cartilage covering that portion of the articulating extremity of the femur which corresponds to the patella, presented in one spot an irregular surface, as if it had been partially absorbed, but not to a sufficient extent to expose the surface of the bone below. Mr. Brodie supposes that these were the effects of the greater disease of the synovial membrane.

"In another case, in which the patient, having recovered of inflammation of the synovial membrane, died several months afterwards of another disease, I found, on dissection, that the greater part of the cartilage of the patella, and a small portion of that covering the condyles of the femur, had disappeared, and that its place was occupied by a thin yellow membranous substance adhering to the bone, and forming a distinct cicatrix. I have known many cases in which there was extensive destruction of the cartilages of a joint by ulceration, manifestly arising from neglected inflammation of the synovial membrane. That this should happen, is no more remarkable than that ulcer of the cornea should occasionally be induced by inflammation of the tunica conjunctiva of the eye. At the same time, I believe it will be found, in the majority of cases of caries of the joints, that the disease has begun in the harder textures, and that the inflammation of the synovial membrane by which it is accompanied, is a secondary affection, the consequence of the formation of an abscess in the articular cavity." 13.

Inflammation of the synovial membrane occasionally terminates in suppuration, without having induced ulceration of either the soft or the hard textures of the joints. Mr. Brodie has found this after injury. It is not uncommon after accidents or operations, and constitutes one form of the purulent deposites. We have seen it after fever, and in a case of aneurism of the arch of the aorta. In one instance of articular deposite, Mr. Arnott found the cavity of the knee-joint filled with a tolerably thick pus, of an uniformly reddish colour, as if from an admixture of blood. Mr. Brodie relates a case of what appears to have been rheumatic inflammation of the joints and of the pericardium, in which a similar discoloration was remarked. The synovial membrane of the right knee was full of a dark-coloured fluid; not purulent, but having the appearance of a thick synovia, tinged with blood. The synovial membrane was every where of a red colour, as if stained by this secretion, and the cartilages of the joint had the appearance of having been stained in the same manner. There were some small extravasations of blood in the cellular membrane external to the joint. Those who are acquainted with the morbid anatomy of the heart and lungs are aware, that effusions of bloody serum in the pleura and the pericardium are by no means rare. We have frequently witnessed examples of both. M. Laennec has devoted a chapter to the "hæmorrhagic pleurisy." Probably the bloody colour of the pus, in Mr. Arnott's case-of the synovia in Mr. Brodie'sand of the serum in those to which we have adverted, are analogous in principle.

We arrive at the causes and symptoms of inflammation of the synovial membrane. This may occur as a primary affection, or be consequent to inflammation of some of the other textures of the joint. At present, Mr. Brodie treats of it as a primary affection. It very seldom attacks young children -becomes less rare about the age of puberty-and is very frequent in adults. This is an important distinctive circumstance. It may constitute a symptom or effect of rheumatism, or gout-of syphilis-of abuse of mercury. But, in these cases, the disease, for the most part, is not very severe; it occasions a

preternatural secretion of synovia; but does not, in general, terminate in the effusion of coagulated lymph, or in thickening of the inflamed membrane. Sometimes it attacks several joints at the same instant, and even extends to the synovial membranes, which constitute the bursæ mucosa and sheaths of the tendons. At other times it leaves one part to attack another, and different joints are affected in succession. In other cases, the disease is entirely local-the result of an injury, of cold, or of no very evident cause. Cold is, perhaps, the most frequent agent; and on this account, the knee is more commonly attacked than the shoulder or the hip. Where the inflammation is thus confined to a single joint, it is more probable that it will assume a severe character, and that it may be of long duration. It is likely to leave the joint with its functions more or less impaired; and occasionally terminates in total destruction. The complaint is most usually of a chronic kind, impairing, but not altogether destroying, the functions of the joint. If not relieved in the first instance by judicious treatment, it may continue, with occasional recoveries and relapses, for months, or even years.

The symptoms are as follow; and an accurate acquaintance with them is indispensably required.

At first the patient experiences pain in the joint, which, although affecting the whole articulation, is often referred principally to one spot. The pain usually increases for the first week or ten days, when it has attained its acmé. Sometimes even now it is inconsiderable--at others it is distressing.

When the pain has existed for one or two days, the joint may be observed o be swollen. At first this depends on a collection of fluid, which, in the superficial joints, may be felt on examination to undulate. When the inflammation has existed for some time, the fluctuation is less distinct, in consequence of the thickening of the synovial membrane. In proportion as the swelling consists of solid substance, the natural mobility of the joint is impaired.

