WHITE SWELLING. 



WHITLOW. 



910 





motions of the joint are but little impeded, whilst in others they are 

 entirely destroyed. These general symptoms however admit of dis- 

 tinction, and several forms of white swelling can now be traced to 

 different parts of the joint as their seat. 



Amongst old writers these diseases have been described under the 

 names of tpina centum, fungus articuli, lymphatic tumour, and other 

 names. A common division of these diseases is also into rheumatic 

 and scrofulous, according as they were supposed to have their origin in 

 a rheumatic or scrofulous state of the system. The more active were 

 referred to the former and the chronic to the latter. Many other dis- 

 tinctions are founded more upon the age, temperament, and constitution 

 of the patient, than upon essential differences of the disease. The 

 following are the diseases of the joints which are generally denominated 

 white swellings. 



1. Inflammation of the Synmial Membranes. This disease may be 

 either acute or chronic. When acute, the skin is generally red, and the 

 joint very painful and tender. It commences with pain at one 

 particular spot, and in a day or two after, swelling takes place. The 

 swelling may be felt at first to undulate, from the effusion of fluid into 

 the membrane ; but this becomes less evident as the disease advances, 

 from the thickening of the membranes and also from the effusion of 

 lymph. The swelling always assumes the form and direction of the 

 synovial membranes. In a few days the disease subsides altogether 

 or assumes the chronic form. When the inflammation is chronic 

 from the beginning, the pain and tenderness are much less, so that the 

 patient is able to walk about without much difficulty. There is little 

 or no fever, the skin retains its natural colour, the swelling increases 

 only slowly, and the symptoms are rendered worse by exposure to cold 

 and exertion. In these cases, although the effused fluid may at length 

 become absorbed, the synovial membrane remains thickened, and 

 swelling and stiffness of the joint are the consequence, constituting a 

 very common form of white swelling. The causes of this disease aro 

 both constitutional and local. It may arise as an effect of phlebitis, 

 gout, rheumatism, syphilis, or mercury ; or it may be produced by 

 sprains, contusions, wounds, dislocations, or fractures of the heads of 

 the bones. 



The treatment of this disease must vary according as it is acute or 

 chronic, or dependent on local or constitutional causes. In the acute 

 and local form of the disease perfect quietude must be insisted on, 

 cupping and leeches to the part should be had recourse to, with saline 

 purgatives and diaphoretics. When the skin U tense, fomentations 

 and poultices may be used ; but where not, cold lotions will be best. 

 In the early stage of the chronic form, leeches and cold lotions to the 

 part may be applied and perfect quietude enjoined. In the latter 

 stages, counter-irritants may be used, such as busters, the savine cerate, 

 ointment of tartarised antimony, &c. When persons are well enough 

 to move about, the joint should be kept from movement by strapping 

 it with soap-plaster, or covering it with a bandage or a cap of leather 

 or other material made to fit tight. Bathing with cold salt water, or 

 .ig on the part cold water may be recommended. For the 

 removal of the stiffness, shampooing, the vapour-bath, or friction with 

 the hand, may be employed. When the inflammation arises from 

 rheumatism or syphilis, the treatment should be the same as for those 



(H :-.-. 



1. Pulpy Thickeniny of the Synnrial Membrane. This disease 

 generally occurs in young persons between the ages of sixteen and 

 twenty-five, and is mostly confined to the knee-joint. There is not 

 much pain in the joint, but swelling and rigidity come on slowly. 

 The joint on being touched appears to have fluid in it. This disease 

 goes on sometimes for years, till at last it destroys the joint ; and 

 unless the limb is amputated, hectic symptoms ensue and destroy the 

 patient. This disease consists in a total disorganisation of the synovial 

 membrane, which is converted into a brownish or lightish brown pulpy 

 substance, varying from a quarter of an inch to haH an inch in thick- 

 ness. In its advanced stages the cartilages, bones, and ligaments of 

 the joint become implicated in the disease. 



The well-marked cases of this disease must be looked upon as incur- 

 able, and only amputation will give a chance of relief. In mild or 

 doubtful cases the only plan that seems to offer success is perfect 

 quietude of the joint, which may be secured by pasteboard or other 

 splints, or by soap-plaster. The general health should be attended to, 

 and local applications made according to the symptoms. Inflammation 

 should be subdued by leeches, and gentle counter-irritants may be 

 kept constantly applied. 



:!. riceratir/n of the Cartilages. This disease occurs chiefly in 

 children or adults under the middle age. It is frequently a conse- 

 quence of the preceding diseases, but often occurs alone, although in 

 in progress it may involve the whole joint. The joint in which it is 

 most frequently seen is the hip, producing the greater amount of the 

 diseases known by the name of hip-joint disease. When it occurs in 

 the knee, it differs from inflammation of the synovial membrane by 

 the pain at the commencement of the disease being slight, and its 

 going on increasing in intensity. The pain is also present sometimes 

 four or five weeks before any swelling is perceived. The swelling, 

 when it does o<jur, arises from inflammation of the cellular tissue out- 

 side the joint, and often appears much larger than it really is, from 

 the previous wasting of the leg from want of use. In many cases an 

 effusion takes place into the synovial membrane and increases the 



swelling. In the progress of the disease abscesses form, having fistulous 

 connections with the synovial membrane and the surrounding inflamed 

 tissue. As the cartilaginous tissue is renewed with difficulty, the 

 most favourable termination of this disease is generally attended with 

 anchylosis of the joint. 



