No. 1556.

JUNE 25, 1853.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

CASES OF AFFECTION OF THE KNEE-JOINT.

(Continued from p. 561.)

CHARING-CROSS HOSPITAL.

Chronic Thickening of the Synovial Membrane of the Knee-joint,and extra-articular Cellular Tissue; Hectic; Amputation;present state satisfactory.

(Under the care of Mr. AVERY.)

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum, etdissectionum historias, turn aliorum proprias, collectas habere et inter secomparare.—MORGAGNI. De Sed. et Caus. Morb., lib. 14. Proœmium.

WILLIAM C-, a brick-burner, aged,fifty-seven years,livingnear Dover, a stout, heavy-looking man, was admitted Sept. 6,1852. It would appear that about two years before admissionthe patient slipped and almost fell upon the right knee, inwhich joint he had for a considerable period had rheumaticpains. The uneasiness following upon the accident was notof a severe kind, for the man bore with it for about five

months, busily engaged in very laborious occupations. At theexpiration of this period swelling and pain occurred in thejoint without any fresh exciting cause, and the patient thensought the advice of a surgeon.The usual remedies were then resorted to, as abstraction of

blood, blistering, rest, &c., and temporary improvement wasseveral times obtained; but the external enlargement of thejoint, the constant, though not very distressing pain, theinability to walk with comfort, continued more or less untilthe patient was admitted into the hospital.Or examination, the right knee-joint was found considerably

enlarged in all directions; it felt tough, slightly elastic, andneither flexion nor pressure seemed to give the patient verygreat pain. No external opening was noticed, and no symp-toms of suppuration within the joint were present.Mr. Avery ordered the joint to be painted with the astherial

tincture of iodine, and prescribed at various times such internalremedies as seemed indicated by the general health of thepatient, and the state of the functions and secretions. Iodideof potassium, colchicum, liquor potasssæ, &c. &c., were usedby turns, but appeared to have but little effect upon themorbid state of the knee-joint. The local application ofiodine procured, however, some improvement, and we shouldnot omit to state that we have seen this manner of usingiodine particularly successful in this hospital.We understand from Mr. Muirhead, the apothecary to the

institution, that the fluid consists of sulphuric sether, which ismade to take up the maximum amount of iodine, the tincturethus becoming very strong. The effect being powerfullyderivative, has been found very satisfactory in several in-stances. The benefit was, however, but temporary in Mr.

Avery’s patient; though it was thought at one time that thejoint might become anchylosed, and the limb be saved.Inflammation of a severe kind recurred after several months’stay in the hospital, and it became evident that suppurationwas taking place in the joint; fluctuation was detected; theabscess opened with the lancet and a considerable quantity ofpus evacuated.Several months again elapsed, during which the patient had

generous diet and stimulants; but the morbid state of theknee-joint at last produced alarming exhaustion, and it becameMr. Avery’s duty to propose amputation. The operationwas performed on the 25th of April, 1853, almost sevenmonths after admission, by Mr. Luke’s antero-posterior flaplnethod. The joint, on being opened, after the removal of thelimb, presented a good specimen of thickening of the synoviallnembrane, connected with the suppurative process; but thearticular cartilages were not attacked, and it was thusinteresting to notice how long they will resist in some cases,

whilst in others, as shown by several instances in the presentseries, they are destroyed, in a comparatively short time, bythe morbid processes going on in the joint.The patient has done well since, and he is very likely to

recover, with a good stump. There has been a kind of epidemicerysipelas reigning in the hospital for the last few days,but it is to be hoped that the man will escape this very un-pleasant complication. We must not conclude without

adverting to the method of amputation adopted in this case,and which we have seen repeatedly succeed, both in Mr.Avery’s and other hands. The fl ips may be so accuratelymeasured and fashioned, and the bone is so well covered, thatthe stump generally turns out extremely well.We now draw near the close of our list, and find the next

case to be one of those in which the disease has remained insome degree dormant for many years, the joint becomingfinally spoilt by accidental violence.

LONDON HOSPITAL.

Inflammation of the Synovial Membrane of the Knee-joint, fol-lowed by Suppuration in the Cavity of the Articulation,eighteen years before Admission; imperfect Use of the Limbfor a considerable period; accidental Violence to the Joint afew months before reception into the Hospital; severe Symp-toms; Amputation; Recovery.