"The form of the swelling deserves notice. It is not that of the articulating ends of the bones, and, therefore, it differs from the natural form of the joint. The swelling arises chiefly from the distended state of the synovial membrane, and hence its figure depends, in great measure, on the situation of the ligaments and tendons, which resist it in certain directions, and allow it to take place in others. Thus, when the knee is affected, the swelling is principally observable on the anterior and lower part of the thigh, under the extensor muscles, where there is only a yielding cellular structure between these muscles and the bone. It is also considerable in the spaces between the ligament of the patella and the lateral ligaments; the fluid collected in the cavity causing the fatty substance to protrude in this situation, where the resistance of the external parts is less than elsewhere. In the elbow, the swelling is principally observable in the posterior part of the arm, above the olecranon, and under the extensor muscles of the forearm; and in the ancle it shows itself on each side, in the space between the lateral ligaments and the tendons, which are situated on the anterior part. In like manner, in other joints, the figure of the swelling whether it arises from fluid alone, or joined with solid substance, depends in great measure on the ligaments and tendons in the neighbourhood, and on the degree of resistance which they afford and these circumstances, though apparently trifling, deserve our attention, as they enable us more readily to form our diagnosis." 20.

:

Circumstances connected with particular joints deserve to be adverted to. The disease is less frequent in the hip and shoulder than in the superficial

1

joints; the fluctuation of fluid is not perceptible, but the existence of swelling beneath the muscles is sufficiently distinct.

"When the shoulder is affected there is pain accompanied with a general tumefaction of the part; and, in most instances, if the hand be placed upon it, at the same time that the limb is moved, a crackling sensation is observed, which probably arises from an effusion of fluid into the cells of the neighbouring bursæ. After some time the swelling subsides, or the joint may even appear to be smaller than natural, in consequence of the muscles, especially the deltoid, having become wasted from want of exercise.

When inflammation attacks the synovial membrane of the hip, there is an evident fulness of the groin, and, in some instances, of the nates also. There is pain which is referred, not to the knee, as in cases of ulceration of the cartilages, but to the upper and inner part of the thigh, immediately below the origin of the adductor longus muscles. The pain is aggravated when the patient stands erect, and allows the limb to hang, without the foot resting on the ground. It is also increased by motion, but not by pressing the articulating surfaces against each other, so that it does not prevent the weight of the body being borne by the affected limb. The pain is often very severe, yet it does not amount to that excruciating sensation which exhausts the powers and spirits of the patient in whom the cartilages of the hip are ulcerated." 21.

Mr. Brodie cannot doubt, from cases which have fallen under his observation, that inflammation of the synovial membrane of the hip occasionally terminates in dislocation of that joint, the round ligament being separated from one of its attachments by ulceration.

After inflammation of the synovial membrane has subsided, the fluid is absorbed, and, in some instances, the joint regains its natural figure and mobility; but, in other cases, stiffness and swelling remain. Sometimes the swelling retains the form it assumed whilst fluid was contained within the joint; this probably depends on the inner surface of the synovial membrane being lined with a thick layer of coagulable lymph. At other times, the swelling has nearly the natural form of the joint, when, perhaps, the synovial membrane is thickened. In whatever way enlargement may be perpetuated, the patient is very liable to a recurrence of the inflammation from exposure to cold, unusual exercise, or indeed, without any evident reason. When the synovial membrane continues thickened, it occasionally happens, that not only a certain degree of inflammation still continues to linger in the part, but that the morbid action invades the other tissues, and terminates in ulceration of the cartilages and suppuration in the joint. In such a case, the history must form the foundation of our diagnosis, and amputation is generally the only remedy.

Sometimes inflammation of the synovial membrane is more acute than that which has been drawn. The swelling takes place immediately after, or at the same instant with, the first attack of pain; there is redness of the skin: the pain is more severe; and it is so much aggravated by the motion of the parts, that the patient keeps the joint constantly in the same position, and usually in an intermediate state between that of flexion and extension. In addition to these symptoms, there is more or less of symptomatic fever of the inflammatory kind. In a few days the disease, if left to itself, assumes the chronic form; or, perhaps, under proper treatment, it subsides altogethThe boundaries of acute and chronic inflammation are too ill defined

er.

to admit of accurate description. The intermediate varieties of disease must be left to the recognition of the practical and the observant surgeon. Inflammation of the synovial membrane is modified, as might be imagined, by the state of the patient's constitution. Where the disease is strictly local, it is generally more severe.

In syphilitic cases inflammation of the synovial membrane occurs under two conditions-in the early stage of syphilis, and usually in combination with the papular eruption, when there is little pain, inconsiderable effusion, and, after the absorption of the latter, restoration of the joint to nearly its natural condition-in an advanced stage combined with nodes, productive of much more inconvenience to the patient, more difficult to be relieved, leaving the synovial membrane thickened and the joint enlarged.

