WHITE-SWELLING. 



tion of a joint is much more eafily produced than in other 

 conftitutions ; and no one can doubt, that when once ex- 

 cited in the former clafs of fubjefls, it is much more dan- 

 gerous and difficult of removal than in other patients. 



The doftrine of particular white-fwellings being fcro- 

 fulouu difeafes, is fupported by many weighty reafons, the 

 opinions of the mod accurate obfervers, and the etidence of 

 daily experience. Wifeman (book iv. ch. 4. ) calls the 

 fpina ventofa a fpecies of fcrofula, and tells us, that in- 

 fants and children are generally the fubjefts of this difeafe. 

 The diforder is faidby Severinus to be exceedingly frequent 

 in young fubjefls. Petrus de Marchettis has obferved both 

 male and female fubjefts affefted with what are called ftru- 

 itious difeafes of the joints, as late as the age of five-and- 

 twenty ; but not afterwards, unlefs they had fuffered from 

 fcrofula before that period of life, and had not been com- 

 pletely cured. R. Lowerus alfo entertains a fimilar opinion. 

 Even though a few perfons may have fcrofulous difeafes of 

 the joints, for the firll time, after the age of twenty-five, 

 this occurrence, like the firft attack of fcrofula after this 

 period, muft be confidered as extremely uncommon. 



Another argument in favour of the doftrine, which fets 

 down particular kinds of white-fwellings as fcrofulous, is 

 founded on the hereditary nature of fuch forms of dif- 

 eafe. 



Numerous continental furgeons, particularly Petit and 

 Brambilla, have noticed how very fubjeft the Englifh are 

 both to fcrofula and white-fwellings of the joints. We 

 every day fee, that young perfons alHifted with the prefent 

 difeafe, are generally manifeftly fcrofulous, or have once 

 been fo. Very often enlarged lymphatic glands in the neck 

 denote this fatal peculiarity of conflitution ; very often the 

 patients are known to have defcended • from parents who 

 had itrumous diforders. Crowther. 



Befides the general emblems of a fcrofulous conflitution, 

 we may often obferve a fhining, coagulated flaky fubftance, 

 like white of egg, blended with the contents of fuch ab- 

 fcefles as occur in the progrefs of the difeafe. This kind 

 of matter is almoft peculiar to fcrofulous abfceffes, and 

 forms another argument in fupport of the foregoing obfer- 

 vations relative to the fhare which fcrofula frequently has 

 in the origin and courfe of many white-fwellings. Cooper's 

 Dift. of Pradlical Surgery. 



The caufes of white-fwellings are divided by furgical 

 writers into external and internal. Amongft the former 

 are reckoned mechanical injuries of the joints, fuch as 

 wounds, contufions, fprains, immoderate exercife in cold 

 damp weather, refiding continually in a low humid fitua- 

 tion, &c. It is certain, however, that thefe tumours are 

 feldom produced altogether by external caufes ; and even 

 when their formation has been preceded by fome external 

 Tiolence, this is rather to be regarded only as the determin- 

 ing caufe of the difeafe, while the real caufe in this, as well 

 as in other cafes where the complaint begins fpontaneoufly, 

 is of an internal kind. Rheumatifm and fcrofula are the 

 ordinary caufes of white-fweUings ; and it may be alleged, 

 without rilk of error, that more than three-fourths of thefe 

 tumours are owing to thefe conftitutional difeafes. Thofe 

 white-fwelhngs which attack ftrong plethoric fubjefts of 

 adult age, commonly depend upon rheumatifm ; while other 

 cafes which happen in children, are almoft always caufed by 

 fcrofula. It is well known that rheumatifm is particu- 

 larly difpofed to make its attack upon the large joints, and 

 that it efpecially affeds the ligaments and neighbouring 

 cellular fubftance, which it thickens and hardens, by caufing 

 an effufion of coagulable lymph. Hence, fays Boyer, in 



fuch white-fwellings as arife from rheumatifm, tfiefe parts 

 alone are found difeafed in the early ftage of the complaint. 