(Under the care of Mr. ADAMS.)RICHARD G-, a grocer’s shopman, aged thirty-four years,

of dark hair and complexion, and nervous temperament, wasadmitted on the 5th of April, 1853. The patient states thatwhen sixteen years of age he had a slight fall upon the rightknee, which caused but very little pain at the time of theaccident, and hardly any uneasiness for a few weeks after-wards ; but at the end of that period the joint was attackedwith severe inflammation, matter quickly formed, and a con-siderable amount of pus was evacuated on the abscess beingopened by a surgeon. The morbid process took such a firmhold on the articulation that the patient was laid up for atwelvemonth, during which time active suppuration continued.The openings made around the joint finally healed up, and theknee so far improved that progression became practicable bythe aid of a stick. Partial anchylosis probably took place,and for sixteen years the man contrived to attend to hisoccupations, the state of the knee sometimes requiring thesupport of one or two sticks for walking, and the fits of painand uneasiness recurring at various intervals. (See an

analogous case in this series, THE LANCET, vol. i. 1853, p. 539.)The patient now and then met with falls upon the affected

joint, but they never were of a serious kind, and he generallyexperienced but little pain or trouble from these accidents;but about five months before his present admission he fellover one of those mischievous orange-peels, and injured hisknee so severely that he was unable to get up. The poor manwas now laid up for several months at his own house; matteragain formed in the joint, the abscesses opened spontaneously,the tibia became dislocated backwards, and the pain wasduring the whole period of a very severe character. Suppu-ration was very abundant, and the patient at last applied atthis hospital in a state of great debility and exhaustion.On examination the knee was found considerably enlarged,

the outline of the joint lost, the tibia dislocated backwards,and the textures hard and unyielding. Movements of flexion,extension, or rotation, gave very great pain; there were severalapertures around the joint discharging pus, and the generalhealth of the patient was much impaired.Mr. Adams endeavoured, for the first four weeks of the

man’s stay in the hospital, to improve his health by good dietand tonics; and apprised him, after that time, that the onlymode of restoring him was the amputation of the limb. Theoperation was performed on the 7th of May, 1853; and whenthe joint was cut open, it was found that none of the texturesentering into its formation could any longer be recognised;the suppurative process had even destroyed the originallythickened synovial membrane; the cartilages and ligamentswere likewise gone; and nothing was discernible but cariousbone. The false anchylosis which had existed for so manyyears had perhaps been formed upon the remains of the jointafter its disorganization; and the series of abscesses whichhad closely followed upon the inflammation excited by theaccident, had probably destroyed whatever had escaped theoriginal morbid action. The analogy of this case with that ofSt. Bartholomew’s, to which we have referred above, is in

D D

576fact only partial, as in the present instance the anchylosisseems to have been of a sufficiently firm character to allow oftolerably easy progression, the fits of pain being widely sepa-rated. It is very likely that if this patient had not had themisfortune of severely hurting the anchylosed joint by slippingover an orange-peel (the dropping of which in the street shouldbe visited by a penalty) he might have gone on using his limbfor many years to come.The progress of the case was not at first calculated to allay

all fears, for the traumatic fever ran high, and the patient’sgreat debility was very alarming, but he struggled throughthis stage by the aid of a good diet, tonics, and wine, and isnow in a fair way of recovery. ’

Such a case as the present is an additional illustration’ ofthe propriety of advising persons having anchylosed joints ofthe lower extremity to be extremely careful of accidents, asinflammation set up in an articulation, partially soldered byanchylosis, is controlled with much difficulty, and generallyfollowed by such extensive suppuration that the removal ofthe limb becomes imperiously called for. The same caseshows, however, very satisfactorily, what good hopes we mayhave of these numerous youths lying in the hospitals ofLondon with suppuration in the cavity of knee-joint. How-ever tedious the malady may appear, we should alwaysrecollect that as long as the patient’s strength is not com-pletely exhausted, we may be buoyed up by the expecta-tion of obtaining anchylosis.

‘ .

UNIVERSITY COLLEGE HOSPITAL.

Inflammation of the Periosteum and Bone of the lower part ofthe Femur; Suppuration; Extension of the morbid processto the Knee-joint; Suppuration in the Cavity of the Articula-tion; eventual Anchylosis.

(Under the care of Mr. ERICHSEN.)AMELIA M—, aged fifteen years, was admitted, Nov. 26,

1852, with pain and swelling of the lower part of the left

thigh, which she attributed to cold taken about three weeksbefore. The girl presented the principal signs of a strumousdiathesis, and other members of her family were said to evincethe same tendencies.Mr. Erichsen, on examining the part, convinced himself

that very rapid formation of matter had taken place; andfluctuation being quite distinct, an incision was made threeinches above the patella, whereupon about ten ounces of veryfgtid, oily pus escaped. On the probe being introduced, theinstrument could be carried for four or five inches along thedenuded bone. Poultices were placed around the affected i

parts, and Mr. Erichsen ordered a combination of stimulantsand diaphoretics.Three days after this, a considerable quantity of fœtid pus

was again evacuated by another incision, the same treatmentbeing continued. Soon after the opening of these abscessesthe patient began to show symptoms of exhaustion, and thepowers of life seemed to be ebbing so fast that Mr. Erichsenthought it his duty to propose amputation. The friends of thegirl expressed, however, great alarm on hearing of this extrememeasure, and could not bring themselves to consent to theoperation. Under these circumstances the line of treatmentbecame very simple, and all efforts were directed to counteract,by tonics and stimulants, the debilitating effects ’of profusesuppuration. Good diet, wine, quinine, the mineral acids, &c.,were therefore ordered.For the next five days the wounds continued to pour out up

