others more; and in those parts where the membrane was reflected over the bones, near the border of the cartilages, it was destroyed in spots by ulceration.

The semilunar cartilages were in a natural state, but in a great measure concealed, in consequence of their being enveloped in the mass of substance formed by the diseased synovial membrane. The cartilaginous surfaces of the femur and patella were extensively, but not entirely, destroyed by ulceration; the ulceration being greatest towards the circumference. On the internal portion of the head of the tibia, the cartilage was destroyed only for a very small extent, the ulceration being entirely confined to the margin. On the external portion of the head of the tibia, the cartilage was absorbed to a greater extent. The bones possessed their natural structure and hardThe cavity of the joint contained matter, and sinuses which opened externally communicated with it.

ness.

In another instance, besides ulceration of the cartilage, and morbid alteration of the structure of the synovial membrane, abscesses existed in the substance of the latter, and carious surfaces of bone were exposed.

These cases illustrate in a sufficient manner the pathological characters of the complaint. Mr. Brodie remarks that in every case the progress of which he has been enabled to watch, the disease has advanced slowly, and sometimes has remained in an indolent state during a long period of time, but ultimately it has always terminated in the destruction of the joint. He has never known an instance of affection of the hip or shoulder. It is usually met with in the knee. Mr. Hodgson met with an example in the ankle, and another in one of the joints of a finger. Mr. Brodie relates a case in which, on examination, the synovial membrane was lined on its interior with a straw-coloured gelatinous substance, very intimately attached to it. The membrane bore no marks of inflammation. The cartilage was partially ulcerated and the bone exposed. Mr. Brodie thinks that the effusion was not the result of inflammation, but of some other morbid action, and conjectures that it might be an early stage of the alteration of the synovial membrane. The symptoms of the disease are thus described by Mr. Brodie. It generally takes place in persons who are not much above the age of puberty. For the most part it can be traced to no evident cause, but occasionally it is the consequence of repeated attacks of inflammation.

"In the origin of this disease, there is a slight degree of stiffness and tumefaction, without pain, and producing only the most trifling inconvenience. These symptoms gradually increase. In the greater number of cases, the joint at last scarcely admits of the smallest motion, but in a few cases, it always retains a certain degree of mobility. The form of the swelling bears some resemblance to that in cases of inflammation of the synovial membrane, but it is less regular. The swelling is soft and elastic, and gives to the hand a sensation as if it contained fluid. If only one hand be employed in making the examination, the deception may be complete, and the most experienced surgeon may be led to suppose that there is fluid in the joint, when there is none: but if both hands be employed, one on each side, the absence of fluid is distinguished by the want of fluctuation." 85.

The patient suffers little till abscesses begin to form and the cartilage to ulcerate; even then the pain is often less severe than when the ulceration is a primary disease, and the abscesses usually heal more rapidly and dis

charge less. At this period the patient becomes affected with hectic, and sinks unless the limb be removed by amputation. The progress of this disease varies in different cases. In general, one or two years elapse before it reaches its most advanced stage; but sometimes the period is much longer; and occasionally it becomes indolent, so that it remains during many months without any sensible alteration.

The diagnosis is seldom difficult. The gradual progress of the enlargement and stiffness of the joint, without pain, and the soft elastic swelling without fluctuation, are sufficiently distinctive in the majority of cases. But the disease may be confounded, under two sets of circumstances, with chronic inflammation of the synovial membrane.

"1st, When the synovial membrane has undergone a morbid change of structure, it occasionally happens that a preternatural secretion of fluid takes place at the same time from its inner surface; and the joint becomes distended, not with synovia, but with a turbid serum, having flakes of coagulated lymph floating in it, which causes the tumour to present nearly the same external characters as where the synovial membrane is inflamed. But here the swelling will not yield to that treatment, under which it would be speedily reduced if it depended on simple inflammation; and attention to this circumstance, joined with an accurate previous history, will enable us to recognize the real nature of the disease. 2dly, When the synovial membrane, after inflammation has subsided, has been left in a thickened state, and coagulated lymph has been effused into the articular cavity, the tumour in some instances, a good deal resembles the tumour which occurs in cases of this disease; so much so, that it will be very difficult to give a correct opinion, merely from observing the present appearance and condition of the joint. The surgeon must in great measure form his judgment from the account which he receives of the origin and early symptoms of the complaint; or (when an accurate statement cannot be procured) by waiting to observe its future progress." 87.