We have witnessed cases which do not quite tally with the foregoing description. Synovial inflammation has existed in combination with the papular eruption, with psoriasis, and with tubercle-it has been very acute, occasioning much pain, and recurring and disappearing under vigorous treatment. In combination with nodes, or at least with the series of cachectic symptoms that are commonly, but perhaps improperly, styled an advanced stage of syphilis, it has been unattended with acute symptoms, and neither demanded nor supported strong remedial measures.

In cases of rheumatism, continues Mr. Brodie, several joints are simultaneously or successively affected, and the synovial membranes of the bursæ mucosa and tendinous sheaths are frequently involved. There is usually a good deal of pain and swelling, and the joints are often left stiff and enlarged afterwards. Where the inflammation is connected with gout, the pain is generally out of all proportion to the other symptoms of inflammation; and the patient feels as if the joint were in a vice, or forcibly torn open.

"There is a remarkable, yet not uncommon form of the disease, which may be considered as bearing a relation to both gout and rheumatism, but differing from them, nevertheless, in some essential circumstances. The synovial membrane becomes thickened, so as to occasion considerable enlargement of the joints, and stiffness, there being at the same time but little disposition to the effusion of fluid. In the first instance, the disease is often confined to the fingers; afterwards it extends to the knees and wrists; perhaps to nearly all the joints of the body. Throughout its whole course, the patient complains of but little pain; but he suffers, nevertheless, great inconvenience, in consequence of the gradually increasing rigidity of the joints, and the number which are affected in succession. The progress of the disease is usually very slow, and many years may elapse before it reaches what may be regarded as its most advanced stage. Sometimes after having reached a certain point, it remains stationary, or even some degree of amendment may take place: I do not, however, remember any case in which it could be said that an actual cure had been effected. The individuals who suffer in the way which has been described, are, for the most part, those belonging to the higher classes of society, taking but little exercise, and leading luxurious lives: but there are exceptions to this rule, and the disease occasionally occurs in hospital practice; in men, and even in females, of active and temperate habits." 27.

We now arrive at an important section-on the treatment of the disease. In common acute inflammation of the synovial membrane, leeches and the ordinary antiphlogistic treatment are required. Where tension exists warm applications are most grateful, but otherwise cold evaporating lotions appear to produce a better effect.

For the chronic inflammation, quietude, local abstraction of blood, especially by cupping, with cold applications in the intervals of its employment-and blisters when the inflammation has been in a great measure subdued. Mr. Brodie prefers frequent blisters to one kept open. They should be large; if the joint is deeply seated they may be placed as near to it as possible if superficial it is well to apply them at a little distance from it. The surgeon should remember that in this, as in other instances of inflammation of the deeper parts, blisters are improper until blood has been abstracted; that is, they are inapplicable to an early stage of inflammation. Mr. Brodie alludes to another remedy.

"When I have seen the knee joint much distended, I have, in some instances, ventured to evacuate the fluid by puncture; and the following is the result of my experience as to the effects of this operation:

ist. In a thin person, if a few punctures be made with an instrument, a very little broader than a couching needle, by means of an exhausted cupping-glass applied over the punctures, a large quantity of fluid may be easily abstracted without the smallest danger, and with no inconsiderable relief to the patient. But while inflammation exists, the relief is not permanent, the fluid being rapidly regenerated; so that in a day or two, or perhaps in a few hours, the swelling is as large as ever. If, on the other hand, the inflammation be already subdued, the absorption of the fluid usually goes on so rapidly, that any more expeditious method of removing it is unnecessary. 2dly. If suppuration has taken place in the joint (not in consequence of ulceration, but from the surface of the synovial membrane,) a free opening made into it with a lancet will often be attended with the best effect. I have known, under such circumstances, anchylosis to become established almost immediately, and the patient to obtain a speedy cure with an anchylosed joint. The most prudent method of proceeding is to make a puncture with a needle first, and allow a small quantity of fluid to escape, so as to ascertain its nature. If it be not simply turbid serum, but actual pus, the lancet may be used afterwards." 33.

Of course the surgeon would resort to such a measure in the spirit of caution in which it is commended. It will be seen that Mr. Brodie only approves of it in cases in which suppuration has occurred.

When the inflammation is in great measure relieved, stimulating liniments may be rubbed on twice or thrice in the day. Those contained in the Pharmacopoeia do not seem to Mr. Brodie sufficiently powerful. He gives a formula for one which he prefers.

R. Olei Olivæ, 3iss.

Acidi Sulphurici, 3iss.
Olei Terebinthinæ, iss.
Fiat linimentum.

For private patients, the proportion of sulphuric acid in the liniment should be diminished. The effect of this liniment is to excite some degree of inflammation of the skin: the cuticle becomes of a brown colour, and separates in thick broad scales. Mr. Brodie also recommends the ointment of the emetic tartar. We have found the following an improvement on the ordinary form of this ointment.

B. Ung. hyd. fort. 3i.

Ant. tart. 3iss.
Iodinæ, gr. X.

M. ft. ungentum.