No. 1592.

MARCH 4, 1854.

Clinical LecturesON

DISEASES OF THE JOINTS.DELIVERED BY

SAMUEL SOLLY, ESQ., F.R.S.,SURGEON TO ST. THOMAS’S HOSPITAL.

GENTLEMEN,—From the lower extremity we must ascend tothe upper, and we have already some cases in the wards whichwill serve to illustrate this series of lectures. The sterno-clavicular articulation would, in the regular surgical course,be the next joint to engage our attention; but as we haveno case in the house in which this joint is the subject of disease,I must proceed at once to the shoulder-joint. As a generalrule, you will find a great disproportion in the number of casesin which the joints of the arm are diseased, in comparison withthe legs; and this fact you will readily understand when youconsider how much more the legs are exposed to injury thanthe arms; also hovs much more difficult it is to induce a patientin the early stage of disease to rest the leg than the arm. The

consequence is, that we shall not find such an ample supply forillustration as we have hitherto enjoyed; nevertheless, I thinkwe shall not long wait for ample food for thought.The synovial membrane of the shoulder-joint is not unfre-

quently inflame 1, and the joint soon becomes distended withfluid, and the whole form of the shoulder is altered. In a well-developed muscular man, the beauty of the deltoid is lost, anda large pyriform swelling appears to occupy its place. In athinner subject, the point of the shoulder is a little less pro-minent, from an unnatural bulging of the arm just below it.In the examination of this joint for the purpose of detectingthe existence of disease, and diagnosing its nature, you will.find it necessary, as I stated in reference to the knee-joint,that you should expose both joints at the same time, to be ableto compare them one with the other. It is then that you seethe features of the disease clearly, and the slightest deformitybecomes at once apparent. We have two well-marked cases ofdisease of the shoulder-joint at present in the house, and thesewe will take as the text of further observations on the moreimportant forms of disease of this joint.Chronic Inflammation of the Shonlde1’-jo’int,. Enlargement of

the H ea,l of the H nmenlS Abscess discharging at middleof A rrn.

(Reported by Mr. CHIPPERFIELD.)Thomas S-, a labourer, aged twenty-seven years, ad-

mitted into Abraham’s ward, under the care of Mr. Solly, onthe the 22nd of November, 1853." H1’story.- Was born at Halstead, in Essex, and has always

lived in the country, and been much exposed to the air, havingfollowed the occupation of a farm-labourer. His. parents areliving, and healthy, but he has lost two sisters from phthisis.He states that he has always enjoyed very good health untilthe commencement of his present disease. He is married, andhas three children. He is not aware that he has ever receivedany injury to the shoulder; but about fourteen months ago he- experienced a sensation of coldness, and a slight pain betweenthe shoulder-blades, which he attributes to having been ex-tremely wet for ten hours whilst employed in dipping sheep aweek or two previously. This coldness and pain continued forsome time ; but he felt no inconvenience at his work until amonth afterwards, when a "’stiffness’’ of the left arm came on,unattended by either redness, swelling, or pain. The "stiffness"of the joint increased, and upon extra exertion or any slightblow he felt some degree of pain, so that he was constrainedto relinquish his employment, and place himself under thetreatment of Mr. Sinclair, of Halstead, who told him that hehad rheumatism in the shoulder, and ordered him colchicum,with warm clothing, and perfect rest to the joint, and fomen-tations, &c. Six weeks after giving up work he found that theshoulder had become very much swollen, the integumentsslightly red, and he experienced some pain, but not of a severe ’character. The swelling gradually increased until it attainedthe size of a man’s head. Counter-irritation was induced bythe application of an ointment, which brought out a crop ofpustules; this was continued for some time, but the swellingalso continued, and spread down the arm. In June or Julythe pointing of an abscess was noticed at about the middle ofthe upper arm. An incision was made, and about a pint and Ia half of thin, unhealthy pus evacuated. The swelling of the I’8h0111iJI’’’ -hTt sHfrh+.lr iJI’’’’’I’>I.>lI’iI. ’1’nl’ rHaQrfQ rnr!

