No. 1500.

MAY 29, 1852.

Clinical Lectures,Delivered at Guy’s Hospital,

BY JOHN HILTON, ESQ., F.R.S.,SURGEON TO THE HOSPITAL.

LECTURE III.

ON FRACTURED RIBS CONNECTED WITH EMPHYSEMA.

Fractures of ribs connected with emphysema ; case of fracture!ribs from severe blows on the chest; emphysema manife8tetvery rapidly, and as rapidly subsiding; complete recovery.mechanism of the escape of the air; why does the air not pas,into the pleuml cavity; influence of old adhesions in preventing the cavity of the pleura from filling with ai7-; ad.

vantage of strapping in cases of fractured ribs with em,

physema; escape of air into the areolar tissue without anlexternal wound; possibility Qf air being admitted through thowound, as in fracture of the skull, thigh, &c.; mor or les,,certainty as to the fact of the lung being injured; various way,in which emphysema may occur independently of broken ribs.air in the cavity of the pleura; air in the anterior anoposterior mediastina.-Case of a boy who had emphysema, bu.no fracture of ribs, in whom the air occupied the posterior?mediastinum.-Case of a young man with whom 8trainincaused the rupture of pulmonary cells and difusion of airinto the posterior mediastinum post-mortem examination.-The tracing of the course of the air when the pleura pulnaonalisis not ruptured; causes of the symptoms manifested when ai?has penetrated the posterior mediastinum tlae most commoncause of emphysema is fracture of ribs, with laceration of tlaepleurae; possible consequences of a severe blow upon the chest,the most frequent causes of emphysema extent of the em-physematous distention; rapid disappearance of emphysema,the manner in which the air escapes, unknown to the surgeon;prognosis of fractured ribs, with emphysema; analogy witlianasarca ; treatment of traumatic emphysema.WHEN I had last the pleasure of addressing you, I dwelt

principally on the means in our possession for diagnosingfracture of ribs, and I offered some remarks on the lattel

injury when complicated by pneumonia. I laid before youmy views as to the mechanical and medical treatment of such

cases, and I am fain to hope that you are fully prepared to act-according to the principles laid down, when your assistance isrequested in accidents of this kind. According to promise, Inow pass to the consideration of fractured ribs, when suchlesion is accompanied by emphysema, and at once read to youa case strikingly illustrative of this complicatioa:—

" Mary Ann H-, aged twenty-five years, was admittedMay 25th, 1850, under the care of Mr. Hilton. The patientis a married woman, and has enjoyed remarkably good health;she has always had abundance of food, and is in the habit ofdrinking to excess. On the morning of her admission,her husband and herself (both being intoxicated) beganquarrelling, and he beat his wife repeatedly about her left sideand arm with the kitchen poker. She fainted, and, accordingto the statement of a woman who was present, the patient wasstruck several times whilst in the swoon, a condition favourableto the supervention of fracture on the application of much force.She was rescued from the violence of her husband, and laidupon the bed, and when she had revived a little, was broughtto the hospital, being very sick during the journey." On admission into the hospital, fractures of the fifth, sixth,

seventh, and eighth ribs were detected, and there was evidenceof a considerable amount of sub-cutaneous emphysema." Youcannot fail to remark in how very short a time externalemphysema had taken place. " The patient’s left arm was verymuch contused and swollen; -she complained of intense painat each act of respiration, and was distressed by a very severecough. Her side was now tightly strapped -this measureafforded her much relief (see engraving in THE LANCET, V04 i.1852, p. 141)-and cold lotions were applied to the injuredarm. Mr. Hilton ordered also twenty minims of antimonialwine, and the same quantity of tincture of henbane, to betaken in a mixture of acetate of ammonia every fourth hour.

" own the second day, the patient appeared rather better, butstill complained of much pain, and as the bowels were con-fined, she took a dose of sulphate and carbonate of magnesia..

