JOINTS. 



t' ;.itc Mr. Hunter. It was his belief, that a coagiilum of 

 t ■.i-.i.af.ited blood might, under certain circumllaiices, be 

 11 v.. r.erted into an organized vai'cular fubltancc, by the vef- 

 I'els growing into it from the neighbouring living furface. 

 No one doubts tiiat the coagulatiuj^- lymph has conllantly a 

 tendency to become vafciilar, when efTufed on the furface of 

 an inflamed membrane. Now, if we take the trouble of 

 peruling the cafes which are related by different authors, we 

 fhall find, that the formation of loofe cartilaginous fubllances 

 in the joints, has generally been preceded by violence done 

 to the part, and by fymptoms of inflammation. Of this de- 

 fcription are the examples publiihed by Mr. Ford, M. 

 Brocbjerin Default's Journal, Mr. Abernethy, and Mr. Hey. 

 Latta mentions four inllances which were preceded by 

 rheumatifm. In this ftate, we conceive that the capfular liga- 

 ment, or its delicate layer, reflected over the articular car- 

 tilages, effufes coagulating lymph upon a part of its furface j 

 that fuch lymph foon becomes vafcular and organized ; and 

 that it gradually aflumes a ftructure more or lefs like that of 

 cartilage. 



Loofe preternatural cartilages are moilly attached to feme 

 part of the articular cavity, which does not fuffer attrition 

 when the joint is moved. Dr. Alexander Monro, in dilfeft- 

 ing the knee of a malefactor, found in the joint an ofTeous 

 tumour, which was connected by a ligamentous pedicle 

 with the exterior edge of the cartilage covering the ex- 

 ternal cavity of the tibia. (Edin. Eflays, vol.iv. p. 245.) 

 Perfeft quietude is effential to the growth of new veffels into 

 coagulating lymph, and in the cafe juft now quoted, if the 

 exudation had taken place, where it would foon have been 

 diilurbed in the motion of the limb, its organization could 

 Icarcely have happened. Alfo, if fuch cartilaginous bodies 

 were to be commonly formed on a part of the articular ca- 

 vity, necelTarily expofed to friciion in walking, &c. then 

 patients would experience pain from the iirft. But, as they 

 do not feel inconvenience till the tumour has become very 

 moveable by the gradual elongation, or fudden rupture of 

 its pedicle, and only then when the tumour glides into a fitu- 

 atioM where it is pinched between the articular furfaces, 

 we have a right to conclude, that moll cartilaginous bodies 

 of this kind grow originally in a fituation, where they are 

 not particularly expoled to dillurbance in the motion of the 

 joint. In moll inllances, the communication of vafculanty 

 muft alfo happen, during the tendernefs of the joint, at which 

 period the patient naturally keeps his limb in a quiet ftate, in 

 order to avoid pain. Aiter all inflammation has fubfided, 

 the limb is again moved with freedom ; the organized coa- 

 gulum is gradually loofened by the motion, and at length it 

 only remains connefted with the joint to which it was ori- 

 ginally attached, by means of a long flender pedicle, through 

 which its nutrient veifcls proceed. At la(l the pedicle 

 breaks, and the cartilaginous fubllance is left quite loofe, 

 like an extraneous body, in the cavity of the joint. 



The irritation of loofe cartilages in the knee often occa- 

 fions an increafed quantity of flaid in the capfular ligament, 

 but this is not invariably the cafe. When the irritation is 

 fuch as to induce a degree of heat and tendernL-fs in the joint, 

 there is ufually a preternatural quantity of the fynovia fe- 

 creted : when pain and inconvenience have not lately been felt, 

 this flaid is generally not more abundant, than in the natural 

 flate of the joint. 