 Traite des Mai. Chir. t. iv. p. 501. 



With refpeft to fcrofula, every furgeon is aware that it 

 frequently attacks the head? of the bones, particularly in 

 children, occafioning thofe morbid changes which we have 

 already endeavoured to defcribe. We have likewife men- 

 tioned what is now generally admitted, that in white- 

 fwellings originating from fcrofula, the difeafe commences in 

 the bones, the ioft parts becoming affefted only fecondarily. 

 The contrary is faid to happen in all rheumatic cafes, the 

 difeafe beginning in the foft parts, and only affefting the 

 bones in a fubfequent advanced ftage of the complaint. 



The prognofis in cafes of white-fwelhng is, generally 

 fpeaking, unfavourable ; but it is more or lefs fo, accord- 

 ing to the caufe of the difeafe, its duration, the accompany- 

 ing fymptoms, the patient's conflitution, &c. White- 

 fwellings arifing from rheumatifm are the leaft alarming, 

 efpecially when they are recent. The progrefs of the com- 

 plaint may then be often ftopped, and fometimes a perfeft 

 cure accomplifhed. In this kind of cafe, the joint fome- 

 times returns to its natural ftate, and regains the power of 

 freely performing every motion ; while in other inftances, 

 it continues affefted with a greater or lefFer degree of ftiffnefs. 

 White-fwellings, which appear to depend altogether upon 

 an external caufe, in perfons in other refpefts healthy and 

 found, may-terminate well. The worft white-fwellings of 

 all are thofe which originate from fcrofula ; for they are 

 very feldom cured, and when they do admit of amendment, 

 the joint is always left in a ftate of anchylofis. 



Whatever may be the caufe of white-fwellings, when 

 they are of long ftanding, feverely painful, the bones foftened 

 and rendered carious, the cartilages ulcerated, the articu- 

 lation filled with fanious matter, and abfceffes have formed, 

 the openings of which continue fiftulous, "and emit a more 

 or lefs abundant quantity of a thin fetid difcharge, the 

 difeafe is in general incurable. In this cafe, the violence of 

 the pain, the heftic fever, the profufe fweats, and coUiqua- 

 tive diarrhoea, plunge the patient into a ftate of marafmus, 

 and foon carry him off, unlefs an attempt be made to fave 

 him by the timely performance of amputation. Yet, as 

 Boyer obferves, in fome few cafes of this hopelefs defcrip- 

 tion, nature, fkilfuUy afCfted by art, has been known to 

 fubdue the difeafe. The fuppuration then gradually 

 diminifhes and affumes a better quality, the flow fever, 

 nofturnal perfpirations, and weakening diarrhoea, en- 

 tirely ceafe, the appetite returns, digeftion is well per- 

 formed, the ftrength is reftored, and the patient gets well 

 with an anchylofis. But fuch fortunate cafes are extremely 

 uncommon, and they do not juftify us in leaving the difeafe 

 to nature, inftead of amputating the limb. Traite des 

 Mai. Chir. t. iv. p. 505. 507. 



Of all the difeafes which fall under the care of the fur- 

 geon, there is not one in which a greater variety of remedies 

 has been propofed than in white-fwelhngs. Yet, not- 

 withftanding the numerous means which are occafionally 

 tried, the praftitioner frequently has the mortification of 

 finding, not only that he cannot accomplifh a radical cure, 

 but that he cannot even palliate the complaint, moderate its 

 violence, or retard its progrefs. 



The furgeon, in order to be methodical, fhould adapt 

 the treatment to the particular form of the difeafe 

 and its different ftates. But, in every inftance, perfeft refl 

 of the limb is abfolutely indifpenfable, as exercife always has 

 the effeft of keeping up pain and irritation, and doing harm, 

 whatever may be the fpecies of the difeafe. 



Rheu- 



