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open such an abscess when diseased bone is present, the chancesarc he never leaves his bed, but dies before the end of manyweeks, worn out by profuse discharge; and therefore, if youhave reason to think that the bone is diseased, it is better towait, unless there be some unpleasant circumstance, making itnecessary to evacuate it at once. In pursuing this course, youavoid doing harm to your patient, which of course is the firstconsideration. At the same time, you avoid a step that mayinjure yourselves. If a patient who has had an abscess formonths, or for a year or two, dies a few weeks after youhave opened it, the friends naturally impute the result to yourinterference, rather than to the disease, and discredit is thrownupon the art which you profess, so that others are preventedfrom availing themselves of its benefits. Observe, I never givethe cowardly and unprincipled advice, to abstain from anymeans of treatment, so long as it affords any chance of benefit Ito the patient, however likely it may be to bring either surgery Ior yourselves into discredit by its failure; but, on the otherhand, in a hopeless case, it is quite right that your choice oftreatment should be infinencecl by these considerations. I willnow show you a patient, who has just come to the hospitalwith a large abscess in the groin, and we shall endeavour toascertain whether or not it is connected with disease of thespine.[The patient, a very robust man, thirty-one years of age,

from Wick, in Caithness, was now brought into the theatre. Alarge abscess existed on the upper and inner part of his rightthigh, and on making alternate pressure with the hands, placed,one over the abscess in the thigh, and the other above Poupart’sligament, the sense of fluctuation communicated to the fingersmade it clear that the collection of matter extended higher thantimt band, but the size of the tumour in the thigh remainingthe same in the recumbent as in the erect posture, Mr. Symeinferred that the extent of the abscess above Poupart’s ligamentcould not be great. The man stated that for the last threeyears he had experienced some uneasiness and weakness in theback till five months ago, when the abscess appeared, sincewhich his back had been quite strong, and free from pain. Thatthe symptoms referred to the back were not very severe, isevident from the fact, that he continued his violent exercise asa sawyer for nine to eleven hours per diem during the whole ofthe three years, till within eight days of his admission to thehospital. He said that the abscess had not increased appre-ciably for some months, and gave him very slight inconvenience:he could walk twenty miles without difficulty, but after suchexertion he felt pain in the limb, from the knee to the hip-joint, but the perfect similarity of form of the two nates putdisease of the latter articulation quite out of the question. Mr.Syme, in remarking upon the case when the patient had leftthe theatre, said,] ]

There can be no doubt that abscesses such as this very fre-quently proceed from incurable disease of the spine. Someauthorities have not hesitated to affirm that this is always thecase; but I am happy to say that such a statement is toosweeping, for I have again and again met with distinct cases ofrecovery. Not long ago I saw a young man who was under mycare twenty years ago, with abscess in both groins, the collec-tions of matter of the two sides communicating freely with oneanother, so that when he lay on one side, the tumour in thatgroin became tense, while that on the other side was relaxed. Ashe suffered considerable pain in the back, I applied the actualcautery as a preliminary measure,with the effect of removing thatsymptom. I then opened the abscess by trocar, and partiallyemptied it, and afterwards repeated the process. This patient isnow grown up to a strong healthy man, and one such case servesas well as a thousand to prove the point. With regard to thepresent case, I am inclined to think that the abscess is not con-nected with the spine, otherwise he would, I think, hardly beable to walk so well, or, still less, to continue his employmentas a sawyer for hours together; for this occupation, besides re-quiring proverbially great exertion, implies also a degree offlexibility in the spine, which seems inconsistent with the ideaof caries of the lumbar vertebras. Persons affected with suchdisease commonly have more or less rigidity of the spine, as ifthey had a poker in their back, as it is said; and you will re-member that the boy with acute curvature had this symptomto a marked degree. While, therefore, I cannot help enter-taining some lurking apprehension of caries of the vertebral inthis case, I, on the whole, incline to think it more likely thatthe abscess is independent of diseased bone. I shall, therefore,proceed to evacuate the cavity, and as it is very extensive,there would be some danger of serious results from inflammationof its parietes, were it opened freely, and, therefore, I shall use ’the method recommended by Abernethy—viz., to puncture it

