No. 1057.

LONDON, SATURDAY, DECEMBER 2, 1843.

LECTURES

ON THE

DISEASES OF THE BONESAND THE JOINTS.

BY

ROBERT LISTON, ESQ., F.R.S.,Surgeon of University College Hospital, and

Professor of Clinical Surgery in Univer-sity College, London.

LECTURE VIII.

Disease of the hip-joint. Shortening fromabsorption of the neck of the fenaur. Ne-crosis and abscess of the femur. Place fOl’incision. Disease of the knee-the jointmore frequently diseased than any other.Rheumatic affections and effusion into the

synol;ial membrane. Malignant diseases ojthe knee-joint. Adventitious warty andcartilaginous bodies ill the joint. Treat-ment. Best position fol’ the limb in anky-losis. Resection of the knee-joint inadmis-sible. Disease of the patella. Necrosedtibia and operation. Abscess of the upperend of the tibia : rapid disorgrtnisatioaa ojthe kreejoint. Spmined ankle and stnu-mous disease of the ankle-joint and tal’Sus.Necrosis of the tarsal bones. TI’eatment.Disease of the great toe: more frequent illNorth than South Britain.

THERE is another disease of the hip,-adisease which has been named by Dublinsurgeons morbus CM’<s senilis, but whichmay occur in young persons (that is to say,l,ersoi3s between the ages of from twenty tothirty years), as well as in old people. Itconsists in the absorption of that portion ofthe neck of the thigh-bone which lies be-tween the head and the attachment of the cap-sular ligament, and causes shortening of thelimb in a small space of time. It generallyfollows injury, particularly bruises over thetrochanter; but sometimes this atrophy, orinterstitial absorption of the neck of thethigh-bone, occurs in a very unaccountablemanner, the patient not being able to refer itto any injury received over the hip. Hereis a specimen of this kind of shortening

which took place in a young man abouttwenty years of age, who received a blowon the hip, and in whom the disease rapidlybrought about the deformity you now see.

Another case of this nature was related tome by Mr. Gulliver. An artillery-man atWoolwich fell and bruised his trochanter ;there were great pain and tenderness aboutthe joint for some time, and the patientwalked lame. As he did not soon get betterhe was discharged. He subsequently en-

tered the East Indian Artillery Service, andserved for some time in India. He was ul-

timately invalided, and returned home withone lower limb about two inches shorterthan the other. He still walked about,however, with tolerable ease, wearing ahigh-heeled shoe. The history of this caseclearly showed that it was one of atrophy ofthe head and neck of the femur.

I do not know that there is much to bedone for these cases. The disease may bechecked, perhaps, in the commencement, byantiphlogistic treatment, but further thanthat these cases appear to be so insidious intheir nature as to evade all our care. Themischief, too, is done in a short space of time;and the shortening, when it occurs, is irre-mediable.

It is important that you should be awareof the existence of this form of disease, inorder that you may be on your guard ingiving your prognosis in injuries of the hip.A patient falls and bruises his hip ; hethinks he has received a fracture or someother severe injury, and a surgeon iscalled in to examine the limb. Under thesecircumstances there may be no shorten.ing or deformity of the limb, and no crepi.tation on rotating the thigh ; in short,there may be no signs of any injuryof the bone, and yet in a few weeks thepatient limps about with one leg a coupleof inches shorter than the other. If thesurgeon who examined the limb gave anunguarded opinion, and made very light ofthe injury, he will most likely fall into dis-

grace, and it will be thought that fractureor organic lesion of some kind must haveexisted at the time of examination, and wasoverlooked. The case will not occur often ;but you should remember that it may happen

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in any instance, and not let it take you by ’,surprise. i i

Necrosis of the femur is not so common a ’idisease as necrosis of the humerus, and for-tunately so, as, owing to the thickness ofmuscular and adipose tissue around thethigh, sequestra are with considerable diffi-culty removed. Necrosis, however, mayoccur either in the processes or shaft of thethigh-bone, and this may be accompaniedwith more or less extensive abscess in the softparts, and perhaps of the bone itself. I haveoccasionally met with cases of abscess of thefemur, and have applied the trephine to thebone in order to make an exit for the col-lected matter, but from the depth at whichthe bone lies it is difficult to make out suchcases earlv.

Necrosis of the back part of the condylesof the femur and lower part of the shaftsometimes takes place in- consequence of

suppuration in the ham, causing destructionand sloughing of the adipose and loose cel-lular tissue so abundant in that part of thelimb. The periosteum is in consequenceseparated from the bone, and superficialnecrosis is thus produced in an exceedinglyawkward situation.

