(From the same). A white swelling. Dr. Cullen places this genus in the class locales, and order tumores, which he defines a tumour of the joints, chiefly of the knee; at first the swelling is slight, of the same colour of the skin, very painful, diminishing the mobility of the part affected.

Mr. Bell, in his Treatise on Ulcers, speaks of this disease under the name of white swellings of the joints, and distinguishes two species, viz. the rheumatic and the scrofulous: each is more frequent in the large than in the smaller joints. The first species begins with an acute pain in the joint, and frequently the tendinous aponeurotic expansions of the muscles connected with it. There are, from the beginning, an uniform swelling and tension of the surrounding teguments; but, in this period of the disorder, the skin is discoloured. The patient, from the beginning, suffers much pain from motion; and finding it easier in a relaxed posture, keeps it bent; which, especially in the knee, renders the flexor tendons of the limb rigid, and in time stiff. The swelling gradually often increases to thrice the natural size of the part. The cuticular veins become turgid and varicose; the limb, below the swelling, decays, or becomes oedematous; the pain increases, especially if the patient is warm in bed; and abscesses form in different parts of the swelling. In these abscesses a fluctuation is evident on pressure; but the swelling is elastic, and rises when the pressure is removed. These different collections, when they break or are laid open, discharge matter; at first of a good consistence, but soon degenerating into a thin fetid sanies, without apparently diminishing the size of the swelling. The orifices, if not kept open, soon heal, and new collections, forming in different parts, again break out and heal as before: at last the whole surrounding tcguments are covered with cicatrices; bat the patient's health hath suffered considerably in the interval, first from the pain, which destroys both sleep and appetite; and secondly, from the absorption of matter, producing a quick pulse, night sweats, and diarrhoea. These changes occur independnet of any affection of the bones of the joint; but when by a continuance of the complaint the ligaments are eroded, the cartilages, and even the bones, soon suffer. Though such are the appearances recorded, and usually confined to the first species, yet we are confident that they are peculiar to the second; and though they sometimes occur in hydarthrus from rheumatism, yet it is only when the rheumatic inflammation has produced the scrofulous. The causes of this species are strains, affecting the ligaments of the joints, so as to produce inflammation; bruises, luxations, or rheumatic disposition. This species of white swelling occurs most frequently in young plethoric people: the swelling is confined to the soft parts, and is from the beginning evident. When such swellings occur in young, strong, plethoric persons, and especially those who have been subject to rheumatism, they are generally of the rheumatic species. The rheumatic white swelling is always inflammatory, and bleeding will be the best remedy; at first from the arm, and afterwards from the part affected. Cupping and scarifying are useful remedies; and at least eight or ten ounces of blood should be discharged from each side, repeated at proper intervals, according to the violence of the symptoms and strength of the patient. Cupping is preferable to leeches; but when the swelling of the joints is considerable, it is impossible to procure a sufficient quantity of blood by this operation, and leeches must be applied. On the anterior part of the joint, where the cupping glasses or leeches have not been placed, a blister should be put; and the part be kept open, till the wounds from whence the blood was discharged are so far healed that a blister may be laid on one side of the joint; and, as soon as this is nearly healed, the other side should be also blistered. By thus alternately applying them, first to one side, and then to the other, almost a constant stimulus is kept up; from which the greatest advantages are derived. Cooling laxatives are necessary at proper

5 E 2 intervals; as well as a strict antiphlogistic course of diet. In the first stages only this or any other plan can be beneficial; and in these cures are sometimes effected. When the original inflammatory disease is removed, the drains should be stopped, and while there are yet no appearances of the formation of matter, mercury has been sometimes recommended for a few weeks, to keep the mouth merely sore. This medicine can, however, be only useful in the case just suggested, of the inflammation exciting the action of scrofula; and indeed the mode in which it is advised shows that the friction is of as much service as the remedy; for the proportion of mercury in the ointment is so small, that two drachms of the ointment must be used three times a day; and in order to rub in this ointment with advantage, an hour should, it is said, be spent each time in rubbing. Falls of warm water on swellings of this kind are strongly recommended by Le Dran, etc. By a proper use of the several topical evacuants in the first or inflammatory state of the disease, and afterwards, previous to the formation of matter, of mercurials and friction in the second stage, many have been cured. When by the bent position in which the limb has long been kept the use of the joint is lost, pure olive oil may be applied warm: as much as can be easily consumed by an hour's gentle friction should be rubbed in, three times a day, extending the friction over all the muscles around. Gentle action of the parts as soon as it can be borne, as recommended by Mr. Pugh, on the Utility of Muscular Motion, is highly beneficial. Should suppuration come on, opening the different abscesses soon after their formation may probably prevent the matter from injuring the capsular ligaments of the joints; the destruction of which renders amputation necessary.