with a canula and trocar, not drawing off all the fluid at once,but after allowing the cavity to contract to a certain extent inthe first instance, draw off the remainder after eight or tendays, and we shall then, perhaps, inject tincture of iodine, ifthis should then appear expedient. We know the effect pro-duced by this agent in causing the obliteration of serous cavities,and I have tried it repeatedly upon abscesses like this. I can-not say, however, that the results hitherto have been veryencouraging, but this is just a case for it if ever it is to be

employed. -- -

LecturesON

DISEASES OF THE JOINTS.Delivered at St. Mary’s Hospital.

BY WILLIAM COULSON, ESQ.SURGEON TO THE HOSPITAL.

LECTURE XI.

DISEASE OF THE KNEE-JOINT.

(Concluded from p. 381.)

WE have next, gentlemen, to enter on the consideration of avery interesting disease-viz., chronic inflammation of theknee-joint. This is a very common complaint, and it has beenstudied more carefully than any other form of articular affec-tion ; its morbid anatomy is investigated without difficulty,because the frequent operations performed on the lower extre-mity in connexion with the disease give frequent opportunitiesof investigating it under various circumstances. Notwith-

standing these advantages, we must confess that there are stillmany questions relative to chronic inflammation of the knee-joint which require further elucidation. Let me give you asingle example. Even in the present advanced state of ourknowledge, it is extremely difficult, I might perhaps say im-possible, to form a satisfactory classification of chronic diseasesof the knee-joint. We can advance to a certain point, butbeyond this commences the difficulty. Thus we may placemalignant diseases in one class, gouty and rheumatic inflamma-tions in another, traumatic inflammations in a third, &c.; we

may eliminate the principal inflammations of a specific or con-stitutional nature; but beyond them we find a large number ofchronic cases, which present themselves every day in practice,and which it would be useful to distinguish into certain classes,if we could do so without danger of confusion. But on com-

paring the symptoms which have been laid down as diagnosticsigns between inflammation of synovial membrane, cartilages,and bones, with the progress of articular disease, such as wesee in the living body, we must confess that many of thembelong as much to one class as to another. Thus it is generallystated that scrofulous inflammation of the joints is an inflam-mation of the ends of the bones which compose an articulation;but if we confine our notion of the disease to the symptomswhich indicate osteitis, we shall fall into error, because expe-rience teaches us that the complaint is very frequently an in-flammation of the synovial membrane, and not of the hardparts of a joint. In this difficult matter I do not pretend tooffer you anything better than my predecessors. It appears tome, however, that much of the confusion relative to this sub-ject depends on the circumstance that different stages anddifferent degrees of the same lesion have been described as somany classes or varieties of disease. To avoid, if possible, thiserror, I would divide chronic inflammations of the knee-jointinto two kinds. In the one we have common inflammation

running its ordinary course, and accompanied by slight effu-sion of plastic matter, which have no tendency to becomeorganized. In the other form we have chronic inflammation,attended from an early stage with the effusion of plastic matter,lymph, fibrine, (call it what you will,) which has a tendencyto become organized and transformed into a vasculo-cellular,pulpy, or fungous tissue, the development of which continuesin various degrees until pus is secreted, the cartilage destroyed,and the soft parts outside the joint involved in the disease.This form will include white swelling or scrofulous inflamma-tion of the knee-joint, which is nothing more than the chronicform of inflammation now alluded to, occurring in scrofuloussubjects. With these preliminary remarks, let us pass to themorbid anatomy of chronic inflammation of the knee-joint..