On the third day, the improvement continued; the emphysemawas fast disappearing." You perceive how soon the em-physema gave way. " The arm was less swollen, and morecomfortable, and the cough rather better. Pulse 84, small.On the fourth day, the patient breathed with more ease, andon the fifth, she left the hospital at her own request, freefrom any urgent inconvenience. She was directed to applyagain at the hospital in the course of a few days; and as shenever made her appearance after her discharge, she is pre-sumed to have completely recovered."You will observe this case presents one special and distinct

feature-viz., the emphysema supervening upon the fracturedribs, and that is the reason for my adducing it. The latterinjury was inflicted by direct violence; it is very probable,or almost certain, that the instrument used by the husband(the poker) drove the fractured ends of the ribs inwards, andthat one or more of these wounded the lung; but the elasticitywith which the ribs are endowed enabled them to resumetheir original position,-to rebound in some degree from thelung, and leave an aperture through which the air escapedinto the external areolar tissue, thus producing the emphy-sema.

But in considering these pathological phenomena, it maybe asked why the air did not escape into the pleural cavity 1Before discussing this point, just cast a glance on this

diagram; it represents a transverse section of the chest; itbrings to your recollection that the oesophagus, pneumogastricnerves, thoracic duct, aorta, &c., surrounded by areolar tissue,occupy the posterior mediastinum; and it well shows inhow close a contact are the pleurae pulmonalis and costalis,merely, at most, a synovia-like fluid intervening. Now, yousee, that after wounds of the lung, there is nothing to preventthe air passing into the cavity of the pleura, and you willunderstand how it may, by its accumulation there, causethe lung to be compressed towards the spine and medianline of the chest. But you have heard, amongst the circum-stances of the case, that the patient is a drunkard, and youare perhaps aware that with such people pleural adhesions,as the result of pleurisy, are very frequent. This woman wasprobably so situated; the adhesions between the pleurae, closingthe interpleural space, prevented the air from passing into theotherwise cavity of the pleura, (where it would have causedmuch distress of breathing and danger,) and compelled it togo direct into the subcutaneous areolar tissue. I think I maysay that in this patient the habits of intemperance, thoughvery baneful in the end, had, under these circumstances, sofar an advantageous and a beneficent effect.From the account of the case, we learn that the patient’s

chest was strapped in the manner I have described before;1,ny object here was to prevent the external and internal partsfrom moving upon each other. Without going into a detail ofthe direction of the movements of an expanding lung, I may sayin general terms the lungs expand during inspiration from theirown centre, whilst the costal parietes of the chest, having theirfixed points above and posteriorly, move upwards and out-wards. These parts, with their pleural surfaces, therefore, donot move in the same direction. Hence a tendency of theapertures in the pleura pulmonalis and pleura costalis to losetheir relative position of directly opposite each other, as theywere at the moment of the accident, and a danger of the airpassing from the lung into the cavity of the pleura. Thestrapping was then applied, in order to keep all the points ofthe thoracic parietes and lung exactly opposite each other, oras nearly so as possible, and the two apertures just mentionedin direct communication. An important point to notice isthis: By means of perfect quiet, the wound of the lung isextremely likely to be sealed up with lymph in the space oftwenty-four hours, but such would not be the case if free andtumultuous movements were permitted.Allow me now to make a few general remarks on emphy-

sema. What is meant by this term? It might be called anescape of air within the economy, in varying directions,according to the circumstances of the case. Now, as to em-physema as connected with fractured ribs, you must observe,that when the fracture is not associated with an externalwound, it may at once be inferred that the air which isescaping into the areolar tissue must have been freed by awound of the lung. When, however, an external wound doesexist, and the emphysema is limited and stationary, such diffit-sion of air may have been caused by its admission through theexternal wound. Indeed, I have seen a limited emphysemaoccur in cases of compound fractures of other bones besides theribs, as of the skull, the thigh, leg, and lower jaw. When the