As an illustration of the symptoms, and an exposition of the diagnostic signs laid down, we will introduce the history of a case, of which we have already given the dissection.*

Case. A young man, æt 24, was admitted into St. George's Hospital, with one knee swollen to nearly twice its natural size. The swelling was prominent on the anterior and lower part of the thigh. It was soft and elastic, so that at first it appeared to contain fluid; but, on particular examination, the absence of fluid was ascertained by the want of fluctuation. The leg was kept in the half-bent state, and the joint admitted of only a very limited degree of motion. He had no pain, even when attempts were made to move the limb. The skin over the diseased part was of a pale colour, with some dilated veins ramifying in it. On each side of the joint a small orifice was observed, through which the probe might be introduced into a sinus; but the sinuses appeared to be of small extent. His general health was unimpaired. He said that, two years ago, he first experienced some pain in the knee, but it was not sufficient to prevent his going about bis usual occpuations. Soon afterwards the joint began to swell, and the

*Case 3 of those intended to display the pathological condition,

enlargement gradually increased from that period. Several abscesses had formed at different times; but the greater number of them had healed.

A few observations on the treatment conclude Mr. Brodie's account of this disease. Those few observations may be readily compressed into two brief sentences-palliation of symptoms-amputation as soon as the case demands it, and the patient will consent to it.

We now proceed to an important subject-ulceration of the articular cartilage. As very many of the diseases of the joints consist in, or tend to, this condition, it is highly incumbent on the surgeon to be familiar with its symptoms, its progress, and its treatment. Specimens of gross and injurious ignorance of the nature and the characters of this disease are too frequent in public and in private practice. We shall, therefore, pursue, in a strict analytical order, the descriptions and remarks of Mr. Brodie.

IV. ULCERATION OF THE ARTICULAR CARTILAGES.

Mr. Brodie commences, by alluding to the doctrine which has sometimes been advanced-that the cartilages not being endowed with vascularity, ulceration when it occurs, must necessarily have been effected by the vessels of other tissues. As this opinion has lately been supported by Mr. Key, in a paper published amongst the Transactions of the Medico Chirurgical Society, perhaps it would be well to advert to it succinctly.*

Mr. Brodie is induced to oppose this doctrine on the following accounts. 1, The phenomena of growth seem to indicate vascularity of the cartilage. -2, Analogy would lead us to entertain a similar opinion respecting the condition of the cartilage in the adult. Thus, the transparent cornea is sometimes injected with red blood, and Mr. Brodie has seen bloodvessels extend from a diseased bone into the cartilage covering it. 3, The cartilage exhibits a power of reparation, for, although exposed to constant friction, it is not observed to be worn away, like the enamel of the teeth. 4, The cartilage undergoes an alteration of structure, being sometimes converted into a number of ligamentous fibres, each of which is connected by one extremity to the bone, while the other is loose towards the cavity of the joint. 5, In some cases, the free surface of the cartilage is removed by absorption, while that immediately attached to the bone remains unaltered. But, in other cases, the ulceration begins on the side in contact with the bone, while the free one continues smooth and perfect. Under these circumstances, the space formed by the absorption of the cartilage becomes filled up by a vascular substance resembling granulations, and uniting the bone and cartilage to each other.

In whatever way ulceration of the cartilage takes place, suppuration seldom occurs so long as it is not extensive; sometimes, indeed, it is absent when the disease has proceeded so far as to cause considerable caries of the bones. But this by the way.

But Mr. Key supposes that the ulceration of the free surface of the cartilage happens only through the medium of the vessels of the synovial

That paper was fully noticed in the last Number of this Journal. It will presently appear that Mr. Brodie has coincided with the Reviewer, and that the arguments which he employs are of the same description.

membrane. When the ulceration is at the margin of the cartilage his theory is easily accommodated to the fact. But when it is seated in the centre, he is under the necessity, as our readers are aware, of resorting to the agency of processes of inflamed synovial membrane, which, lying in contact with the surface of cartilage, effect its absorption. Mr. Brodie pointedly observes that, if this be correct, it establishes a new fact in pathology; there being, to his knowledge, no analogous instance. Mr. Brodie relates four cases, which militate against the views of Mr. Key. Of these the first is perhaps as striking as any, and will serve as a specimen of all.