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In the simple form, which may succeed the acute inflam-mation just described, or may be subacute from the com-mencement, we find the usual appearances of common inflam-mation. The synovial membrane presents various degrees ofinflammatory injection and thickening; lymph is deposited inthe sub-synovial cellular tissue; there is also effusion of

lymph, though in smaller quantity, on the free surface of thesynovial membrane, giving it a rough appearance. In some

places, perhaps, this lymph has produced adhesion of the

opposite surfaces of the membrane; it is then white and fibrous,like the lymph of pleuritis. The cavity of the joint containsturbid serum, or a fibrino-albuminous fluid. When the diseaseis more advanced, erosion of the cartilages at various pointsexists; the bones may be laid bare and carious. We now findsome purulent matter in the joint, though this is not constant,the effused fluid being, even at this stage, sometimes sero-sanguineous. The ligaments and soft parts external to thejoint are not implicated in any considerable degree ; the tume-faction of the soft parts is chiefly produced by serous effusioninto the cellular tissue. Such are the changes which charac-terize the most simple form of chronic inflammation of thejoint, but we must not expect to find this simplicity in allcases, for there are many in which the morbid appearances are Ifound running with various degrees of intensity into those of ’,the next kind. Indeed, it seems highly probable thatdestruction of the cartilages and secretion of pus cannot existwithout the previous organization of coagulable lymph; this,however, is one of the points which require further examina-tion.

Chronic inflammation of the knee-joint, accompanied by thedevelopment of cellulo-vascular tissue, is the most frequentform under which the disease appears. It constitutes, whenin a severe degree, white swelling of the joint, and thereforerequires a minute and careful description. Let us examinethe lesions as they occur in the synovial membrane, the carti-lages, the bones, and the extra-articular tissues. The disease,I may premise, commences either in the ends of the bonesor in the synovial membrane; and as this latter, in themajority of cases, is the tissue originally affected, I shall takethe series of lesions which ensue as the type of the disease.In the earliest stages, then, the synovial membrane is moreor less red and injected; the internal or free surface has lostits brilliant appearance, it looks dull and opaque; it is no

longer smooth, but here and there rough; in some cases themembrane is of a brownish-red colour, either uniformly or inspots, probably from effusions of sanguineous serum. Themembrane is somewhat thickened, but at this stage it has notyet become soft; it adheres to the subjacent cellular tissue

through effused lymph, and it is principally on this effusionthat the thickening and opacity of the synovial membranedepend. The fluid contained in the joint at this stage is notabundant; it consists at first of synovia somewhat modified inquality. The synovia is less transparent than natural; it isthick, and of a greenish colour. The dull, opaque colour isproduced by an admixture of fibrin, as is shown by the effectof mixing with it a solution of caustic potass; this dissolvesthe fibrin, and the fluid becomes clear. As the disease ad-vances we discover more palpable evidences of inflammation.The synovial membrane is thicker and more firmly adherentto the subjacent cellular tissue from the effusion of lymph; itis often raised up, and forms a ring round the cartilage atthe points where it is reflected; it is now generally soft-ened in some degree from the influence of the lymph,which has been effused on its surface or in its substance.The injection and the deposit of lymph are usually mostabundant in those parts which are naturally most providedwith vessels. Thus it is very abundant in the sub-synovialtissue, where it forms a whitish or yellowish layer, andlikewise in those places where the membrane is doubled onitself. The lymph, which is found in shreds, packets, or inthin layers of false membrane, is the product of inflammatoryaction. In the simple cases already described, these falsemembranes are exactly similar to those which are found on theinflamed serous surfaces of the pleura and peritoneum; theyhave the same appearance, the same structure, and, whenexamined by the microscope, or through chemical agents, theyfurnish the same results.