z

508

skull is broken and emphysema is produced, there is generally be distinctly recognised on pressure by the finger; no othera wound of the frontal bone, implicating the frontal sinus, and emphysema existed at that time below the shoulder. Thethe air passes under the occipito-frontalis muscles. Thus, in exterior of the chest under and about the pectoral musclesfractured ribs, with emphysema, we might suppose the lung was occupied with air.. But even with this extent of emphy-uninjured if there be a wound of the skin; but if there be no sema, there was a disproportionate shortness of breath. Ethersuch external wound it is certain that the lung has suffered and ammonia were administered in small quantities; for onlyperforation. a little could be swallowed at a time, and that with difficulty,But besides these circumstances, you should bear in mind His dyspncea proceeding, and his life in immediate danger fromthat areolar emphysema may occur from without, indepen- suffocation, I made a free, clean, and direct incision nearly an

dently of broken ribs, by an external perforation of the skin. inch in length on each side through the cervical fascia, at theAgain, emphysema may occur from within, independently of posterior margin of the sterno-cleido-mastoideus; the air camebroken ribs, by a rupture of the lung. In such a case, the puffing out of the incisions. This escape of air or removal ofcourse of the air will be determined by the giving way or not pressure gave him some temporary relief; subsequently, otherof the pleura pulmonalis. If the latter be ruptured, the air incisions were required, and alwaysafforded some benefit to thewill of course escape into the pleural cavity, causing great dis- patient’s condition. Notwithstanding all such efforts, and thetress of breathing by compressing the lung, though old pleu- effects of the administration of stimulant medicines, theritic adhesions may limit the diffusion of the air, and consider- dyspnoea continued, and so did the difficulty of deglutition; .

ably diminish the distress. If the pleura pulmonalis be not indeed, after a few hours from my first seeing him the attemptruptured, then the course taken by the air will be very to swallow was dispensed with, and enemata, both stimulatingpeculiar; it may come to occupy the anterior and posterior and nutritious, were frequently administered, but withoutmediastinum, and even raise the pleura from off the dia- permanent effect, and he died on the second day after thisphragm. attack, Oct. 13, 1845.

I will just adduce the case of a boy in whom such a lesion I will now trouble you with a detailed account of the post-took place; you will find it extremely instructive. The patient mortem examination, which took place forty-eight hours afterwas about eleven years of age, and had the misfortune of being death. There was very little evidence of putrefaction; nonerun over a short time before he was brought to the hospital. was noticed, except at the posterior part of the body, theThe vehicle had passed over his chest, and when admitted he result of gravitation. The emphysematous state of the areolarwas under the influence of a severe shock. The whole frame tissue extended from the neck, which was very full of air, intowas cold, the boy was very low, and he could not swallow, the face, puffing the cheeks, and rendering them white fromThere was no external wound whatever, but the whole of the distention. There was also air diffused throughout the back,neck and the face were emphysematous, and he was in the chiefly, however, on the right side; and the parietes of thegreatest possible distress in his breathing. When touching thorax were everywhere emphysematous. Neither the rightthe radial artery, crepitation could be felt, the latter being of nor the left leg was affected; but the parietes of the abdo-a deep kind, and appearing to accompany the artery only. It men, superficially to the muscles,were slightly emphysematous.was, in fact, extremely likely that the air had crept down the There was no emphysema in the muscular layers forming thesheath of that vessel, and had, according to all appearance, walls of the abdomen; but the interposed areolar tissue of thediffused itself with the arterial system of tubes, rendering the thoracic muscles was occupied by air.-Cavity of the abdomen:pulse so extremely feeble. No air behind the peritonseum, nor any fluid in that cavity;The boy was put to bed, and stimulants were given him. I liver large and coarse; bile pale; gall-bladder small; spleen