,’, The abscess, perhaps, points in the centre

of the popliteal region, and the dead bonemay be felt through the opening ; but it isimpossible to extract any sequestrum fromthis direction, inasmuch as the large vesselswould be very inconveniently placed, andprobably in great danger. The safest planis to make an incision on the outer and backpart of the knee, the leg being flexed, or thethigh after that, so as to relax the hamstringmuscles. The finger is then passed deeplyto feel for the dead bone, and the forcepsguided along the finger so as to seize oneend of it. Even here the operation is trouble-some and tedious, as can easily be under-stood when the anatomy of the parts con-

cerned is considered.Disease of the kllee-joint requires no par-

ticular notice from me here, as in describingthe symptoms, progress, &c., of inflam-mation of synovial membrane and other cora.ponent tissues of joints in general, I had theknee-joint most in view. Indeed, the kneeis more frequently diseased than perhapsany other joint, and you are constantly seeingcases of this kind at the hospital, which pre.sent themselves in different stages of advance-ment, and afford you ample opportunities of

observing for yourselves the different symp-toms, signs, and appearances I have alreadyenumerated and described.

Disease may commence in any of thestructures, as I have before told you, butafter existing for any length of time it generally involves them all in a greater or lessdegree, and it becomes impossible (except inas far as the history of symptoms may be aa guide) to say what tissue was first atfault.

Rheumatic affections sometimes simulatedisease of the articulations themselves, andoccasionally the inflammation actually ex-

tends from the fibrous structures to the arti-cular apparatus. Chronic effu: ion into thecavity of the synovial membrane, distendingit with clear glairy fluid, and deforming theshape of the part, is very common in theknee. We have before mentioned it, and themethod of treating it; I therefore need onlyadd that it often attains an immense size

(fluctuation being felt nearly as high as themiddle third of the thigh), and is a very ob..stinate and unmanageable affection.There are one or two other curious dis-

eases of the knee-joint, which we may notice,although you will rarely meet with them.It is occasionally the seat of malignant dis-ease, the ends of the bones degenerating intoa brain-like or fungoid structure, similar inappearance to the ordinary encephaloidtumours. Sir B. Brodie describes anotherdisease approaching in its characters to car-cinoma, having white dense streaks in apulpy and softer substance. I cannot saythat I have seen any appearances in thesynovial membranes which I could call car-cinomatous.

There is a specimen in the museum of theCollege of Surgeons in Edinburgh, and an-other, I believe, in St. George’s Hospital,London, of a very rare warty affection of thesynovial membrane. There is no history at-

tached to either of them, however. I cannottell you, therefore, whether there are anysymptoms by which you may recognise sucha change in structure. You sometimes see theedges of the semilunar cartilages coveredwith a fine fringe of villi, or rather villousprojections, which seem to grow from thesynovial membrane. They have also beenseen in the elbow-joint.

Sometimes larger bodies, of a bony con-sistence, covered with cartilage, are developedin the interior of the knee-joint ; and some-times these become quite loose, apparentlyfrom the absorption or sudden detachmentof the pedicle from which they were first

developed. These bodies are generallyrounded or oval, perfectly smooth, and verymoveable. They occasionally get between

the femur and the head of the tibia, when theyproduce such sudden and severe pain thatthe individual is almost thrown down.

The treatment of disease of the knee-jointmust be conducted on a similar plan to thatrecommended in disease of the elbow. Inthe commencement the measures must be

sufficiently active, for the inflamed surfaceis large, the general excitement very consi-

derable, and, unless soon checked, the mis-chief rapidly increases to a dangerous ex-

tent. When the disease is too far advancedto hope for resolution by active antiphlogisticmeasures only, the employment of lateral

splints to keep the joint immoveable will befound attended with the best results. The

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best position is that which shall enable thepatient to walk most easily provided anky-losis takes place. It is best to keep the 1knee a little flexed, and this, indeed, is thenatural or rather the most easy position indisease of the knee-joint, because then the iweight does not bear so heavily on the in- Iflamed and perhaps ulcerated cartilage. Ifthe knee should become fixed in a perfectlystraight position, the limb would be verymuch in the way, and the patient would beforced to swing his leg round like a falselimb without a joint.When ulceration of the cartilage and ab-

scess of the knee-joint have existed for a

length of time, and the effect is beginning tobe perceptible on the patient’s constitution,amputation is the only remedy where anky-losis fails ; at least, if remedy it may becalled, which implies the loss of the limb.