In the second form of chronic inflammation, the plasticmatter which was primarily effused does not assume the sameappearance as the effused coagulable lymph ot serous inflam-mations under ordinary circumstances. It undergoes a gradualtransformation into a vascular or fungoid cellular tissue, andthen passes by further development into lardaceous, fibrous,or, it may be, osseous tissue. This tissue of new formation in-

vades the integral tissues of the joint, and of the surroundingsoft parts; it produces gelatinous degeneration of the synovialmembrane, and is probably one of the chief causes of destructionof cartilage, being found in the cancellous structure of the endsof the bones; in a word, the development of this tissue coii-

stitutes the essential element of the chronic inflammation whichI am about to describe to you, and of which the type is the well-known disease called white-swelling of the joints-tumouralbus. I shall therefore enter into some details relative to thedevelopment of this tissue.The lymph effused both in the substance and on the surface

of the tissues of the joint, instead of remaining white, becomespenetrated with a number of fine vessels, which graduallyincrease in number and calibre. This is the first change thattakes place. The false membranes are in the first stage ofdevelopment, just becoming vascular. On examining themembrane at a later stage under the microscope, it is found tocontain a number of globules, each enveloping a single nucleus.These globules, as development proceeds, are graduallyelongated into fibres similar to those of cellular tissue, and asthis tissue is penetrated by numerous fine bloodvessels, wehave at last a cellulo-vascular tissue of new formation. Theextent to which the tissue has been formed, and the degree ofdevelopment at which it may have arrived, constitute theprincipal varieties of appearances found in chronic inflamma-tions of the knee-joint. In some cases, it is formed in thesynovial membrane, from the surface of which it projects likethe papillar eminences of velvet tissue; in others, the wholesurface of the membrane is covered with a layer of it; thebloodvessels are not very numerous; the new tissue is infil-trated with serum; the synovial membrane and the subjacentcellular tissue are much thickened and softened. This changeconstitutes the pulpy, gelatinous degeneration which was firstdescribed by Sir Benjamin Brodie. In other cases the wholejoint is invaded by this tissue, which is extremely vascular andsoft; the synovial membrane is converted into a pulpy mass;the cartilages are eroded or ulcerated; tissue has been deve-loped between the bone and cartilage, rendering this latterloose, or even detaching it altogether from the bone; it pro-jects from the surface of the denuded bone in the form offungous granulations; or it fills the cancellous structure ofthe ends of the bone, under the appearance of softenedspleen-tissue. All the parts external to the joint are con-verted by it into an homogeneous mass, in which liga-ments, nerves, and vessels are traced with difficulty. Thiscondition forms the last stage of white swelling-the fungoustumours of some foreign writers. It would, indeed, almostappear that this tissue has the power of generating itselfby the effusion of fresh albuminous, fibrinous matter, whichis gradually transformed into cellulo-vascular or fungoustissue. When examined with the aid of chemical reagents,it is found to contain the same elements as ordinaryfalse membranes; it is composed of albumen, fibrin, fattymatter, and salts. There is, however, this difference, thatthe fibrin seems to be in great measure replaced by gela-tine. There is also another difference which is worthy ofnotice. The cellulo-vascular tissue always contains a certainquantity of exudation globules and nucleated cells, in courseof being transformed into cellular tissue. This shows thatsome pathological change is constantly taking place in thistissue, whereas the false membranes of healthy inflammationundergo no such change. Lastly, I may observe that thelymph effused into the sub-synovial tissue during this form ofchronic inflammation is rapidly transformed into cellulo-vascular tissue, whereas the effusions underneath the pleura,peritoneum, and arachnoid never undergo this change.The effused plastic matter does not always present itself

under the appearance of vascular tissue. It is often of a

yellowish, whitish appearance, rather firm than soft, andsometimes even fibrous. This difference arises from the pre-dominance of the fibrous element over the vascular in thedevelopment of the tissue, the vessels are smaller and lessnumerous, the nucleated cells in greater number. Hence, asdevelopment proceeds under these conditions, we have a paler,firmer tissue with the appearance which has been calledlardaceous. It does not seem quite certain whether thisdepends on an original tendency, or on the obliteration ofbloodvessels in the more vascular deposits which are thusgradually converted into lardaceous and fibrous tissues.However this may be, we often find various stages of tissuesin the same diseased joints, where one is apparently passinginto another.The cartilaginous coverings of the ends of the bones present