at the same time made incisions into the neck, in order to natural; kidneys large and coarse, the cortical structurefree the accumulated air, and this measure seemed to give the becoming white with deposit ; bladder small and empty;boy great relief. The emphysema gradually went off, and the stomach and intestines free from disease. On raising thepatient was progressing very favourably, when, after about ten sternum, the areolar tissue of the anterior mediastinumdays, he imprudently exposed himself to cold, was attacked was found occupied by air, distending it. The whole track ofwith pneumonia, and died. On examination, no fractured ribs the phrenic nerves was occupied by air, distending the areolarwere found, although carefully sought for, and the fearful tissues immediately surrounding them. This emphysema,emphysema which had ensued upon the accident must have following the defined course of the phrenic nerves, reached toarisen from a rupture of a certain number of pulmonary cells, the diaphragm, and had separated the pleura from that musclewithout associated broken ribs. to the extent of two or three square inches on the left side,You will see how obscure the full comprehension of such and to a less extent on the right side.

cases must naturally be; and as it is important that you I will just make a short pause here, to remind you that theshould be able to form a tolerable diagnosis of such cases, phrenic nerves, at the upper part of the chest, enter and thenceI will bring another before you, replete with interest and pass through a sort of fibrous tube between the pleura andinstruction, and which will fully exemplify the extraordinary pericardium; air had penetrated this tube, and had, by com-course of the air when it escapes from the air-cells, but with pression of the nerve, rendered respiration so difficult. Alongan unbroken pleura pulmonalis. this phrenic nerve the air had then descended to the diaphragm,The case refers to a private patient of mine, who was where it acted with such force as to raise the pleura lining the

formerly a pupil here. He was about twenty-six years of age, muscle. You may imagine, from the consideration of theand suffering from phthisis, and had been ill during several latter fact, how much pressure must have been exercised onmonths. One evening, while straining at the water-closet, he the phrenic nerve, for the connexion between the pleura andfelt something suddenly give way between his shoulders; he convex surface of the diaphragm is very firm, and great forcewas then attacked with dyspneea and difficulty of swallowing. is of course required to raise the one from the other. But theThe distress inbreathing and difficulty in swallowing increased diffusion was very extensive; the posterior portion of therapidly, and I was hastily sent for about four or five hours sub-pleural space between the ribs and the spine, and theafter he had felt something give way in his back. I found posterior mediastinum, were quite full of air.him sitting up in bed, supported by pillows; his breathing No air had penetrated into either pleura, nor into the peri-most difficult and gasping; pulse small, and very weak; hands cardium, the latter being occupied by about an ounce of fluid,and feet, nose, ears, and lips, cold and congested; pain in his slightly tinged with blood. Heart large; left ventricleback; his voice feeble, and incapable of speaking a long sen- slightly hypertrophied; mitral valve decidedly contractedtence, so small was the quantity of expired air; any such attempt and thickened; aortic valves thickened, and somewhat rigid;at speaking augmented his distress; he was therefore directed some opaque deposits, about the size of pins’ heads, werenot to say a word, but to write his wishes. The crepitation observed in small groups under the lining membrane ofof emphysema was felt throughout the whole of his neck, the ascending aorta, a little below the origin of the arteriaextending amongst the deep structures under the deep innominata, and opposite to the aortic opening. The bloodfascia, making his neck thick and large, and render- was black, and feebly coagulated-firmer, however, on theing the larynx and trachea almost fixed. The air occu- right side than on the left. No air had passed through thepied to distention all the sub-fascial space reaching to pleura or pericardium; no exosmosis or endosmosis of air.the temporal fossa, and producing a bulging of the tem- The left pleura was free from adhesions, except towards theporal aponeuroses. The air occupied the neighbourhood, of apex on the posterior part, where old ones were found; thethe clavicles and the axillse, but had not been diffused, either rest was free. No effusion of fluid was noticed. On raisingsuperficially or deeply, beyond this in the upper extremities, the left lung, the left serous wall of the posterior mediastinumexcepting in the course of the brachial artery, and its divisions was seen projecting outwards towards the lung, being forcedinto the ulnar and radial arteries; along the tracks of these into that direction by great distention of air. Near theblood-vessels the minute crackling of extravasated air could mediastinum the pleura costalis was, in various places, raised