to ten ounces of pus per diem, and the patient became accord-ingly very much emaciated, and hectic set in. The appetiteremained, however, very good, and the perspirations at nightbegan to diminish.On the twenty-eighth day after admission the discharge

was still about ten ounces a day, the feverishness continued,the pulse was 130, the skin hot and dry, and the appetitefalling off. The patient began also to complain of the kneeon the affected side.When the joint was examined, it was found that it presented

an abnormal fulness, which led to the supposition that effusionhad taken place in the articulation. The knee became graduallyflexed, and the discharge from the abscesses around the thighbegan from day to day to diminish. The contraction, however,went on increasing, and in about fourteen days from the timewhen the swelling of the knee was first noticed the leg hadbeen drawn up at a right angle with the thigh. The knee now

presented a considerable and uniform enlargement, the in-teguments were red and shining, and fluctuation was quite

distinct. The probe could still be passed very high along thesinuses of the thigh, but the girl’s spirits were better, herappetite became ravenous, and the bowels remained veryregular.On the 1st of February, thirty-seven days after the implica-

tion of the knee, the abscess which had formed in the cavityof the joint broke spontaneously, and with this event the painand swelling almost disappeared. Matters now began to weara more cheerful aspect, the discharge from the thigh and kneegradually lessened in quantity, and the wound in the jointhealed up one month after the spontaneous rupture of theskin over the abscess. The patient’s general health improvedrapidly, the purulent matter coming from the thigh becamevery trifling, and the knee was getting anchylosed in astate of extreme flexion. Thus the patient continued im-proving up to the fourth month of her stay in the hospital,when Mr. Erichsen thought that the time had come to

straighten the leg. The girl was therefore put under theinfluence of chloroform, and the limb forcibly extended; itwas then placed on a splint, and given a few days’ rest. Thepatient was finally discharged in a fair way to complete re-covery, with a very small sinus in the thigh.Most of our readers will agree with us that this case is

extremely valuable as showing the course taken by an affec-tion, which, in the eyes of the surgeon, required extrememeasures. We do not mean for -an instant that the candidopinion of the medical adviser should ever be modified by therecollection of these exceptional cases ; but- the naturalhistory of these maladies may teach us that it is impossibleabsolutely to calculate the amount of resistance which even adebilitated frame may offer to pathological complications. Weare convinced at the same time that the majority of thosewho suffer as did Mr. Erichsen’s patient, sink under the ex-hausting effects of irritative fever and profuse suppuration.We would finally allude to the advantages of using sys-

tematic compression to the whole limb, in cases of chronicinflammation of the synovial membrane of the knee-joint.This practice was adopted by Mr. Erichsen, with the mostsatisfactory results, in a case lately under his care at thishospital. The principal facts are as follow.

William S-, aged nineteen years, was transferred to Mr.Erichsen from the Physician’s Ward, Jan. 15, 1853, with allthe symptoms of chronic inflammation and thickening of thesynovial membrane of the right knee. The startings in thelimb were very distressing, the pain of a severe character, andthe least attempt to put the foot upon the ground was muchapprehended.The limb was encased at once from the foot to the hip in a,

firm starch bandage. Very great relief was experienced fromthis application, the pain and startings seeming much con-trolled. Small doses of bichloride of mercury in decoction ofsarsaparilla were ordered.The apparatus was worn for twelve days, when the patient

complained of severe pain in the joint; to relieve this thestarch bandage was removed, twenty-four leeches applied tothe knee, and the limb placed on a pillow.A week after this the starch bandage was again put on, as

the inflammatory symptoms had subsided. The patient nowremained free from pain, and soon began to walk about theward with his leg in a sling. The apparatus was left -on foralmost one month, when it was cut up, and the limb orderedto be rubbed with the following liniment, to promote absorp-tion : iodide of potassium, one drachm; soap liniment, oneounce.

A few days afterwards Scott’s strapping plan was adoptedfor the knee, and in a fortnight’s time the patient could bearconsiderable weight on the affected limb. Cod-liver oil wasnow substituted for the bichloride of mercury, and on the 29thof March two months and a half after admission the patient

could walk on the affected leg and was therefore discharged.The favourable results obtained in this case by compression

of the whole limb are suggestive of improvements which. might be introduced in the treatment of sub-acute iuflamma-, tion of the synovial membrane of the knee. There can be no

doubt but that complete rest and immobility of the joint canl hardly be obtained but by a contrivance of this kind, and wer would strongly urge a trial in recent cases, or those in which- the more acute inflammatory symptoms are passed. Thestarch-bandage, applied with strips of pasteboard, has been

Probable Chronic Inflammation and Thickening of the SynovialMembrane of the Knee-joint; Starched and Scott’s Bandagesused in succession; Recovery.

(Under the care of Mr. ERICHSEN.)