very profuse for nearly three months, and then graduallydiminished, and at the same time the shoulder became lessswollen. A slight, thin, puriform fluid has continued to flowfrom the orifice up to this time, and the shoulder has becomevastly less than it was. "

This acount of his previous history, which is more completethan we usually obtain, shows how extremely insidious theseinflammatory attacks are in some instances. The exposure towet and cold is a very frequent cause of inflammation of thejoints, and the labouring population are not sufficiently care-ful of themselves. Such histories as these, however, arm youwith positive facts to warn your patients against these dangers.Many an individual among the middle and upper classes hashad occasion to regret his imprudence in allowing his wetclothes to remain on after exposure to rain, &c.; yet how oftenwe find men saying, "Oh ! it wont hurt me." If, however,you can say to such a man, I have seen the shoulder-joint con-verted into one large abscess by similar neglect, they begin tothink that that you have just grounds for your advice, andthat they ought to attend to it.

" Our patient is a stout-built, tolerably healthy-lookingcountryman, but exhibiting the strumous diathesis. Happeningto be in London, he was induced to apply at the hospital, andbecome an in-patient." The left shoulder is manifestly of larger size that the right-

the increase being chiefly due to an expansion of the head andneck of the humerus. This is ascertained by manipulation,and it appears that the anterior part of the bone is more en-larged than the posterior."The head of the humerus is, as you know, surrounded by

thick, strong tendons. In fact the capsule of the joint-forthere is no true capsular ligament as in the hip-joint-is formedabove, behind, and before, by the tendons of the supra-spinatus,infra-spinatus, teres minor, and subscapularis muscles. Whenthis joint is actively inflamed, this capsule is infiltrated withinflammatory deposit, and these thickened tissues surroundingclosely the head of the bone, convey to the hand of the ex-aminer the idea that the bone itself is enlarged. It is only byvery careful and repeated manipulation that you ascertainwhether the bony tissue is really enlarged, or whether it isonly thickening of the capsule." The integuments around the joint are somewhat thickened

and indurated, but not discoloured, except what may be theresult of the continued counter-irritation which has been

pursued. There are three large cicatrices, apparently of issues,but he does not think that anything else was applied besidesthe ointment.

" On the inner side of the arm, just above the insertion ofthe coraco-brachialis, there is a small, oblique, fistulous opening,from which a thin, synovial-looking fluid escapes in smallquantities. This leads upwards towards the joint, and ap-parently into it, for a small probe of ordinary length can bepassed up the whole of its length.

" He says that he suffers very little pain now-none, infact, when the arm is at rest; but although he can adduct,flex, and extend the limb, these motions are limited, andabduction can only be performed to a very slight extent. Hecomplains of no pain upon manipulation, except when thefingers are firmly pressed upon the head of the bone, or whenrotation on its axis is performed. His health appears tolerablygood. He says that he has gained flesh lately, though he wassomewhat reduced by sweating at the time the abscess wasdischarging freely. Mr. Solly examined him, and ordered fulldiet. Sulphate of quinine, one grain, twice a day."

"Dec. 3rd.-He continues in much the same state, butbelieves himself that his arm is stronger. He finds that he ismuch better when the arm is quite at rest. Health very good.Pulse firm and steady; tongue clean; bowels open; appetitegood. To continue the pills, and have the arm confined tothe side by a broad roller.

’

" In statu MO. Mr. Solly had a long probe procured, andupon introducing it found that it passed readily into the joint,he believed through the bicipital groove. This produced somepain and an increased flow of fluid, but no carious bone couldbe felt.

11 complete rest to be observed. To continue the quinine ;and the seton to be introduced through the deltoid."As I have already stated, it is extremely difficult, in these

cases, to distinguish between actual enlargement of the head of £the bone and apparent enlargement from an infiltratedcapsule. Do not confound an illfiltrated capsule with a dis-tended capsule.

