are experienced, which may or may not subside, leaving, however, more or less tenderness and weakness of the affected joint. At every attempt to use the limb, puffiness about the joint will be observed, and this, as well as the pain, will be sensibly increased by any unusual exertion.

Abscess will form and discharge itself; the ligaments will become softened and extended, and the limb will be flexed.

In this form of inflammation the synovial membrane becomes much altered in structure, being thickened and softened, with deposits of curdy lymph upon it. Displacement of the articular surfaces of the bones takes place, as has been already explained.

Syphilitic synovitis partakes of the characters of both of the former forms of inflammation-rheumatic and scrofulous-according to the period of development of the constitutioual disease itself. When it occurs in secondary syphilis, it assumes somewhat of a rheumatic character, the fibrous structures being at this period of the constitutional malady specially affected; while in tertiary syphilis inflammation assumes somewhat of a scrofulous character, the tendency of syphilis itself at this time being to resemble scrofula. This subject will be again alluded to.

SECTION III.

EXTRA-CAPSULAR PARTIAL ANCHYLOSIS.

Gonorrheal Rheumatism-Syphilitic Synovitis-Strumous Abscess-Phlegmonous Erysipelas-Mechanical Injury.

Extra-articular anchylosis is the result of inflammation and the formation of adhesions external to the joint. It may be induced by gonorrhoeal rheumatism, syphilitic synovitis, strumous abscesses, phlegmonous erysipelas, and mechanical injuries.

The fibrinous inflammatory exudation is deposited in the cellular tissue external to the joint, and becoming consolidated, it causes immobility of the parts around. And when it is poured out between muscles and tendons, it renders them immovable, and the articulation which they govern motionless.

Gonorrheal Rheumatism. - Before I proceed to show what are the results of this form of inflammation, it will be well, perhaps, in some few words, to explain what is understood by the term. Sir Benjamin Brodie says "I shall have occasion to notice hereafter some very remarkable cases of inflammation of the synovial membrane, preceded by purulent inflammation of the urethra and purulent oph

thalmia, to which the name of gonorrhoeal rheumatism is commonly applied; though it must be plain to any one who has watched their progress, that the relationship of the disease to rheumatism extends no further than a partial resemblance in the symptoms. There seems to be no doubt," adds Sir Benjamin, "that, while it occurs in most instances as a consequence of gonorrhoea, it may take place quite independently of gonorrhoeal infection."*

The disease, then, is rheumatic synovitis of a peculiar character, which is preceded or accompanied by urethral inflammation or irritation. Such an affection will, doubtless, be recognised by every practical surgeon.

It is to be regretted that the term "gonorrhoeal rheumatism" was ever used. This nomenclature was adopted in error; on the supposition, namely, that this affection of the joints was necessarily consequent on gonorrhoea virulenta.

It is true that this affection of the joints is usually preceded by gonorrhoea, but it is not absolutely necessary that the disease should be preceded or accompanied by urethral discharge. Sir Benjamin Brodie has shown that the use of the bougie may induce

cr

gonorrhoeal rheumatism." I will narrate a case,

'Pathological and Surgical Observations on the Diseases of the Joints,' pp. 28 and 43. Ed. 5, 1850.

2