A system of surgery . ain centres, until nodules of soft granulation areformed, which, as they increase at the periphery, undergo degenera-tive changes towards their centre (Fig. 437). This process may extendfrom the epiphysial line or under the encrusting cartilage throughthe latter, and so invade the whole joint in all its parts. But itmust not be forgotten that it may also extend in a lateral directionaltogether, and though very close to the joint surfaces, may neverpenetrate through them, but may open on the surface of the limbhard by, leaving the joint proper intact (Fig. 435). Limbs have
A system of surgery . ain centres, until nodules of soft granulation areformed, which, as they increase at the periphery, undergo degenera-tive changes towards their centre (Fig. 437). This process may extendfrom the epiphysial line or under the encrusting cartilage throughthe latter, and so invade the whole joint in all its parts. But itmust not be forgotten that it may also extend in a lateral directionaltogether, and though very close to the joint surfaces, may neverpenetrate through them, but may open on the surface of the limbhard by, leaving the joint proper intact (Fig. 435). Limbs have over and over again been removed under the im-pression, on the part of the surgeon, that the joint was gravelyaffected because sinuses ran down from the surface almost intoit, when it has been found afterwards that the joint proper wasin no wise involved, and that the focus of disease might havebeen reached without any interference with its surfaces. On theother hand, we must remember that chronic tuberculous disease. Fig. 435.—Metacarpal Bone, with tuberculous sequestrum in centre,cut off from tbe inflamed bone by granulations. The tbickeninejof the periosteum over the inflamed area is well seen, but botbjoint surfaces are free. (Prom a Photograph by Prof. Chejne.) TUBERCULOUS DISEASE. 1063 is frequently so quiet in its progress, that it may have passed from thebone through the cartilage and extensively invaded the joint cavity,without having produced much disturbance in the latter. In sucha case we often find that there are bosses of tuberculous granulationsprojecting through holes in the cartilage from below (Fig. 434),where the chief centres of disease lie, while the cartilage itself, on therest of its surface, seems quite unaffected, and the synovial mem-brane almost or entirely healthy. In other instances, when such aninvasion of the joint takes place from the bones, the granulation, oncehaving entered the joint, spreads rapidly over its surfaces, andcommences at once
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