several changes worthy of notice in cases of chronic inflam-

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motion. Thess changes are always most evident at the points numerous and thinner than natural; the cells contain a softwhere the cartilage is in contact with the false membranes pulpy vascular tissue ; hence the substance of the bone ap-already described. Swelling of the cartilage, with or pears to be softened, it breaks down readily under the pressurewithout softening of its substance, is one of the earliest and of the probe, but the osseous tissue itself has not really under-most common changes. The tumefaction is produced by infil- gone any other change than that produced by absorption. Thetration of serum, and this is probably derived by imbibition softening of the bone depends on the disappearance of the osseousof that fluid from the cavity of the joint. The cartilage now walls of the areolae, and the presence of the pulpy matter inlooses its natural colour, and beccmes yellowish, it is also the dilated cells.

deprived of its natural elasticity, for on pressing the point of At a still later period the softened bone tissue contains pus,the scalpel against it we feel no resistance. When the softening and we then have caries fully established, with its characteristicis extensive, the whole cartilage may be converted into a changes-viz., thinning of the osseous tissue, development ofsubstance like gelatine. soft, vascular tissue, and secretion of pus. The pus is eitherAnother change, of very frequent occurrence, is loss of sub- infiltrated through the meshes of the vasculo-cellular tissue,

stance of the cartilage. The nature of this change has been or it is contained in small cavities lined with a pyogenicvariously explained by different authors. Some regard it as membrane. In many cases these cavities or abscesses containtrue ulceration; others attribute the loss of substance to im- small yellowish masses, which, if carefully examined, are

peded nutrition; some, again, hold that the cartilage is found to be composed of albumen and fibrin. Althoughabsorbed by the vascular or fungous tissues which are deve- the rtrified substance of the spongy tissue is in most cases

loped from the synovial membrane and bone, and they assert filled with vascular pulp, it sometimes contains a more firmthat the eroded surfaces are always in contact with false mem- tissue, resembling the lardaceous, into which numerous vesselsbrane. Whatever explanation of the cause may be adopted, may be traced. The circumscribed abscesses in the ends of thethe effects are the same-viz., more or less destruction of the bones occasionally contain sequestra, for necrosis is one of thecartilage. This occurs in various degrees. Sometimes a few terminations of chronic inflammation of the knee-joint, It is

points of the surfaces are removed superficially-the cartilage much rarer, however, to find the bones necrosed than carious.is then said to be eroded; in otiier cases, the whole of the The tibia is the bone oftenest affected. The museum of the Col-articular cartilage has disappeared. Between these two ex- lege of Surgeons contains numerous preparations illustrative oftreme points we find every degree of change. The destruc- necrosis of the articulating ends of bones. In some cases wholetion or uleeration may be of the perforating kind, proceeding plates of bone die and are detached. There is a preparation indeeply from one surface to another, and penetrating the whole the College, showing necrosis of nearly the whole extremity ofthickness of the cartilage, though, to a limited extent, laterally. the femur. Sir Benjamin Brodie found the whole of the upperThe form of the ulceration is round or irregular; in some epiphysis of the tibia necrosed. Many of these cases of exten-cases it looks as if a piece had been chiselled out ; the eroded sive necrosis of the ends of bones, however, are compoundsurface is often lined with a thin false membrane or plastic cases, partly relating to the joint, partly to disease of the boneexudation, containing some fine bloodvessels. The substance independent of the joint. The articulation does not becomeof the cartilage surrounding the ulcerated points is free from involved until the disease of the bone has lasted for a consider-injection; it is sometimes softened, sometimes of natural con- able time, and it is implicated in consequence of the abscesssistence. When the destruction of the cartilage has com- having made its way from the bone into the cavity of the joint.menced at the attached surface, we find a layer of organized The communication between the abscess and the joint is some-lymph between the cartilage and the bone; as this becomes times very small. Occasionally the sequestrum is found loose indeveloped, it raises up the cartilage before it, renders it loose, the articular cavity, or it may have even found its way into one.and sometimes detaches it altogether from the bone, when the of the fistulous sinuses external to the capsule. In many caseswhole cartilage, or some portions of it, may be found loose in of chronic inflammation of the joint, especially when the patientthe joint. is yonng, we find a peculiar condition which must not be passed