With lefpecl to the treatment of thefe cafes, we are not 

 acquainted with any certain means of freeing the patient 

 from the inconveniences of the difeafe, if we except making 

 an incilion into the joint, for the purpofc of ixtracling the 

 cartilaginous f«bftance. To this plan, the danger attendant 

 on ali wounds of fo large an articulation as the knee is a very 



ferious objection. Hence, Middkton and Gooch tried 

 anoiliL'r method, which was to conduft the extraneous body 

 into a fituation where it produced no pain, and to retain it 

 in that poliiion a long time, by means of bandages, under 

 the idea, that the cartilaginous fubllance would adhere to 

 the contiguous parts, and occafion no future trouble. Thcfc 

 furgeons appear at lead to have thus afforded temporary 

 relief. 



Mr. Hey, imprefled witli a juft fenfe of the dangerous 

 fymptom.s, which have occafionally rcfulted from the moll 

 limple wounds penetrating the knee-joint, tried the efficacy 

 of a laced knee-cap, and the cafes which he has adduced 

 clearly demonllrate, that the benefit thus obtained is not 

 tranlient, at leall as long as the patient continues to wear the 

 bandage. In one cafe, the method had been tried, for ten 

 years, with all the fuccefs which the patient could dcfire. 



•All things confidered, it is our decided opinion, that the 

 effect of a knee-cap, or of a comprofs and roller, ought 

 generally to be tried before having recourfe to the knife, fup- 

 pofiiig the cartilaginous fubftance can be placed in a fituatiorr 

 where it gives no pain, and admits of being compreifed. 

 But doubtlefs there are inllances, in which it is the duty of 

 the furgeon to operate. If a man be deprived of his liveli- 

 hood by not being able to ufe his knee ; if he canHOt, or will 

 not, take the trouble of wearing a bandage ; if he be urgently 

 defirous of running the rifle ot the operation, after ciicum- 

 ftances have been impartially explained to him ; if a band- 

 age fail in affording fuSicient relief; and laflly, if cxcefiive 

 pain, fevere inflammation of the joint, and lamenefs, be 

 frequently brought on by the difeafe ; the employment of 

 the knife leems juftiliable and proper. It is very certain, 

 that fuccefs has generally attended the operation ; but fmall 

 as the hazard may be of lofing the limb, and even life, in 

 the attempt to get rid of the complaint ; yet, fince the in- 

 conveniences of the difeafe are in moil cafes very bearable, 

 and are alfo capable of palliation by means of a bandage, 

 endangering the limb and life in any degree mull appear to 

 many perfons contrary to the diclates of prudence. 



We have no inftance recorded, where there was a necclTity 

 for removing a cartilaginous tumour from any joint but the 

 knee. 



The difeafe being often attended with a degree of heat and 

 tendernefs about the joint, there can exift no doubt ot the 

 propriety of keeping the patient in bed a day or two before 

 he fubmits to the operation, the danger of which is in a 

 great meafure proportioned to the fubfequent inflammation. 

 When the attempt to heal the wound by the firtl intention 

 fucceeds, much of the hazard is alfo paft. Therefore, the 

 joint Ihould be brought into as quiet a Itate as poflible before 

 the incifion is pradtifed, andbefides a little confinement, the 

 furgeon fliould direcl leeches and cold faturnine lotions to be 

 applied to the knee, and an opening draught or two to be 

 taken. 



As the loofe piece of cartilage may, in general, be moved 

 round the joint, the furgeon frequently has it in his power 

 to choofe the place where he will make the incifion. Ford, 

 Latta, and others lu-ive made the wound on the outiide of 

 the joint. Default ufed to bring the loofe cartilage to the- 

 inner fide of the articulation, againlt the attachment of the 

 capfular ligament, and then make the cut in that fituation. 

 Mr. Aberuethy has recommended bringing the extraneous 

 fubftance to the outhde of the inter.nal condyle of the os 

 femoris, and dividing the capfular ligament at that part. 

 Mr. Ruflell adviles us to pufli the moveable body upwards, 

 on the infide of the thigh, in order that the i jcifion may he 

 as ditlant as pofliblc from the moving furface of the joint, 

 Mr. Hunter alfo preferred removing ihcfcloofe bodice at the 

 6 upper 