509

from the ribs by air, and the same thing had occurred slightly And it should, lastly, be observed, that if the air in the pos-where the pleura passes from the sternum over the cartilages terior mediastinum raises, after great ti’nsio:), the pleura cos-of the ribs. talis, then the air reaches the areolar tissue of the exterior ofThere existed strong adhesions opposite the middle of the the chest/and finally produces the ordinary external emphy-

convex surface of the right lung and the fifth rib; and around se: ra. When you see these symptoms manifested in a giventhe base of the pulmonary end of this adhesion the pleura case, I expect you will have no difficulty in determining thepulmonalis was thickened, opaque, and somewhat contracted nature of the accident.for abjut two inches square. Under this was subsequently nut you will do well to remember that these cases of em-found a cavity, which might have lodged a pigeon’s egg, lined physema without fractured ribs are the exceptions; most fre-by a well-marked opaque membrane. quently there is a wound inflicted upon the lung by the endsExtensive adhesions of the right pleura were noticed near the of fractured ribs, and emphysema, pursuing the ordinary course,

apex of the lung, towards the median line, reaching along the thus ensues. You should notice, besides, that a severe blowconcave surface of the lung to near the entrance of the right upon the chest, or other external force acting violently upon it,bronchus into the lung. The rest of the pleura was free from may, without causing any fracture of ribs, lead to a tearingadhesions, of the interior of the lung, almost immediately followed by

It was now important to discover the sources of the extra- copious bloody expectoration, this symptom not being accom-vasated air and its point of escape from the lungs. After very panied by any recognisable emphysema, nor any evidence ofcareful inflation of these organs in situ, it was ascertained that broken ribs. Pneumonia may occur under similar circunidthe air had escaped from a cavity covered by the above- stances, from the lung being bruised. I was informed by onementioned adhesions, just over, and communicating with, the of the pupils, of the case of a prize-fighter who came to hisright bronchus. The air issued at two points, one through the death in this manner: he received a severe blow upon the

, wall of the cavity direct into the posterior mediastinum; the chest, which, without breaking any ribs, literally tore theother outlet took a course under the pleura pulmonalis to the lung; extensive extravasation and spitting of blood imme-point of entrance of the bronchus into the lung, raising diately followed, and he died in a short time. The post-mortemthe pleura pulmonalis from the lung, and thence proceeding examination revealed the existence of the lesion which I haveinto the posterior mediastinum, the openings being very small. just mentioned, and no broken ribs.The pulmonary cavity presented cavernous walls, and was But, I repeat it, the most common association of emphysemaoccupied, in part, by dark, offensive, and broken-down pul- from external injury, is frccctured ribs and perforation of bothmonary tissue, the result of recent mischief.* pleurce and th lung by the ends of the fractured ribs. It may

Sections of the right lung presented several small cavities happen that the latter remain fixed in the lung; the mischiefin the upper lobes towards the median line. The whole of is then of a very severe nature. Or, after having been thrustthe lung was filled with small accumulated inflammatory by external force into the lung, they may resume their posi-tubercles, in groups about the size of large shot; others as big tion, leaving an opening in the lung through which the airas peas. Numerous lobules presented the ordinary pneumonic escapes into the pleural cavity; and when an opening hasconsolidation. taken place in the pleura costalis, the air may be driven to theNo cavities were found below the upper lobe; the left lung exterior of the chest.