Chronic inflammation of the knee-joint, when it has existed over without notice. 1 allude to the deposit of tubercularfor any length of time, generally extends to the osseous tissues. matter which sometimes takes place when the disease occursThe disease, on the other hand, may commence in the bones in scrofulous subjects. The tubercular matter may be depositedthemselves, and hence we have two series of lesions, the one in the cavity of the joint or in the ends of the bones; it maysecondary, the other primary. Both lesions exist in the ex- be solid, or softened, and fluid. Rokitansky was, I believe,tremities of the bones, close to the cartilaginous coverings, and the first who pointed out the occasional presence of tubercularseldom extend to any distance from them, but when the medul- matter in a free state within the cavity of the joint. Accord-lary membrane becomes inflamed the disease may extend along ing to this pathologist, the tubercular matter is deposited ona considerable portion of the limb. Secondary lesions of the the surface of the synovial membrane and cartilages, sometimesosseous tissue are observed when the cartilages have been re- covering the whole internal surface of the joint, sometimesmoved by erosion or ulceration. The denuded surfaces of the occupying certain points only. It forms layers, somewhat simi-bone are then found inflamed and in a carious state, often lar to false membranes, of a yellowish colour, and soft likecovered with granulations, or with the cellulo-vascular tissue cheese: no vessels or cellular tissue can be traced in thesealready described. layers. The matter itself contains molecular granules and irre-

In the primary form we have the various stages and effects of gular globules, without any nucleus on which acetic acid doeschronic in&a.mma.tion. Few opportunities are afforded of ob- not act, but which are soluble in saturated solutions of the

serving it in a very early stage, but we can often trace the alkalies. Pus is often mixed up with the tuberculous matter,changes to which it gives rise in that part of the tissue conti- also primary exudation globules, and blood globules, &o.

guous to the healthy bone-that is, in the portions of inflamed In the osseous tissue of the heads of the articular bones, thebone most remote from the joint. The slightest form of lesion tubercular matter is either found infiltrated or solid; in a fewconsists in an increased injection of the spongy tissue of the cases it exists under the form of grey granulations. Tubercularbone. This change is found in a very early stage, when no infiltration of the osseous tissue does not differ from the sameother can be discovered. The injection of the vessels is not state in other parts of the body. The cells of the spongyvery distinct; it is rather an uniform and diffused reddish tissue are filled with a soft material, which is either a greyishcolour, much of which probably depends on the discoloured colour or yellow and opaque. These form the grey andserum effused into the cells. The vessels soon become more yellow tubercular infiltrations ; they are not defined, but,distinct and the injection more regular; the tissue is of a deep- diffused through the areolar tissue; they gradually soften,red or brownish colour ; the vascular canals and the cells of the become converted into purulent matter, and form cavities

spongy tissue are dilated, or, to speak more correctly, enlarged; analogous to tubercular cavities in the lungs. The osseousthe cells contain a semi-fluid gelatinous substance. This tissue which surrounds these cavities is always more or less in-effused matter is gradually converted into a soft cellulo- jected, and the cavities, in addition to softened and diffluentvascular tissue, with the development of which the subsequent tubercular matter, frequently contain true pus, cellulo-changes are connected. The tissue is probably derived from vascular tissue, and fragments of bone. The solid tuberclethe fibro-vascular membrane which lines the areola in a healthy is enclosed in a cyst; it is of a cheesy consistence, and palestate, and it is characterized by its great vascularity, softness, yellow colour; it is often softened in the centre. The sur-and richness in exudation globules. As this new tissue be- rounding osseous tissue is much injected, and contains some ofcomes developed, the compact tissue of the bones is converted the products of inflammation. When the tubercle has beeninto a structure somewhat resembling the spongy tissue, while deposited near the cartilage, it gives rise to absorption orthe spongy tissue undergoes the change which has been deno- ulceration of its substance; when near the periosteum, itminated caries. The cells and areola become gradually larger excites inflammation of the fibrous membrane, followed byfrom absorption of their osseous partitions, which are less tumefaction, the deposit of osseous matter, or the secretion of

eno-

.rger

402

pus. Sir B. Brodie has given us an excellent description of Ithis state of the bones in scrofulous subjects; and I may takethis opportunity of reminding you that it is to his patient in-vestigations we owe the greater part of our knowledge ofdiseases of the joints. He was the first who took up the sub-

ject in a scientific manner, and we may be allowed to hopethat his labours are not yet drawn to a close.

