WRIST-JOINT (ABNORMAL ANATOMY). 



1529 



above the annular ligament), while the fingers 

 of the opposite hand are placed on the other 

 extremity, which is placed beneath this 

 fibrous band, we readily perceive a "frotle- 

 ment " which is quite peculiar. This " frotte- 

 mcnt " is caused by the passage to and fro, 

 under the true annular ligament of the wrist, 

 of small foreign bodies which are not unlike 

 barley grains or those of boiled rice. Their 

 forms are exceedingly variable. They are 

 usually of a white colour, and have a polished 

 surface. They are found in vast numbers in 

 the same cyst, mixed with a more or less con- 

 siderable quantity of glairy synovial liquid. 

 They are ordinarily free from all adhesions to 

 the parietes of the bursa. 



Many theories have been formed as to the 

 origin of these little bodies found loose in the 

 bursa, about the wrist, and elsewhere. 



Dupuytren thought he had established the 

 theory that they were hydatids. Laennec and 

 Kaspail agreed with him in this view ; but 

 Bosc, to whom Dupuytren referred, dissented. 

 The last-mentioned naturalist looked upon 

 them as concretions of lymph of an adipo- 

 cerous nature. He says, "They are not to 

 be considered as ' hydatids,' because they 

 have not given any sign of life on escaping 

 from the cyst." On dividing these bodies, he 

 found them uniform throughout, whilst that 

 of hydatids are always hollow ; and again, 

 because submitted to a strong lens, they have 

 appeared to him to be nothing else than an 

 inorganic mass, whether he examined them 

 when recent or dried." 



Sir Benjamin Brodie's opinion now seems 

 generally to prevail. It is adopted by 

 Nelaton * and other French physiologists : 

 " There seems to be no doubt but that these 

 loose bodies have their origin in the coagu- 

 lated lymph which was effused in the early 

 stages of the disease ; and I had opportuni- 

 ties, by the examination of several cases, to 

 trace the steps of their gradual formation. At 

 first the coagulated lymph forms irregular 

 masses of no determined shape, which after- 

 wards, by the motion and pressure of the 

 contiguous parts, are broken down into small 

 portions. These by degrees become of a 

 regular form, and assume a firmer consist- 

 ence, and at last are converted into the oval 

 bodies above alluded to."f 



Examples of these have been seen in the 

 synovial sheaths of the radial extensors as 

 well as on the back of the wrist in the course 

 of the extensors of the fingers. But it is, 

 nevertheless, certain that the bursa of the 

 flexor tendons, situated in front of the wrist 

 and carpus, and behind the true annular liga- 

 ment of this region, is the special locality in 

 which these foreign bodies are most frequently 

 found. 



Painful Crepitation of Tendons around the 

 Wrist. We notice, sometimes, around the 

 carpus and in the inferior extremity of the 



* En 1819 M. Brodie donna une interpretation 

 satisfaisante de leur e'tiologie en les rattadiant aux 

 epanchemens sero-albumeux. (Xelaton, Pathologic 

 Chirurgicale.) 



j- Brodie on the Diseases of the Joints. 



forearm, a swelling which is peculiar in this, 

 that, whenever the tendons around which the 

 swelling forms are moved, there is thereby 

 elicited a very peculiar crepitation. 



This crepitation is noticed along the course 

 of the extensor carpi radialis longior and 

 brevior, and in that of the long abductor and 

 short extensor of the thumb. This swelling 

 is not globular, nor is it so well defined as a 

 ganglion, but may be said to represent in its 

 form a portion of a spiral which, parting from 

 the dorsal surface of the forearm, soon turns 

 round the external part of the radius to gain 

 the root of the first metacarpal bone. 



This swelling seems to be of an inflamma- 

 tory nature, and is occasionally accompanied 

 with a superficial redness of the skin ; and 

 pressure on this part becomes painful to the 

 patient. If the surgeon places his thumb or 

 fingers on the postero-external surface of the 

 forearm, near to the wrist-joint, where the ob- 

 long swelling exists, and at the same time de- 

 sires the patient to move the hand by flexing 

 and extending the wrist-joint, or exert the 

 muscles, the peculiar crepitation which cha- 

 racterises this lesion is soon perceived. 



It is not very easy to convey an idea of this 

 crepitation ; but it has been compared by 

 many to that produced by the crushing to- 

 gether, with our fingers, portions of finely 

 powdered starch, or to the effect which we 

 feel produced when we walk over snow. 

 When once recognised, it is perceived to be 

 quite different from that crepitation which is 

 produced by the movement on each other of 

 the fragments of broken bones or the rubbing 

 together of roughened articular surfaces. 

 This disease has for its anatomical seat the 

 fibro-synovial sheaths of the tendons already 

 mentio'ned. These extensor tendons, namely, 

 the two extensor radialis longior and brevior, 

 as well as those of the long abductor and short 

 extensor of the thumb, cross each other, each 

 in special sheaths or canals formed on the back 

 part and external edge of the lower extremity 

 of the radius ; and if inflammation attack the 

 lining membrane of these fibro-synovial 

 sheaths, it is plain that, in this anatomical 

 arrangement, there may be seen many circum- 

 stances to favour the development of this 

 crepitation. 



This affection has not, we believe, ever 

 been observed to have come on sponta- 

 neously, but generally to have arisen from 

 some violent and continued efforts of the 

 wrist and hand. 



It has been noticed in soldiers and masons, 

 and in those who are in the habit of twisting 

 the forearm, as in the act of forced pronation 

 of the forearm of washerwomen in wringing 

 clothes. The tumefaction, the swelling, pain 

 and heat, and the crepitation also, once com- 

 menced, augment generally for four, six, or 

 eight days ; and if the patient be guilty of 

 any imprudence, the evil is maintained to the 

 same degree even to the twelfth or fourteenth 

 day, after which it ordinarily terminates in 



resolution. 



(JRobert Adams.) 