was studded with the same kind of tuberculous deposits, but As to the course which the air takes, it must naturally bethere were no cavities. Recent pneumonia had occurred here determined by the continuity of the areolar tissue and theand there in lobules or groups of lobules. , attachments of fasciae. As to the extent of the emphysema, youThe bronchial glands were enlarged. The larynx and easily perceive that it will vary in different cases, according to

trachea presented nothing remarkable. the size of the openings of communication with the lung. InThis case clearly demonstrates the course of the air when the first case which I this day brought before you, it was

emphysema arises without rupture of the pleura, or when it reported as considerable, yet in three days it was nearly gone.has entered the posterior mediastinum. It is very probable, This rapidity in the disappearance of emphysema naturallythat whilst the patient was straining, the air had been forced suggests the question as to what becomes of the air thus dif-from the bronchial tube into the cavity adverted to, and thence fused through the sub-cutaneous cellular tissue. We find thatinto the posterior mediastinum. Now, you are all aware after a few days the air is absorbed; but is it absorbed by thethat the latter is continuous with the middle mediastinum, lymphatics or veins, and carried into the blood? 1 Is it possiblewhich transmits the phrenic-nerves, and also with the ante- that so much air can be mixed with the blood without veryrior mediastinum, and that its boundary above is the cervical serious, if not fatal consequences ? 1 I very strongly doubt thatfascia, which forms a dome over the entrance of the chest. this kind of absorption takes place. Does the air escapeThis dome, as you know, is perforated with holes for the through the skin or mucous membrane 1 know not; it reallypassage of vessels and nerves; and it is through these holes, disappears, but by what channel is not explained. It mightinto the sub-fascial spaces, and along the sheaths of the blood- be worth while to put a patient of this kind into a warm bathvessels and nerves, that the air passes and diffuses itself, pur- for as long a period as is quite safe, to observe if there be anysuing the course of the blood-vessels, much in advance of the escape of air from the surface of the body.more general diffusion, and so presenting itself, as it were, a Now, as to the prognosis of cases of this nature, I considerpathognomonic or characteristic indication of the escape of that emphysema need create no alarm, except in relation tothe air from the lung into the posterior mediastinum, and its pressure upon the blood-vessels (especially the veins), ordistributed therefrom. The air, having escaped from either other parts important to life, such as those which minister tobronchus or the thoracic portion of the trachea, might pro- the respiratory functions. It is plain that, independently ofduce the same series of symptoms as observed in the case now any uneasiness which the trachea, lungs, or pneumogastricbefore your notice. Hence you may derive valuable prac- nerves may experience, the pressure of air upon the musclestical information. When you,for instance, find the neck full and of respiration impedes, and interferes witl, their free action.crackling with air, and tlielarge arteries only of the upper limbs Another source of danger should not be overlooked-viz., thesurrounded by it, and if there be no external wound and no fact that the pressure upon the superficial veins occasions afractured ribs, the inference must be, that the air has escaped great accumulation of blood in the interior of the body, morefrom a bronchus or the trachea, and found its way into the particularly at the heart and lungs, which organs are alreadyposterior mediastinum. Recollect, then, these points when overburdened by the immediate results of the fractured ribs.you come in contact with such a case, so that you may be You will be pleased to notice that the same phenomena areenabled to form a correct diagnosis. observed in general anasarca. If, then, emphysema of theThe peculiar dyspnoea noticed in these cases is owing to sub-cutaneous cellular tissue be connected with some danger,

the compression, by the air, of the phrenic and eighth pair of it becomes a matter of importance that such cases should benerves; and the difficulty of swallowing arises from the pressure properly treated.exercised upon the oesophagus by the air diffused through the I would advise you not to be in a hurry to interfere; but whenposterior mediastinum. The air, traversing the limbs, exer- you wish to give relief, it may be done by puncture or incision.cises a compression upon their arteries; hence arises an accu- Punctures are sometimes made into the emphysematous parts,mulation of blood in the aorta and left side of the heart. and they are strongly recommended by some surgeons; but I- ——————————————————————————————————————— prefer incisions to punctures, as the latter, as far as I have seen,I had seen this sub-pleural course of air from the posterior medias- act very unsatisfactorily. These incisions should be made with

tinum twice before this case; each instance presented the same general care and important parts be sedulously avoided; you will findand local symptoms; but no opportunity (before this case happened) had that a length of hHlfnn inch wlll b qnite sufficient, but thobeen offered which could enable me to ascertain the cause of the peculiar, that a length 0 half an mc Will e quite sufficient, but theand, as believe, the pathognomonic and diagnostic course which the extra- incisions must be precise, clean, done at once, and deep enoughvasated air had pursued. to give free exit to the air pent up in the cells of the sub-