In synovitis, followed by hydrops articuli, or purulent effu-sion, you have a distended capsule. In this very case,

236

previous to his admission, and the bursting of the abscess, thejoint was distended. But an infiltrated capsule is the result oflong continued inflammation, and the one must not be con-founded with the other. The physical examination of thispoint certainly gave the impression, as stated by my dresser,in his notes, that the bone itself was enlarged. In which caseit was more than probable that the enlarged head containedwithin it a piece of necrosed bone. As this condition of thejoint could only be ascertained by further examination, and itwas evident that he was not suffering from any actual inflam-mation of the joint at the present time, I determined tosupport his system, and watch his general health.

It is very necessary in the treatment of the agriculturallabourer in a London hospital to avoid frightening him withthe idea of any operation being necessary, however slight.

After your patient has been in the hospital a short time,and seen you from time to time, he gains confidence in you,and will readily submit to much that he would have shrunkfrom at first, or the bare proposal of which would have senthim flying back to the country.The examination by means of the probe did not educe any

fresh fact, and the comparatively slight disturbance of thetissues surrounding the capsule induced me to hope that therewas not any sequestrum to be removed. The fact of the jointbeing much easier when at rest, and the pain being greatestwhen the articulating surfaces were brought into contact,induced me to believe that there was ulceration of the carti-lages. I therefore confined the joint by a bandage, and adoptedthat kind of counter-irritation which I have found most con-venient and serviceable in the treatment of diseases of theshoulder-joint-namely, the seton.

"Dec. 14th.-The seton has been put in, and a free dischageof pus set up. Since its introduction the fistulous opening atthe middle of the upper arm has discharged much more freely;the pus being of a thin, ichorous nature, irritates the surround-ing integuments to a considerable degree. His health is suffer-ing ; the bowels are confined, he is thirsty, has slight pyrexia;with some little cough. To have a dose of house medicine.17th.-The medicine has relieved the bowels, but he still

suffers thirst and anorexia; complains also of headache, watch-fulness, and night-sweats. The swelling of the shoulder isdiminished, and the acromion process is now prominent, andthe shoulder flattened above in consequence of wasting of thedeltoid. The head of the bone can consequently be moreplainly felt, and its expansion is considerable and beyondquestion. The sinus continues to discharge freelv, as does alsothe seton. To omit the quinine for a couple of days.

"21st.-Health somewhat improved; appetite returned;thirst diminished; pulse 84, soft; skin cool and moist; tonrueclean; bowels open. The joint is in much the same conditionas at last report. To resume the quinine.

.

"28th.-Says he feels better, but thinks the air of the

hospital disagrees with him. Has symptoms of hectic fever,not fully established at present. He shows signs of generalemaciation, but his appetite remains pretty good, and he hasnearly lost his thirst. The night perspirations are diminished.Has no pain in the shoulder, the limb being kept at perfectrest, but the seton is a source of uneasiness to him, and Mr.Solly therefore ordered it to be removed.

"Jan. 4th, 1854.-His general health is improving; theshoulder remains in much the same condition; the seton is

healing ; the sinus continues to give exit to a thin, purulentfluid. "

The next case to which I must direct your attention isinteresting, in the first place, as contrasted with the last, inreference to the origin of the disease. A direct injury, weshall find, has been the immediate cause of the mischief. Weneed not warn our friends to avoid blows, but still we may beuseful to them by telling them not to consider any blow over ajoint as a trifling matter.

There is no science to which the old and homely proverb of"a stitch in time saves nine" is more applicable than in thetreatment of diseased joints; very mild treatment will oftensubdue that disease in its onset which the most active fails tocontrol when the disease has been neglected some weeks.

" inflammation of the rticzzla7 Cm-tilages of the Right<S7:o;tMe)’-’o.