"At page 93 of this volume," says Mr. Brodie, "I have mentioned the case of a boy in whom this partial absorption of the cartilages of the knee had taken place. In some parts the cartilage had altogether disappeared; in other parts, it had been absorbed on the surface towards the cavity of the joint, while the layer next the bone remained entire; thus presenting the appearance of grooves, as if a portion of its substance had been removed by a chisel. Now, according to Mr. Key's hypothesis, the absorption of the cartilage, in this case, ought to have been produced by villous processes of the synovial membrane projecting into the cavity of the joint, and lying in contact with the articulating surfaces. But no such villous processes existed, nor is any thing said in my manuscript notes of the synovial membrane having been even inflamed. Indeed, if it were inflamed at all, it must have been so only to a very small extent, as it is expressly stated, that there was no effusion either of pus or synovia, into the cavity of the joint. It is to be presumed that, if the absorption of the cartilage had been effected through the agency of the synovial membrane, it would have begun, and would have made the greatest progress, at the part most exposed to contact with it, namely, at the margin; and this corresponds with Mr. Key's own observations on the subject. But, in examining the condyles of the femur taken from this patient, which are preserved in spirits in the museum of St. George's Hospital, I find that this is exactly contrary to what has really happened. Throughout nearly the whole of its circumference, for the breadth of one-third of an inch, the cartilage remains of its natural thickness, and otherwise unaltered; in the centre of the bone it has altogether disappeared, and the grooved appearance of it is observable in the intermediate space.' 333.

Mr. Brodie experiences a difficulty in determining the exact mode, in which ulceration of the cartilage ensues after inflammation of the synovial membrane. But he thinks it not improbable that in many cases usually regarded as examples of simple inflammation of the synovial membrane, the inflammatory action may really have begun simultaneously in all the textures of the joint. He cites a case which seems to support this notion. Mr. Brodie also alludes to ulceration of the cartilage as a sequence of scrofulous disease of the bone-as a consequence of a change into a fibrous structure —and as a result of a chronic inflammatory affection of the bone to which it is attached.

Of course, as the cartilage is not an absolutely insulated structure, bloodvessels can only pass to it through the medium of the bone or the synovial membrane. In this sense it may be said that the cartilage cannot ulcerate except through the agency of the vessels of the other tissues. But this is a mere logomachy, or a verbal quarrel, for we might as well contend that the skin could not be ulcerated, unless by the vessels of the cellular tissue, nor the bone be altered, but through the operation of the vessels of the periosteum or medulla.

We arrive at a subject of a more immediately practical description-the causes of ulceration of the articular cartilages.

1, It may be the consequence of disease originating in the neighbouring soft parts, especially of inflammation of the synovial membrane;-2, It may depend on a morbid condition of the cartilage itself;-or, 3, On a chronic inflammation of the surface or substance of the bone with which it is connected. 4, It may be the result of a peculiar alteration in the condition of the cancellous structure of the bones, which is met with in scrofulous persons; and, 5, It may follow the fibrous degeneration.

Ulceration of the cartilage, resulting from alteration of the cancellous structure of the bone, is separately treated of by Mr. Brodie. The succeeding observations principally relate to those cases in which the disease has originated either in the cartilage itself, or in the surface of bone with which it is connected. Mr. Brodie, adopting his usual method, details many cases illustrative of the pathological changes which constitute the disease. 'Those cases display the changes in question in the hip, the knee, and in other joints. We shall merely select sufficient for the purposes of explanation. And first of those cases which exhibit the characters and progress of disease of the hip-joint.

Case 1. A girl, æt. 24, was admitted into the hospital with symptoms of affection of the hip-joint, of two months' duration. In two months after admission she died. The foot was turned outwards, but no other alteration in the position of the limb is mentioned.

The synovial membrane was somewhat more vascular than usual. The cartilage covering the head of the femur had been destroyed by ulceration for more than half its extent; so as to expose the cancellous structure of the bone. The remaining portion of the cartilage covering the head of the femur was thinner than natural: but this was more observable in some parts than in others. Every where the loss of substance appeared to be on the surface towards the cavity of the joint; the layer of cartilage towards the bone being unaltered, except in one spot where it was ulcerated to a very small extent. The cartilage of the acetabulum was entirely destroyed, so that every where a carious surface of bone was exposed. There were no remains of the round ligament. The synovial membrane on one part of the neck of the femur was destroyed by ulceration; and here also a carious surface of bone was exposed. The bones themselves had their natural structure and hardness, not differing from healthy bones, except on the carious or ulcerated surfaces.

In another patient who had laboured under the symptoms for four months, the cartilages covering the head of the femur, and lining the bottom of the acetabulum, were destroyed by ulceration for about one-half of their extent, exposing an ulcerated surface of bone. The round ligament was readily torn in consequence of ulceration having extended to it at the part where it was inserted into the acetabulum. The bones possessed their natural texture aud hardness. There was no pus in the joint.

Case 3. This patient died ten months after the commencement of the symptoms. When admitted, six months after the commencement, the limb