JOINTS. 



upper part of the joint, becaufe there the bag, which con- 

 tains the fyiiovia, has lefs of the nature of a capfular hga- 

 nieiit. 



T5ut whatever place may be chofen for the incifion, it is 

 of great confequence that an afiillant prevent the lool'e car- 

 tilage from flipping away, left it flioiild not cafily be found 

 again, and the piirpofe of the operation be frulirated. It 

 is clear, thut if the capfular ligament were wounded when 

 an accident of this kind occurred, the patient would be ex- 

 puled to all the danger of the operation, witliout any chance 

 of being benefited by it. 



All operators have followed the plan of drawing the integu- 

 ments to one fide before making the incifion, fo that as foon 

 as the excilion of the cartilage is accomplidied, the wound 

 in the capfular ligament may become immediately covered 

 with (kill. TIius the bad effefts of the cavity of' the joint 

 being expofed, are materially prevented. The piece of car- 

 tilage, when brought into view, is to be direitly extratled 

 by means of a tenaculum. 



The (Icin is then to be brought over the opening in the 

 capfular ligament ; the external wound is to be clofed with 

 ilicking plafter ; cold lotions are to be applied to the knee ; 

 and every antiplilogillic meafure adopted, which luay i'eeni 

 prudent and nectflary. 



E.Kperience has further proved, that the patient is not 

 completely out of danger as foou as the wound is united ; 

 and that he ought, fer fome time longer, to keep the limb 

 ■at relt. See Bromiield's Chirurgical Cafes and Obfervations, 

 vol. i. p. 3.;5,3j6. 



Of Hydrops Arfuuli, or Drnpfy of the ,/o('n/j.— This dif- 

 eafe confiils of an accumulation of water in the capfular li- 

 gament of a joint, and is very analogous to the hydrocele, 

 or colleftion of an aqueous fluid in the tunica vaginalis 

 tellis. Both thcfe complaints, indeed, are alike, in not arif- 

 ing from a general dropfical afl'edion of the conllitution, 

 the patient being frequently in other refpedls quite foiuid. 

 There are, it is true, a few exceptions to the latter part of 

 tins obfervation. The knee is, of all joints, the molt liable 

 to the difcafe, perhaps on account of the largenefs and 

 loofenefs of its capfular ligament. 



The precife caufes of hydrops articuli are often beyond 

 tlie reach of invelligation. The diforder, however, is fre- 

 <iuently preceded by fevere rheumatic affedlions, fevers, and 

 local violence. lu moft cafes a fluctuation is very dillin- 

 ^uilhable, unlefs the joint be uncommonly diltended. When 

 the hmb, alfo, is extended, fo as to relax the extenfor 

 niufcles of the leg, the knee-pan may be made to rife up, 

 by prefling tlie tumour, and a fulnefs may then be difccrned 

 on each fide of that bone. The complaint is in general un- 

 attended with ferious pain, though fome uneailnefs, aitd a 

 fenfe of fliflhefs are experienced. 



In confidering the treatment of this, as well as of moil 

 other difeafes, it behoves us to pay efpecial attention to the 

 caufes ivherc they are difcoverable, the mere removal of them 

 being often of itfelf capable of effeftmg a cure. Thus, 

 when hydrops articuli occurs during the debility confequent 

 to typhoid and other fevers, the complaint can hardly be ex- 

 pi-ftcd to get well till the llrength of the conftitution is, in 

 fome degree reftored. The coimeiflion between the local 

 and conilitutional diforder is \«ell illullrated in a cafe which 

 Mr. Rufiell has related, and in which every local remedy- 

 was tried without avail : the difeafe, which would not yield 

 as Vi\\\:^ as the debility confequent to a typhus fever lafted, got 

 veil fpontaueouHy in\mediately wlien the patient regained his 

 ilrength. On ^Io^bid A flections of the Knee, p. 192. 