James S-, a porter, aged fifty years, was admitted intoAbraham’s ward, under Mr. Solly, on the 22nd of November,1853. Ten weeks ago, he fell heavily upon the right shoulder,which in a day or two presented appearances of having sus.tained a severe bruise. He suffered some pain in the joint,but nothing to alarm him, though he found himself unable tc

raise a weight without considerable pain. He continued athis work for a fortnight, and then found the weakness anduneasiness upon motion considerably increased, and began atthe same time to experience pain when the joint was at rest;some trifling swelling also occurred. This condition of thingsprevented him from following his employment, and he gave itup in the hopes that rest would soon put all to rights.

" He has now been out of employment eight weeks, but hasfound no improvement in the state of the shoulder; has ob-served that the arm has become weaker every day, and notonly has the swelling subsided, but there has been gradualwasting of the muscles about the joint." "From this account you will perceive that the inflammatory

action did not run on to suppuration, or even increased secre.tion of synovia into the joint. There has been some swelling,but this has been trifling, and has soon subsided. The form ofthe head of the humerus has not been altered by fibrinousdeposit. But still, observe, the form of the shoulder is altered,its rotundity is lost; the point of the acromion projects un-naturally on the diseased side.What is the pathological explanation of all this? Simply

that the muscles in the neighbourhood of the joint have wasted,but especially that beautifully modelled mass of flesh, thedeltoid.Why do these muscles waste? Because they have not been

used. This certainly is the cause of the change, but this isnot all. Nature always teaches us aright, if we will only takethe trouble to read her book with thought and patience.

I believe that the absorption of muscular fibre in the neigh-bourhood of a diseased joint is a conservative action to keepthat joint at rest; and if we follow this lesson as we ought todo, we shall do more for the poor joint than by all thecounter-irritation that was ever invented. I do not mean to

imply that the benefit derived from counter-irritation is

triflmg, but that the rest is the most important, and the useof blisters, setons, and moxas secondary.

" He is a broad-built, but very thin man, with a sallow,rather unhealthy aspect, but stated that he has always enjoyedtolerably good health. He has some slight power of motion,but each movement is productive of uneasiness, more especiallyabduction of the arm. He does not appear to suffer anyincreased pain when pretty firm pressure is made upon thehead of the humerus in front; but he winces when the fingersare firmly pressed on the posterior part. Passive rotation ofthe bone upon its axis is not irksome, but he complains ofsevere pain when the head of the humerus is percussed, so asto bring it sharply in contact with the glenoid cavity of thescapula.Nov. 23rd.-Mr. Solly saw him to-day and diagnosed the

case as one of inflammation of the articular cartilages. Heordered full diet, the arm to be kept at rest, a seton to be in-serted behind the joint. The seton was introduced as directed,and is now suppurating very freely. There is much less painin the joint; none when the arm is at perfect rest, and con-siderably less upon motion. To have the arm confined to uheside, and the elbow supported by means of a broad roller.

" Dec. 7th. -Feels that the joint is much better ; has sufferedno pain since last report, and thinks he could make much moreextended use of the arm than before admission, without anyuneasiness, were he allowed to attempt it. Seton dischargingpus freely.

"Dec. 14th.-Going on very well. Has no pain, exceptwhen the head of the humerus is struck. The appearance ofthe joint is much the same as upon admission; if anything,emaciation has advanced slightly; a copious discharge takesplace from the seton; general health tolerably good.

" Dec. 21st.-In sta&iacute;1t quo. Feels confident that he coulduse the arm without inconvenience were he allowed to gowithout the bandage. Percussion of the head of the humerusand firm pressure on the posterior part of the glencid cavitydo not give so much pain as formerly. There is a little irrita-tion set up by the seton, which Mr. Solly desired to be re-moved. "

Inflammation of the articular cartilages frequently followssynovitis, but it may, as in this case, arise as a specificdisease, and be limited to a portion of the joint. Thesecases are generally very obstinate. The ulceration of thecartilage often extends to the bone, and caries is the con-

I sequence. Matter is formed in the joints which, finding itsway out, forms a fistulous communication through the skin,and discharges externally. In old-standing cases of this kind

, you will find many such openings, and if by means of theprobe you can detect extensive carious disease, which appears

