When inflammation is more severe than to ter minate in synovial or serous effusion, it ends in the secretion of coagulable lymph, that produces more or less perfect anchylosis; which is the union of the cartilaginous surfaces entering into the forma tion of a joint, or the osseous texture itself, render ing the articulation stiff and immoveable. In such cases, the treatment requires to be still more ac tive; four or five dozen of leeches should be ap plied, followed by anodyne fomentations, alternate blisters and moxas, perfect rest, with the limb placed in INFIntyre's fracture-splint, gentle laxa tives and low diet; and the puncturing of the joint to give exit to any effused lymph if necessary. The leeches may require to be repeated. A patient should be kept confined to bed until every vestige of inflammation has either been subdued, or the joint quite locked by anchylosis, when a splint of some apparatus ought to be worn to prevent the joint shaking; and even then the slightest motion of it ought to he carefully avoided.
When the inflammation is so severe as to termi nate in suppuration, with thickening of the carti lages and ligaments; an effusion of viscid lymph into the cellular substance around the joint, ren dering it thick and soft; a peculiar alteration of the adipose and tendinous substances constituting the chief part of the swelling; and the skin assuming a pale tense glistening colour with large veins;—the disease has been termed white swelling. The puru lent matter is commonly of a shining coagulated nature. This disease, which occurs chiefly in early life, is almost exclusively confined to the scrofulous diathesis, which in so moist a climate pervades al most every constitution. The inflammation is some times slight, and recurs for several successive pe riods before advancing to suppuration, and occa sionally appears alternately acute and chronic. matter either remains within the articulation, or ulceration of the capsular ligament ensues, when it burrows in various directions, occasionally advanc ing to the skin in long fistulous tubes. Ulceration of the cartilages and caries of the bones, accompa nied with hectic fever, takes place, and carries off the patient. The treatment is the same as that re commended in the last, only it ought to be more rigidly enforced. A peculiar treatment has been lately recommended by Mr. Scott of Bromley, which can only be applied to the early and mild stages of this disease; and a similar treatment is ex tolled by Richerand. When ulceration of the car tilages and bones have taken place, amputation is too often the only remedy. The rheumatic species of white swelling appears to be nothing more than the inflamed rheumatic joint terminating in suppu ration. White swelling attacks the elbow, wrist,
and ankle joints, as well as the knee, but the last most frequently.
In wounds of the joints, particularly so large a one as the knee, violent inflammatory action should be apprehended and treated accordingly. No pro bing whatever should be employed, synovia being easily distinguished from pus. The stomach is pe culiarly affected by wounds of this joint, and a blow on the knee produces fainting and vomiting, and also affects the brain.
The articular surfaces forming the joints, espe cially those of the elbow and the knee, have been ex cised in an ulcerated state; the operation of the lat ter consists in making a crucial incision of the integuments on the patellar aspect, so that the trans verse one may extend between the os femoris and the tibia; and dissecting aside each angle of the flap extensively from the patella and capsular ligament. The patella is then removed, the lateral and crucial ligaments divided, by which the condyles of the os femoris can be made to project on bending the leg on the thigh, and then can be carefully and slightly cleaned and sawn off from above downwards, a piece of firm leather being interposed between the bone and the popliteal ves sels. The head of the tibia is next to be divested of its soft coverings, and projected so as to be sawn off from within outwards. One or more of the ar ticular arteries may require to be secured, the flaps approximated, and then the cut ends of the tibia and os femoris are to be retained in apposition by an ingenious apparatus. There are many cogent objections to excision of the joints, few recovering the least use of them.
The disease which attacks the hip-joint, and which is termed the hip-joint disease, morbus cox anus, scrofulous-hip, or scrofulous caries of hip, is evidently a species of white-swelling, consisting first of inflammation, and suppuration of the synovial membrane and ligaments, and afterwards of ulcera tion of these and the cartilages and bones. This joint has been affected with fungus htrinatodes, de ceiving the surgeon for rnorbus coxarius. When anchylosis has supervened after this affection, ajoint may be formed at the cervix of the thigh bone, which consists in making the crucial incision over the trochanter major, and sawing the cervix close to this process of the thigh bone, and preventing union by ossific matter during the cure. In old age, the interstitial absorption of the cervix of the os femoris takes place, which alters the angle formed by it and the shaft, and so shortens the limb that it may be mistaken either for luxation or fracture. An affection, precisely resembling morbus coxarius, sometimes affects the sacroiliac synchondrosis.