Lesions of the soft parts of the joint will comprise those ofthe ligaments and extra-articular tissues. These seldom

present any changes worthy of notice, unless the disease haslasted for a considerable time. The ligaments do not seem tobe susceptible of inflammation, they resist the progress of thedisease long after the integral tissues of the joint havebeen disorganized, and the changes they undergo seem to

depend on the deposit of pus, serum, &c., between theirfibres. The affections of the ligamentous substance are of twokinds, which require to be distinguished from one another. Itis sometimes softened, at other times denser than natural. Thesoftened ligament is infiltrated with a gelatinous-lookingmatter, of a reddish or yellowish colour, its fibres are easilytorn across, and in many cases it appears to have been dissolved,as it were, in this semi-organized material, for no trace ofligamentous fibre can be discovered. In other cases, the liga-ments are more firm than natural, the vasculo-cellular tissuewhich originally penetrated them being apparently convertedinto a lardaceous or fibrous tissue. The swelling of thejoint, so striking during life, indicates that the soft parts aremore or less extensively implicated in the disease. In somecases, as I have said, the swelling is chiefly caused byeffusion of serum, with an admixture of lymph. More c

monly, the tumefaction arises from the circumstance that allthe extra-articular tissues have been invaded by the cellulo-vascular tissue in various stages of development. In severecases, the muscles, ligaments, and cellular tissue outside thejoint appear to be converted into an homogeneous mass by thisfungous tissue, which envelops them on all sides, and penetratesbetween their fibres. In other cases, we find it in differentstages of development-fibrous and lardaceous near the joint;fungous cellulo-vascular more externally; in other points,tending to fatty degeneration. All these may be mixed uptogether, or one form of development may predominate overanother, and this accounts for the great diversity of descrip-tions given by authors of chronic diseases of the knee-joint.The muscles which surround the diseased joint are usuallycontracted; they may be pale and softened, or hard andfibrous; they are often atrophied, and contain an unusualQuantitv of fattv matter between their fibres. The skin isoften of a shining white colour, infiltrated with serum, andcovered with dilated veins. The peculiar colour of the integu-ments suggested the name of "white swelling" for chronicinflammation of the joint; but it frequently happens thatthe skin is more or less red in consequence of the inflammationwhich prevails in the subjacent tissues. The surface of theskin may be uninjured, or it may be perforated in one or morepoints by ulcers, which lead to sinuses and abscesses. In afew cases, the abscess is limited to the cellular tissues externalto the joint; it generally, however, communicates with thejoint, the pus being furnished by the inflamed membranes orbones of the articulation. To avoid repetition, I shall describethe usual course of these abscesses when speaking of symptoms,and shall also defer to another lecture a notice of the changeswhich take place in secondary luxations, and during thereparative processes of soft and hard anchylosis.

STATISTICS OF THE MEDICAL PROFESSION.—ProfessorEscherich, of Wurzburg, has just published tables which wouldestablish that the mortality is greater amongst medical men thanin other professions. The author takes an aggregate of 15,730persons belonging to the following classes :-Medical prac-titioners, Protestant and Catholic clergymen, professors,schoolmasters, the bar, and those employed by the Board ofWToods and Forests. He finds that three-fourths of medi-cal men die before the age of fifty, and ten-elevenths beforesixty. Out of 1168 medical men alive in 1852, four only(S. 34 per cent.) were more than eighty ye-oL1’S old. The tenoldest practitioners numbered together 792 years, whilst theten oldest men taken from any of the above-stated professionspresented much higher igures. Catholic clergymen numbered872 years, professors and schoolmasters 875, and Protestantclergymen 8G5. Out of 100 medical men, only twenty-six hadreached fifty years; and it is well known that, according toCasper’s statistics, the proportion is less favourable in Prussiaas only nineteen per cent. reach the age of fifty.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

ST. BARTHOLOMEW’S HOSPITAL.