I to affect your patient’s health so as to endanger his life, it

237

would be your duty to operate. I do not, however, mean tolimit the propriety of operating to cases in which the patient’slife is in danger, as there are cases in which the joint is sodisabled as to be useless, where you are justified in excising the’head of the bone; but still you must be cautious, the

shoulder-joint must not be interfered with lightly; and youshould ascertain, by careful watching the character of theconstitution of your patient before you touch him. You must

mot admit a patient one day and operate the next. You must

study his constitutional tendencies. As I have frequentlysaid, in one man you may remove a large joint with impunity,in another you can hardly open an abscess without kindling aflame of constitutional irritation which will carry him to hisgrave in spite of the most judicious treatment. I do not meanto say that you can always predicate the effect which an ope-ration will have upon a patient, but long-continued observa-tion in the wards of a large hospital will materially assist yourjudgment, and guide to a conclusion which will generally beaccurate. You may judge a good deal by the usual mannerand countenance of a man. A quiet, phlegmatic mien isgenerally accompanied with a quiet, equable pulse, and witha nervous, excitable manner you almost always find the heartirritable, and the pulse vacillating. As regards complexion, Ishould prefer rather a muddy hue, if the red blood is notentirely obscured, to the transparent skin, which shows thecrimson current in all its superficial channels; but it is diffi-cult to describe in words all these shades of difference. I mustcall your attention again to it in our visits to the bedside.On two occasions I have excised the head of the humerus for

long-standing disease of the joint, and in both successfully.The first case was that of a female, named Catherine C

aged twenty-seven. She was admitted on the 12th of April,1849. I operated on her some time in June, but unfortu-nately the notes of tile case have been lost; but I am able tostate by memory that the operation was perfectly successful,and that she left the hospital quite well on the 25th of August,1849.The second case was peculiarly interesting. The patient was a

remarkably fine man, thirty-five years of age. He had been a

pit-man in the collieries near Newcastle, and after having beenin the infirmary under that prime old surgeon, Sir John Fife,determined to try what London could do for him. He walkedall the way up from Newcastle, and arrived here in prettygood condition. He was a tall, strong, healthy-looking man,with a ruddy, not hectic, complexion, and a quiet, determinedmanner; pulse firm and equable. His condition on admissionwas thus described by my dresser, Mr. Craven:-

" Disease of the Head of the H umerllS." Terence M’C-, aged thirty-five, admitted into George’s

ward, under the care of Mr. Solly, April 12th, 1849.Pi-6,-ent appearance.&mdash;Anteriorly there is a sinus a little

above the lower margin of the pectorus major, about themiddle of a line, extending from the nipple to the shoulder-joint. A probe passed into this opening, reaches up to thet shoulder-joint, but without impinging upon any exposed bone,and opening No. 1. There is another opening, with a scab,over it, on the anterior part of the arm, opposite the insertionof the deltoid; there is a third completely in the axilla; afourth at the back of the arm, even with the lower margin ofthe deltoid; and a fifth over the infra-spinous fossa, about twoinches above the inferior angle. A probe passed through allthese openings, and reaches more or less to the shoulder-joint.The general rotundity of the shoulder is rather lost, thedeltoid being shrunk. The acromion appears to project morethan natural. He can move his arm backwards and forwardswithout any pain, and he can raise it with the scapula; but ifyou attempt to move it, fixing the scapula at the same time,he is in great pain.

"History.&mdash;About fifteen months ago he first felt a pain just.at the insertion of the deltoid, and a difficulty in moving the-arm-, the difficulty was greater than the pain. He continuedhis work for two months. He states that he never had a blowon the part, and he does not know what to attribute it tounless exposure to cold and wet. When he left off hiswork, the arm and shoulder were swollen, and a large quantityof matter formed, which was evacuated by opening No. 3.This opening healed, and he went to his work again in Junelast. It ulcerated again, and a large quantity of matterescaped ; and on the 1’rth of August he went into the New-castle Infirmary, under the care of Sir John Fife, where stimu-lating lotions were injected into the sinuses, which had theeffect of diminishing the discharge. The openings Nos. 2, 3,4, 5, were formed after the original opening was healed up,

and there was a considerable quantity of matter came fromthem. Diseased bone can be distinctly felt with a probe atthe bottom of two of the sinuses."

