2. Pulpy Thickening of the Synorial Membrane.—This disease generally occurs in young persons between the ages of sixteen and twenty-five, and is mostly confined to the knee-joint. There is not much pain in the joint, but swelling and rigidity come ou slowly. The joint on being touched appears to have fluid in it. This disease goes on sometimes for years, till at last it destroys the joint ; and unless the limb is amputated, hectic symptoms ensue and destroy the patient. This disease consists in a total disorganisation of the synovial .membrane, which is converted into a brownish or lightish brown pulpy substance, varying from a quarter of an inch to half an inch in thick ness. In its advanced stages the cartilages, bones, and ligaments of the joint become implicated in the disease.
The well-marked cases of this disease must be looked upon as incur able, and only amputation will give a chance of relief. In mild or doubtful cases the only plan that seems to offer success is perfect f ui e t udo of the joint, which may be secured by pasteboard or other splints, or by soap-plaster. The general health should be attended to, and local applications made according to the symptoms. Inflammation should be subdued by leeches, and gentle counter-irritants may be kept constantly applied.
3. Ulceration of the Cartilages.—This disease occurs chiefly in children or adults under the middle age. It is frequently a conse quence of the preceding diseases, but often occurs alone, although in its progress it may involve the whole joint. The joint in which it is most frequently seen is the hip, producing the greater amount of the diseases known by the name of hip-joint disease. When it occurs in the knee, it differs from inflammation of the synovial membrane by the pain at the commencement of the disease being slight, and its going on increasing in intensity. The pain is also present sometimes four or five weeks before any swelling is perceived. The swelling, when it does arises from inflammation of the cellular tissue out side the joint, and often appears much larger than it really is, from the previous wasting of the leg from want of use. In many cases an effusion takes place into the synovial membrane and increases the swelling. In the progress of the disease abscesses form, having fistulous connections with the synovial membrane and the surrounding inflamed tissue. As the cartilaginous tissue is renewed with difficulty, the most favourable termination of this disease is generally attended with anchylosis of the joint.
In the treatment of this disease rest is essential; whatever moves the limb, affects the diseased cartilage. The limb may be placed in splints, or bandaged up with soap-plaster, or perfect quietude of the joint may be secured by M'Intyre's fracture-splint, which has the advantage of being easily removed for the purpose of making applica tions to the part affected. Where the joint is hot, cold lotions and leeches may be applied ; but where it is cool, counter-irritants, blisters, issues, mesas, antimonial ointment, or croton oil. On the continent the actual cautery is recommended. For the swelling and rigidity which so constantly remain, relief may be sought in the cold douche, shampooing, or friction with the hand.
4. Scrofulous Disease of the Joints, beginning in the Bones.—At one time all white swellings were supposed to involve the bones, and this on account of the apparent enlargement of the bones of the affected joint. That this is not the case the existence of the above forms of disease proves, but even the fact on which the supposition was founded is not correct. So far from the bones being always enlarged in these cases, there are only a very few ou record in which dissection has shown the bones to be enlarged. The bone has been supposed to be swelled from the hardness of the part and its size : but the former arises from the natural texture of the parts, and the latter is made to appear greater by contrast with the wasting diseased limb. But the bones are subject to disease which begins in their cancellous texture. The phosphate of lime is removed from them or deposited in less quantity, and a yellow caseous substance is secreted in its place. The heads of the bones are altogether weakened and softened, and deposits of bony matter of an irregular form are found on their outside. Whilst this change is going on the patient experiences pain; the knee, which is the joint it most commonly attacks, swells ; the motions of the joint are affected, and it becomes more or less contracted, so as to prevent it being straightened. In the course of time matter is formed in the cavity, and makes its way out by ulceration through the eynovial membrane, or abscesses form on the outside of the joint. Sometimes sinuses occur, and run to a considerable extent from the joint under the fascia, or between it and the skin.
This condition of a limb is generally connected with a scrofulous constitution, and the more decided the scrofulous disposition, the more difficult will the disease be to treat. However, whatever may be the state of the constitution, this-must be attended to primarily in the treatment of these cases. [Scaosura.] The local treatment must be the same as for other cases of white swelling. QUietude of the joint should be secured ou some of the plans previously proposed ; and as there is a constant tendency to anchylosis, care should be taken if possible that the anchylosis occurs in a position most convenient for using the limb. Counter-irritants will be found of great utility in these cases, such as blisters, antimonial ointment, and croton oil. Care, however, must be taken that they are not employed whilst there is a tendency to inflam matory action ; and, on the other hand, the means that are employed, such as leeches, cold lotions, &c., for an increased activity of the part, should be immediately abandoned when that activity ceases. When the morbid process has been arrested, shampooing, friction, and pouring water on the part from a height, should be had recourse to for the purpose of strengthening it. The abscesses which form in these cases should be opened early ; if left to themselves, they often leave ulcerations which are difficult to heal.
(Cooper, First Lines of Surgery ; Surgical Dictionary ; Brodie, Patho logical and Surgical Observations on Diseases of the Joints.)