ABDOMINAL TUMOURS; OVARIOTOMY, ETC.

(Under the care of Mr. LLOYD, Mr. PAGET, &c.)

Nulla est alia pro certo noseendi via, nisi quam plurimas et morborumet dissectionum historias, tam aliorum proprias, collectas hahere et interse comparare.—MoM.t.&ifi. De Sed. et Cau.. Morb.lib. 14. Proceminm.

ONE of Mr. Lloyd’s cases in St. Bartholomew’s Hospital hasinterested us a good deal during the last few weeks. It was

chiefly of importance in a diagnostic point of view, and hasterminated in a form not at all expected, that of fistulousopening communicating with the gut, leaving the patient withan accidental or artificial anus.

Mary R-, a poor woman, about thirty years of age, wasadmitted on January 26th, with a hard tumour occupying thecentre and left portion of the parietes of the abdomen, the-

precise nature of which gave rise to much speculation, andengaged a great deal of attention on the part of Mr. Lloyd andhis class. To some it appeared ovarian in its nature; to Mr.Paget, we believe, it seemed malignant; by Mr. Lawrence andMr. Lloyd himself it was diagnosed correctly from the first asseated more immediately in the parietes of the abdomen. Theonly histdry the woman can give is, that the tumour presenteditself after her last confinement, which was attended by nopeculiar circumstances. The tumour to the hand was not un-like the swelling and cricket-ball hardness of the uterus itself,but of course on one side, so common in obstetric practice. Theswelling came on early in January of the present year, andsomewhat gradually. The labour took place in the previous.month of November; it was her sixth child. The tumour didnot at first inconvenience her so much as might have been ex-pected. The treatment for the several weeks we have observedthe case does not present anything worthy of particular re-mark ; the chief indication having been to support the strength,for which she was ordered broths, porter, &c., with iodide ofiron, varied from time to time with cinchona and other tonics,together with the exte1’1wl application of iodine, in the expec-tation of dispersing the tumour, whether in the parietes of theabdomen in the form of cyst, or any other morbid growth. Afew days ago, however, it burst, and there is now establishedwhat might be called an "artificial anus," of a most trouble-some and disgusting character.The Tationale of the case is now rather too plain, and very

obviously that which Mr. Lloyd conceives-namely, that duringlabour some injury of the abdominal walls, of perhaps a slightkind, occurred, causing subsequent irritation and inflammation,with glueing together of the layers of peritoneum. The case,we need scarcely add, is one of very great interest in a dia-gnostic point of view; for in private practice such a result,more particularly if a lancet had been used, might give rise toopinions neither pathologically true nor charitable.

OVARIAN TUMOURS; OVARIOTOMY; PROPRIETY OFOPERATION, ETC.

We may here conveniently state that a case also of ovariotomy,recently under the care of Dr. West and Mr. Paget, in whichthe ovary was not removed on account of old adhesions, butwhere the sac was freely opened, has not terminated success-fully. In some lengthened observations to his class on thiscase, and on some others of the same nature, lately deliveredby Dr. West, he expressed himself as not favourable to largeoperations on such an organ as the ovary. One cannot say in-deed that the general feeling in all the hospitals is not some-thing similar. We do not purpose at present going over allthe objections urged against ovariotomy by Dr. West on thisoccasion, or by Dr. Churchill in a late number of the l3nitiIzCGI2C Foreign Quarterly, contenting ourselves rather with theinstinctive and somewhat simpler experience of many of thebest observers, amongst whom we may place Dr. West, Mr.Paget, &c. It is not necessary either perhaps to allude to the