Ill ordinary examples hydrops articuli is quite a local ma- 

 Jady, unconiicded with .any diforder of thc.ccnlUtutioii, and 



mav be difperfed by topical treatment. One of the moft 

 effeftual means for this purpofe, is the application of a 

 blifter, which fhould be kept open with the favin cerate. 

 The operation of the blifter may alfo be very materially 

 promoted by the pretTure of a bandage. In fome inftawceii 

 the adion of the abfoibents may be fufficiently excited by 

 moderate exercife, and frictions with flannel impregnated 

 with the fteam of vinegar, or by eleftricity, and rubbing the 

 joint with camphorated mercurial ointment. The patient 

 fliould likewife be purged with calomel, or kaU acetatum, 

 unlefs any particular reafons forbid. 



Surjiical writers inform us of cafes, which refift common 

 treatment, are attended with immoderate diftention, and even 

 with fuch irritation upon a weak conftitution, as ferioufly 

 impairs the health. Here, the furgeon would be juftified in 

 making a fmall pun Anre into the joint, in order to difcharge 

 the fluid. Care fliould be taken to make the opening no 

 larger than neceftary, and to draw the integuments to one 

 fide, before introducing the lancet, or trocar, fo that the 

 wound in the capfular ligament, as foon as the operation is 

 finiftied, may become covered with (kin. 



Exc'ifion ofDifeiifed Joints In the year 17SZ, Mr. Park, 



a furgeon at Liverpool, made the propofal of totally extir- 

 pating many difeafed joints, fo as to do away the neccfiity 

 of cutting off limbs, which might ftill be of more ufe to the 

 patients than any artificial contrivance. It was his plan to 

 effect an entire removal of the heads of fuch bones as coin- 

 pofed the difeafed articulation, and then to make the fawn 

 extremities of the bones grow together, like the ends of a 

 fracture. 



After undertaking fome experiments upon the dead fub- 

 jeft, Mr. Park, in ijSi, performed the operation of extir- 

 pating the difeafed knee of a ilrong robuil failor, aged 3;. 

 The method purfued was much like that which had been 

 previoufiy tried upon the dead fubjeCt, and which was a? 

 follows : An incifion began about two inches above the 

 up))er end of the patella, and extended about as far below 

 its lower part. Another one was made acrofs this at right 

 angles, immediately over the patella, down to the bone, and 

 nearly half round the limb, the leg being in an extended 

 ilatc. The lower angles, formed by thele incifions, were 

 raifed, fo as to lay bare the capfular ligament ; the patella 

 was then taken out; the upper angles were raifed, fo as 

 fairly to denude the head of the femur, and to allow a imall 

 catling to be pafted acrofs the pofterior flat part of the bone, 

 immediately above the condyles, care being taken to keep 

 one of the flat fides of the point of the inftrnnicnt quite 

 clofe to the bone all the way. The catling being with- 

 drawn, an elallic fpatula was introduced into its place, for 

 the purpofe of protecting the foft parts during the fawing of 

 the thigh-bone. The head of the bone, thus feparated, was 

 carefully dlfleCted out ; the head of the tibia was then eafily 

 turned out and fawn ofl", and as mtich as poflible of the c?p- 

 fular ligament difleCted away. The quantity of bone re- 

 moved in tlie operation was a very little more than two inches 

 of the thigli-b')ne, and rather more than one inch of the 

 tibia. The only large artery divided was one on the front 

 of the knee, and it ceafed to bleed before the operation was 

 concluded; but the ends of the bones bled very freely. To 

 keej) the redundant integuments from falling inwards, and 

 tlie edges of the wounds in tolerable contaft, a few iutnres 

 were iifed. The drelTings were light and fupcrficial, and 

 the limb was put in a tin cafe, which was long enough to 

 receive the whole member, from the ankle to the trochanter 

 major. 



\Vc learn from Mr. Park, that afterwards many trouble- 

 fome cireumltances occurred, arifing chiefly from the diffi- 