Resection of the joint and removal of thediseased parts of bone only, which we re- Icommended so strongly in certain cases of I

diseased elbow and shoulder-joints, is quiteinadmissible in the knee-joint. The operationhas been attempted, but, as might be ex-pected, without any results to induce a repe-tition of the experiment.As regards the management of cartilagi-

nous bodies in joints, it is often absolutelynecessary to free the patient from the annoy-ance they occasion. After they becomeloose they are apt, from time to time, to slipbetwixt the bones, to cause great pain, andseriously to impede progression. They dooccasionally form a bed for themselves, andcause little or no uneasiness after a while ;but this is the exception. It was the customyears ago to remove these bodies by incision,and this was contrived in such a way thatthe opening through the skin did not corre-

spond with that in the capsule. The skinwas drawn aside, opened, and the body cutupon. After its escape the integument beinglet loose resumed its place, and was theput carefully together. Union often tookplace, and if the joint was kept quiet thepatient recovered without further risk. But,again, if the wound did not unite, and sup-puration was established in its track, inflam-mation of the joint and disorganisation of thetissues composing it not unfrequently hap-pened. The limb was thus put in jeopardy,and sometimes also the patient’s life. An-other and improved mode of proceeding wasproposed some years ago by Dr. Goyraud ofAix, and at the same period by Mr. Syme ofEdinburgh. This plan I have pursued inseveral cases with excellent success. It con-sists in subcutaneous division of the capsuleof the joint, and the lodgment of the cartila-ginous body in the cellular tissue. The pro-ceeding is not unattended with difficulty, andit is one which a person not accustomed toundertake operative procedures will be ex-ceedingly apt to fail in. The fixing of the Imass is often not an easy matter. It may,

moreover, escape into the joint during theincisions. The position of the cartilage beingsecured as well as possible, the small instru-ment-a needle-like knife-is introduced at adistance from it ; the capsule being then cutto the requisite extent, the body is thrust orpulled out and lodged in the cellular tissue,in a space previously prepared for it. Thereit will generally remain without causing theslightest annoyance. In a case which waslately under my care either five or six ofthese cartilaginous masses were thus removedfrom the joint as they became loose andtroublesome. Two of them were ultimatelyremoved by incision of the skin, one neces-sarily on account of diffuse infiltration andformation of matter. The others now lieunder the skin comfortably enough.

Disease of the patella is a rare occur.

rence, except as a consequence of disease inthe knee-joint. The synovial membraneover the back part of the patella becomesinflamed, the thin layer of cartilage under itthen ulcerates, and the surface of the pa-tella being exposed is ultimately implicatedin the ulcerative action.The patella is occasionally partially ne-

crosed ; and cases have occurred in whichthe bone has been perforated by the disease,and severe inflammation of the knee-joint fol-lowed to such extent as to call for earlyamputation.The tibia is often necrosed from injury

and other causes. When the outer layeronly is destroyed, as sometimes happensfrom a kick on the shin, laying bare thebone and bruising the periosteum, the caseis very simple, and is completely cured in afew weeks perhaps. Where, however, theinner shell perishes, the case is very tediousindeed. When the sequestrum is loosened,an operation must be often had recourse to inorder to remove it; and as the bone is verynear the surface, the proceeding is, perhaps,as simple as it can be in any situation. It issometimes sufficient to enlarge one of theopenings, which always exist in necrosis, andtake hold of the sequestrum through thecloacae of the substitute-bone. At othertimes, however, you are obliged to cut awayportions of the new bone, or trephine it at someconvenient point in order to arrive at thedead piece of tibia. If you cannot take holdof the end of it, or if the piece is too long totake out whole, you must saw it across witha small saw, and remove the two halvesseparately. No particular rules can, how-ever, be laid down for these operations ; theymust be varied according to circumstances,and the surgeon must be guided by his owningenuity in planning and executing thenecessary steps of the proceeding.You have seen instances in the hospital

of abscess in the medullary canal of the

tibia, causing swelling and enlargement ofthe shaft of the bone, and attended with ex-treme pain and violent constitutional excite-