510

cutaneous areolar tissue. Do not tear or lacerate the walls ofthe incisions by introducing the finger or forceps, for the pur-pose of enlarging them; for if the cellular tissue be laceratedinto shreds, it is more likely to induce coagulation of the bloodassociated with the incision, and so contribute to a closing ofthe internbrillar spaces of the areolar tissue; indeed, without thisadditional interference with the passage of the air throughthe incision, the air itself in passing seems to have a tendency,by its drying effects upon the exposed structures, to seal theareolar tissue; hence it becomes necessary to make more inci"sions. In anasarca, however, punctures act very favourably,and produce great relief, principally by disencumbering therespiratory muscles of their load of fluid, and so permittingrespiration to be more freely performed. Such puncturesalso allow a great accumulation of blood in the superficialveins, and thus act very beneficially by relieving internalcongestion. Precisely the same reasons, in explanation andas principles for practice, apply to cases of emphysema. Ihave, finally, to observe, that in cases of extreme and pro-gressing emphysema from fractured ribs, unconnected withan external wound, it will be advisable to cut down freely tothe fractured ribs, if feasible, in order to make an externalwound, so as to allow the air to pass towards the external partsand exterior of the body, rather than accumulate in the chest.I have done this in practice with great advantage. You canthus give free exit to the air; such measures will be eminentlynecessary when you perceive that a dangerous kind of emphy-sema is making progress.

I venture to hope, that the suggestions which I have broughtbefore you this day will be sufficient to guide you in the treat-ment of cases of emphysema connected with fracture of ribs.or brought on by any other traumatic cause. The safety ojyour patient will mainly depend on the carefulness with whichyour diagnosis and treatment of his case will be conducted. 7make no pretension that I have examined the whole subjectbut with this lecture I must bring to a close what I had t(

say regarding fractured ribs, and the complications which maaccompany this lesion; next time we meet I shall direct you)attention to a ceitain number of cases of stone in the bladderwhich have lately been treated in this hospital.

Clinical LecturesON

DISEASES OF THE JOINTSBY SAMUEL SOLLY, ESQ., F.R.S.

(Continued from p. 353.)

THE case I have just read is replete with interest to thepractical surgeon. Disease of the hip-joint is for the mostpart a strumous disease, attacking children before the age ofpuberty. The offspring of the poor in this metropolis areespecially liable to it. Scarcely a taking-in day passes with-out one or more of these poor creatures presenting themselvesfor admission. In some of these cases, though I believe rarely,the disease has commenced in the cancellous structure of thehead of the thigh-bone. It is a scrofulous disease of the bone,and extends from its tissue to the cartilages of the head of thefemur, without involving the acetabulum. These are cases inwhich the operation of excision of the head of the bone maybe executed with advantage; but they are rare, and it is ex-

tremely difficult to distinguish them from those in which thedisease has not been limited to the thigh-bone, but in whichthe acetabulum has become implicated.The disease is most frequently set up by inflammation of

the synovial membrane, induced by exposure to cold, or over-exertion, acting on a frame debilitated by London cachexia;sometimes it results from a direct injury, as in the case justrelated, and another to which I have often directed yourattention, in George’s ward, and the details of which I shallcomment upon in the course of these lectures. When thedisease can be traced to accident, even if the constitution onwhich it falls is decidedly strumous, there is always morereason for anticipating a favourable conclusion than when thedisease comes on without any apparent cause; and so insidiousis this morbus coxx in some instances, that Mr. Ford states onhis own personal knowledge that caries of the bone in thecotyloid cavity, and on the head of the thigh-bone, may existbefore any external symptoms had proved its presence there,Generally speaking, the child is first observed to limp in hiswalk, and on being questioned by his parents complains oj

pain in the hip, or not unfrequently on the inner side of thethigh, near the origin of the adductor longus muscle. Thepain is not usually severe, and consequently is too oftenneglected by parents until the disease has considerably ad-vanced, as we have seen in the case which is our text for theseobservations.