In the second species the pain is usually more acute, but more confined to a particular spot, about the middle of the joint. The swelling is at the first inconsiderable; and little difference is seen in the size of the affected joint. The least motion gives great pain; so that stiffness and rigidity are equally produced by the position. As the disorder advances, the pain is more violent, the swelling increases, and the ends of the bones that compose the joint grow large. A very peculiar clastic swelling at last is felt; varicose veins appear overits surface, and collections of matter occur in different parts of it: these, when they burst, or are laid open, discharge considerable quantities of a glairy or purulent matter, but more frequently a thin fetid sanies; and, if a probe can be passed down to the bottom of the sores, the bones are found carious, and pieces are often discharged at the openings. As the disorder continues, the constitution suffers; a diarrhoea, with night sweats, comes on, and the patient is reduced to extreme weakness. From every symptom, and appearance on dissection, this species seems evidently to bean affection of the ligaments, and next of the bones; the surrounding soft parts only suffer from their connection. This species sometimes appears to be the consequence of an external accident; but generally begins without the patient's being able to account for it. From the effects usually produced on the bones which it attacks, it would appear to be a species of the real spina ventosa, and truly scrofulous. This species of white swelling is indeed often cither attended with other evident symptoms of scrofula, or occurs in those descended from scrofulous parents. When any perceptible swelling appears, the bones are found to be the parts chiefly affected, and the surrounding teguments suffer only in the progress of the disease; and when in such patients as are evidently of scrofulous dispositions, if the disorder has begun without any, or from a very slight, external cause, we need not doubt its being of a scrofulous nature. In the small joints, when the diseased parts of the bone begin to cast off, a cure may be sometimes promoted by assisting the efforts of nature; but in all the large joints, particularly in the knee and ankle, amputation will often afford the only means of relief.

The remedies usually employed are those of scrofula, with topical stimulants to the part, to increase the action of the vessels, and to promote the absorption of the. matter. We shall not anticipate the article scrofula by-enlarging on its causes and the manner in which its remedies relieve, but merely remark that the applications of marine plants, sea bathing, and drinking salt water, are the most effectual remedies. They act slowly, but are more successful than any other plan. The burnt sponge, which consists of alkaline or neutral sals, with animal oil, is often serviceable; and the burnt cork has had its advocates, though a remedy of inferior powers. Small doses of calomel are sometimes useful, and the bark is occasionally given, when fevers come on, or the night sweats appear to exhaust the patient. Neither of these latter remedies, however, is peculiarly adapted to the complaint.

The topical applications of most service are blisters frequently repeated; and sometimes the mercurial ointment, in the manner already described, has been found useful. Hemlock has been more frequently applied externally than given as a medicine; but in either way it seems of little benefit, and, when joined with the arum root, its utility is but little increased. A variety of other applications are recommended, but of inferior efficacy.

Practitioners have differed respecting the opening of the tumours of the joints, and, in general, it seems to be decided that they should be left to nature. It is at least certain that the wounds are with difficulty healed, and that the disease is sometimes removed without the discharge of the glairy matter, which fills the place of pus. We have had occasion to doubt the propriety of this decision; and though we allow that the cavities of joints should on no occasion be exposed, we greatly doubt whether the constitution would not be spared by the early discharge of matter which is never salutary, but, when retained, produces hectic, and symptoms of the greatest danger.

Amputation, in cases of white swelling, ought never to be advised till the complaint is far advanced; it has been observed, that amputation has more frequent!;-succeeded when the patient was previously much re. duced by diarrhoea. If this be true, we should never have recourse to the operation, until every probable means of saving the limb has-been tried in vain.

On dissection of the joint, a great thickening of the ligaments, which confounds the several parts, is observable, together with sinuses, formed by crude matter, through this distinguishing mass; and generally an erosion of the cartilages at the end of the bones.

Edinburgh Medical Essays, vol. iv. p. 242 and 246. Reimarus de Fungo Articulorum. Leyd. 1757. Bell on Ulcers, ed. 3. p. 435. etc. London Medical Transactions, vol. i. p. 104. White's Surgery, p. 66.