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ment. On cutting down upon the bone andremoving a small piece with the trephineyou give immediate relief to the symptomsby letting out the pus. This not unfre-

quently occurs in the head of the tibia,perhaps from scrofulous deposit originally.If in the epiphysis, the case is dangerous,and may probably lead to disease of theknee-joint; abscess has thus opened byulceration into the articulation, and the mostviolent inflammation instantly supervened.In these cases you are almost sure to be

obliged to amputate, and the rapidity withwhich the structures composing the joint aredisorganised is surprising. Now and thenthere is slight necrosis, together with ab-scess, and you will find a few loose portionsof dead bone lying in the pus, and, as it Iwere, macerating in it. These may be

scooped out easily when the cavity is firstopened by the trephine.The ankle is very subject to sprains, parti-

cularly in persons who walk awkwardly;and where the general state of health andstrength is low, and the injury not properlyattended to at first, disease of the joint be-tween the tibia, fibula, and astragalus, isliable to occur. In scrofulous girls this isnot an unfrequent thing inflammation quicklyruns on to abscess, and the cartilage coveringthe bones becomes ulcerated and destroyed,and ultimately the bones themselves are theseat of carious ulceration. The same takesplace in the joint between the tarsal bones,the whole foot swelling, abscess forming invarious parts, and sinuses remaining whichburrow in the soft parts, and lead to bareand rough bone. The ligaments betweenthese various bones are sodden and partiallydisorganised; the bones move sideways overone another, and perhaps in an advancedstage of the disease produce a grating sen-

sation from the rubbing of the roughenedsurfaces on each other. Sometimes diseaseof the ankle arises from scrofulous depositin the bones themselves, which softens andleads to suppuration, &c. In these casesthe progress of the disease is very slow ; thepatient feels some pain and tenderness in thefoot and ankle for a length of time before theaffection puts on a serious aspect; and thecommencement of the disease is so littlenoticed that you cannot find any distinct ac-count of any injury or accident which couldhave caused it. This kind of disease not

unfrequently appears in more than one jointat the same time, showing the dependenceof the affeetion on the state of the constitu-tion.

In the treatment of diseases of the anklethe patient must be prevented from walkingor moving the foot, by means of lateral splints,made to fit accurately to the lower part ofthe leg and sides of the foot. When thereis any tendency to scrofula, however, suchmeans should be taken as are consistent withthis principle to allow the patient plenty

of fresh air, and particularly in the neigh-bourhood of the sea.Even after the disease has apparently been

cured, and after the splints are abandoned,you should persevere for some time in theuse of an elastic bandage or stocking, whichmay afford support and protection to theweakened joint. Friction over the ankle withflaunel and hair-powder is also an admirableplan when the symptoms are disappearing.’

The larger tarsal bones, particularly theos calcis, are sometimes the seat of necrosis,and this is generally accompanied with acertain amount of carious ulceration of thebone in the vicinity of the sequestrum.In such cases you can sometimes com-

pletely remove the evil by making a T-shaped incision over the seat of disease, andscooping out the spongy sequestrum, andthe carious sides of the cavity containing it.The part should then be dressed with drylint, placed in the wound lightly, so as toabsorb the discharge as it forms. Perhapsthe operation may not be quite successful,and it will be requisite to apply some escha-rotic, as the red precipitate powder, to thebone, in order to stimulate the parts to throwoff the dead portions which remain. Inthis way I have seen nearly the whole of thecuboid bone removed in a spongy dry state,and the foot completely recover.The same kind of scrofulous necrosis and

caries sometimes occurs in the metatarsalbones and phalanges of the toes, but in thissituation the toe must be removed, togetherwith the diseased parts, if the case advancesto such a state as to call for such an opera-tion. Necrosis of the terminal phalanx ofthe great toe is often caused by inflamma.tion about the matrix of the nail, or onychia.I have, however, already entered pretty fullyon the nature and symptoms of disease of thecorresponding parts of the fingers, and neednot now stop to consider this subject sepa-rately.Where the nail presses into the skin at the

side of the matrix, or, indeed, in almost everycases in which the matrix has long been ulce-rated and irritated, it is necessary to removea portion or even the whole of the nail illorder to afford an opportunity for the part tobeal. When the nail has been removed,nitrate of silver should be lightly appliedover the ulcer in the way I recommend inparonychia.

Disease of the bones of the great toe is avery common occurrence in the north ; andthere are here before you many fine speci.mens, but we do not so often see it here.It is probably owing to the less frequent useof shoes or any protection for the feet amongst

, the children of the working-classes. The’ toes are, therefore, more liable to injury fromstriking against stones, &c. On the other

hand, tight shoes are not unfrequently thecause of onychia in the great toe, and, in-deed, of several other diseases of the foot.