If the patient is brought to you in this stage, you find thatpressure over the joint in front will be attended with pain,for the synovial membrane is less covered in this situationthan behind, and it is therefore more susceptible to the touch.Extension of the limb on the pelvis, and swinging it in theair while the weight of the body is sustained by the oppositelimb, is also extremely distressing to the patient.In the early and acute stages of the disease, when the joint

is distended with an increased quantity of synovia, thebuttock appears fuller than the opposite side; and this samefulness may be observed on the front of the joint in the groin.Still it must be allowed, that though it is not difficult to

diagnose acute inflammation of this joint, yet it is difficult tostate accurately the extent to which that inflammation hasrun. The hip-joint is so much covered in by muscles, that wecannot detect all the changes which go on in it, as we canmore or less perfectly in the knee-joint, which from its ex-posed position can be much more easily examined. In thecase of the knee-joint, we can compare the shape, form, andappearance of the sound joint so much more accurately withthe diseased than we can in the hip-joint.

It has been said, that in the early stages of hip-diseasethe limb is lengthened. But here again the change is moreapparent than real.

I believe that a very slight degree of elongation does takeplace, and from the following causes; but the very enumera-tion of the causes will convince you that this change must bealmost inappreciable.

lst.-Relaxation of the muscles, allowing the bone to dropfrom the socket.

2ndly.-Effusion into the joint, distention of the capsule,and protrusion of the bone.

3rdly. - Thickening from inflammatory deposit of theadipose substance which occupies the centre of the cotyloidcavity.

In a practical point of view, I consider this lengthening,though, as I have already said, it is more apparent than real,.important as diagnostic of the acute and active stage of thedisease.

It is only in this stage that I have found any local deple-tion of service, for, as a general rule, and certainly in the more-advanced stages, leeches, and other means of local blood-

letting, only do harm, by weakening the powers of the patient.It is in this stage that absolute rest is so important, and thatcalomel and opium are of real use.

Pressure of one articulating surface against the other doesnot much affect the patient, unless there is ulceration ofthe cartilages; and therefore this manoeuvre is often a meansof diagnosing this additional mischief. The mere pushing theos femoris directly into the acetabulum will not always giverise to pain, even if there is ulceration; but by giving thethigh a rotation inwards, thus jerking the bone against theinner side of the cotyloid cup, you can generally detect anyincrease of disease beyond mere synovitis.

After the disease has existed for some time, the rotundityof the buttock is lost, and the edge of the glutaeus muscle nolonger stands out in bold relief, the fissure separating thenates from the thigh almost disappears, and the line becomesmore oblique. These changes all depend on the wasting ofthe muscles from disuse, consequent on the state of the jointadmitting of but little motion.The patient often complains of pain of the knee, referring

it to the inner side. This pain has usually been consideredsympathetic, and I believe that it generally is so, but M.Bonnet, to whose work I shall again have occasion to refer;considers that the pain arises from actual disease in that joint."(Tome ii. p. 275.) He is not able to prove this opinion bynumerous facts, for he says, " I have neglected, as precedingauthors have done, to open the knee-joint,"-in those cases inwhich he has dissected the hip-joint; but on one occasionwhen the hip had suffered from chronic disease, he foundsynovial disease in the knee, with absorption of the cartilages.He attributes this secondary affection of the knee-joint to thecompression and distention which the knee-joint suffers frontthe false position in which it is placed by the fixed flexion and.inversion of the thigh.

In the case of E. C-, there was unequivocal shorteningof the limb, so much so, that s]4e required a sole to her shoe of