In the treatment of this disease rest is essential ; whatever moves 

 the limb, affects the diseased cartilage. The limb may be placed in 

 splints, or bandaged up with soap-plaster, or perfect quietude of the 

 joint may be secured by M'Intyre's fracture-splint, which has the 

 advantage of being easily removed for the purpose of making applica- 

 tions to the part affected. Where the joint is hot, cold lotions and 

 leeches may be applied ; but where it is cool, counter-irritants, blisters, 

 issues, moxas, antimonial ointment, or croton oil. On the continent 

 the actual cautery is recommended. For the swelling and rigidity 

 which so constantly remain, relief may be sought in the cold douche, 

 shampooing, or friction with the hand. 



4. Scrofulous Disease of the Joints, beginning in the Hones. At one 

 time all white swellings were supposed to involve the bones, and this 

 on account of the apparent enlargement of the bones of the affected 

 joint. That this is not the case the existence of the above forms of 

 disease proves, but even the fact on which the supposition was founded 

 is not correct. So far from the bones being always enlarged in these 

 cases, there are only a very few on record in which dissection has 

 shown the bones to be enlarged. The bone has been supposed to be 

 swelled from the hardness of the part and its size : but the former 

 arises from the natural texture of the parts, and the latter is made to 

 appear greater by contrast with the wasting diseased limb. But the 

 bones are subject to disease which begins in their cancellous texture. 

 The phosphate of lime is removed from them or deposited in less 

 quantity, and a yellow caseous substance is secreted in its place. The 

 heads of the bones are altogether weakened and softened, and deposits 

 of bony matter of an irregular form are found on their outside. 

 Whilst this change is going on the patient experiences pain; the knee, 

 which is the joint it most commonly attacks, swells ; the motions of 

 the joint are affected, and it becomes more or less contracted, so as to 

 prevent it being straightened. In the course of time matter is formed 

 in the cavity, and makes its way out by ulceration through the synovial 

 membrane, or abscesses form on the outside of the joint. Sometimes 

 sinuses occur, and run to a considerable extent from the joint under 

 the fascia, or between it and the skin. 



This condition of a limb is generally connected with a scrofulous 

 constitution, and the more decided the scrofulous disposition, the more 

 difficult will the disease be to treat. However, whatever may be the 

 state of the constitution, this must be attended to primarily in the 

 treatment of these cases. [SCROFULA.] The local treatment must be the 

 same as for other cases of white swelling. Quietude of the joint should 

 be secured on some of the plans previously proposed ; and as there is a 

 constant tendency to anchylosis, care should be taken if possible that 

 the anchylosis occurs in a position most convenient for using the limb. 

 Counter-irritants will be found of great utility in these cases, such as 

 blisters, antimonial ointment, and croton oil. Care, however, must be 

 taken that they are not employed whilst there is a tendency to inflam- 

 matory action ; and, on the other hand, the means that are employed, 

 such as leeches, cold lotions, &c., for an increased activity of the part, 

 should be immediately abandoned when that activity ceases. When 

 the morbid process has been arrested, shampooing, friction, and 

 pouring water on the part from a height, should be had recourse to 

 for the purpose of strengthening it. The abscesses which form in 

 these cases should be opened early ; if left to themselves, they often 

 leave ulcerations which are difficult to heal. 



(Cooper, First Lines of Surgery ; Surgical Dictionary ; Brodie, Patho- 

 logical and Surgical Observations on Diseases of the Joints.) 



WHITE VITRIOL. [VITRIOL.] 



WHITING. An impure carbonate of lime, prepared by grinding 

 and then washing chalk, HO as to separate the coarser and heavier 

 particles from the lighter and finer ones, which latter are then col- 

 lected into masses and dried. 



WHITLOW is an inflammation affecting the phalanges of the 

 fingers, and generally proceeding to suppuration. The part attacked, 

 however, is not confined to the fingers ; the same disease may also 

 appear in the toes. Paronychia and Onyehia are terms which are used 

 to express the same disease. Surgical authors describe several forms 

 of whitlow, or paronychia, according to the textures which the inflam- 

 mation attacks. Thus it may be situated in the skin, the cellular 

 tissue under the skin, the tendons or theca of the fingers or toes, in 

 the periosteum, or it may be seated in the cellular tissue under the 

 nail When the inflammation is confined to the skin, vesicles appeal-, 

 which quickly advance to suppuration, and the case requires little 

 attention. When the subcutaneous cellular tissue is affected, the case 

 is more serious, though it seldom extends : there is throbbing pain of 

 the part, and there may be severe constitutional disturbance, and 

 suppuration is a less or greater length of time in taking place. The 

 whitlow under the nail differs from this form only in situation. In 

 these cases only the cellular tissue under the cutis is affected, and no 

 great danger or mischief is to be apprehended from the whitlow. 

 When, however, the inflammation extends to the tendons, periosteum, 

 and bone, then the symptoms are very severe ; and by extending from 

 the finger affected, up the arm, and involving a large extent of surface, 