I shall not detain you with any daily notes of this case, butmerely detail the general course and result. On his admission,I gave him the iodide of potassium in the infusion of gentian,and after watching his condition very carefully, and severalconsultations with my friend, Mr. Green, I determined to ex-cise the caput humeri. On the 2nd of June he was broughtinto the theatre. I made a semicircular incision through thedeltoid down to the capsule of the joint, which was nextdivided, and then the head of the bone protruded from thesocket was excised with a small saw through the anatomicalneck of the bone. The whole operation only occupied a fewminutes. The flap of skin and deltoid was kept in contact byeight sutures, strapping, and roller. The greater part of thewound healed by the first intention in a few days, but twosinuses remained open for some weeks. He left the hospital

’ quite well on the 16th of February, 1850, with a very usefularm. The treasurer and almoners kindly paid his passageback to Newcastle, and sent him on his way rejoicing. In

. this case the glenoid cavity of the scapula was quite healthy,but the head of the humerus was soft and carious.

. In the performance of this operation, you must be carefulnot to excise too much of the bone; the less the better, so thatyou remove all the disease.

. In the next case that I have which I think is fitting foroperation, I shall in all probability use the gouge in preference

to the saw, but of course I shall be guided by the state inwhich I find the head of the bone. If the greater part of thehead is diseased, I should then prefer the use of the saw, buton this subject I shall have more to say to you when we arriveat the elbow-joint; and in illustration of this part of my subject,

! I have, as you know, one very interesting case at present inthe hospital.

ON THE

MEDICAL SERVICE OF THE BRITISH ARMY.

BY GEORGE JAMES GUTHRIE, ESQ., F.R.S.LATE PRESIDENT OF THE ROYAL COLLEGE OF SURGEONS.

IN my " Commentaries on the Surgery of the War in Portugal,

Spain, France, and the Netherlands, from the first battle ofRolica in 1808 to that of Waterloo in 1815", showing the im-provements made during that period in the great art and scienceof surgery, both civil and military, I endeavoured to lay downpractical and scientific principles on which the wounded of theBritish army should in future be treated. In another place, Ihave said that the surgical precepts I had thus endeavoured toenforce were not carried into execution on scarcely any of thegreat occasions in which they were most wanted, in consequenceof the defective state of the administrative arrangements. Themedical men were almost always unequal, from the paucityof their numbers, as well as their inefficiency, to the dutiesrequired from them; and the wounded, although all receivingsome little attention, were necessarily neglected on manypoints essential to their safety. To remove or even to dimi-nish these evils some strong prejudices must be overcome;great alterations must be made, which can only be effectedthrough the medium of public opinion, and that so tho-roughly expressed as to command attention. Althoughthirty-eight years have elapsed since the last great Europeanbattle of Waterloo, I have declined entering upon this subject,because I felt I could not do so without, perhaps, causing someannoyance to many whose feelings I was bound to respect. Theyhave now nearly all passed away, and on the eve of another warit would be highly culpable to refrain from making such state-ments as may give rise to those alterations which humanity soimperatively demands. I am aware that it may be asked whythey have not been privately addressed to the Secretary at War,the Commander in Chief, &c.; and, if so asked, the reason Ishould assign would be, that, however powerful these personagesmay be, each in his own department, they are not potent enoughto overcome the difficulties and objections which would be madein other departments whose acquiescence must be obtained.The evils, then, of which I complain cannot, I may say, be rec-tified until they have been thoroughly discussed, and theirremoval declared necessary by public opinion. Some years ago,when Lord Hill was Commander in Chief, and Lord VivianMaster-General of the Ordnance, I drew their attention privatelyto the inefficient state of the carriages in use in the British armyfor the conveyance of wounded men. They assented to a trial