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joints may become implicated when the osseous textures intheir vicinity, or in contact with them, take on a morbidaction. Indeed, it is hardly surprising that a carious andnecrosed state of the patella should excite inflammation inthe knee-joint, though a case will be found below (St. Mary’s)in which the joint escaped. But that the inflammation shouldturn out to be of the destructive kind which was observed inthis case is, perhaps, not common; and we must look to thefrequent injuries which the knee had suffered, or to the

patient’s general health, to find an explanation of the patho-logical phenomena. We have noted other cases in which theknee became implicated by inflammation of bony structuresituated at some distance from the joint, and it will be seen bythe details which we subjoin that the articulation sufferedseverely in all the cases. The first to which we shall directattention is the following. -

MIDDLESEX HOSPITAL,Injury to the Tibia; Slight Exfoliation of Bone; Extension of

the Morbid Action to the Knee; Complete Destruction of theJoint; Amputation; Death; Autopsy.

(Under the care of Mr. SHAW.)JosEpa G--, a cab-driver, aged thirty-six years, who has

not been very temperate, was admitted April 12, 1853. It

appears that the patient received a short time before admis-sion a kick from a horse, by which the upper part of the lefttibia was injured. The wound was not, however, of an alarm-ing kind, and matters went on pretty well for the first few days;but the soft parts having ulcerated, the bone became exposed,and a commencement of exfoliation took place. The woundbegan at this time to take an unhealthy aspect, and the super-ficial veins of the leg and thigh showed signs of inflammation.A slight attack of erysipelas also took place, and it becameevident that the knee-joint was becoming involved.Severe pain was complained of, and it was suspected that

suppuration was taking place within the articulation. Thefever ran high; the matter came to the surface, and it wasfound necessary to open the abscess which had formed in thecavity of the joint. The discharge of pus was profuse, and inspite of tonics and stimulants it became apparent that irritative ’,fever would soon destroy the patient. Mr. Shaw thereforedetermined to take off the leg above the knee, amputationbeing the only means holding out a chance of saving life.The operation was performed on the 20th of May, 1853, the

man being at the time in a very weak state; and on examina-tion of the joint, it was found completely full and distended

by pus, the matter emitting a most offensive smell; the carti-lages and ligaments were softened, the former presenting theHocculent appearance initiatory to complete destruction. Theabscess of the joint had burrowed under the extensor muscles,and formed an enormous sac.The patient remained for several days in a very weak state,

and in spite of the diligent exhibition of tonics and stimulantshe died nine days after the operation.There is a very striking analogy between this case and the

preceding; for in both was the joint secondarily affected by-contiguity, as it were; and we cannot wonder that surgeonsshould be so very anxious to prevent extension of the morbidprocess into joints when treating caries of bone in the vicinityof an articulation. The examples which have fallen under

. Our notice presented this peculiarity, that the patients hadimpaired their constitutions by intemperance; the progress ofthe disease would perhaps have been less rapid had the systembeen able to bear up against the intense inflammation whichattacked the joint. We are the more inclined to take thisview of the matter, as we noticed pretty well the same patho-logical phenomena in another case treated by Mr. Johnson atSt. George’s, the notes of which were kindly furnished byMr. Holmes, surgical registrar to the hospital.

ST. GEORGE’S HOSPITAL.

Periosteal and Bony Inflammation of the lower portion of theFemur; Extension of the Inflammation to the Knee; Destruc-tion of the Joint; Amputation; Death.

(Under the care of Mr. HENRY CHARLES JOHNSON.)ROBERT S-, aged forty-eight years, was admitted July

14,1852. The patient had been ill about six months beforehis admission, the ailment having begun with swelling andpain at the lower part of the femur. An abscess had subse-quently formed in that locality, and had been opened on theinside of the thigh.On admission, the lower and internal part of the latter

presented a sinuous aperture leading down to bone; pain wasstill complained of, and there was a copious discharge ofmatter.The mode of treatment generally employed in caries of

bone was resorted to-viz., emollient applications, tonics,good diet, &c.; but it was noticed, after a few weeks, thatthe knee-joint was becoming involved. The usual symptoms,such as pain on moving the articulation, swelling, redness,&c., were successively observed; and it was soon manifestthat the patient’s health was giving way under the disease.No resource was left but amputation, which was performedOctober 21, 1852, about three months after admission, andnine after the first onset of the disease in the femur. Mr.Johnson examined the joint after the operation, and foundthe articular cartilages destroyed, the cavity full of pus, theinner side of the joint partially anchylosed, and the patellaattacked with caries. Numerous sinuses opening by theinner side of the femur communicated with the articulation.The latter bone was also found enlarged and considerablyhardened.The prospects of the case were by no means favourable, as

the aspect of the patient had never been healthy; his counte-nance was always flushed, his complexion dusky, his mannervery strange, and at times almost delirious. After the opera-tion, he went on pretty well for a few days, except that thebowels were obstinately costive. On the sixth day, however,the man had rigors, followed by vomiting, profuse diaphoresis,and the well-known symptoms of purulent infection. Hedied on the ninth day after the operation.In the next case the inflammatory process began, seem-

ingly, at a little distance from the joint, though the factis not so clear and palpable as in the two preceding ones.But there is much likelihood that the articulation was notprimarily affected. Here, again, we are indebted to Mr.Holmes for the notes of the case :-

Supposed Bursal Inflammation over the Head of the Tibia;extension of the Morbid Action to the Knee-joint; Abscess;Articular Disorganization ; Amputation; Death;’ Autopsy.(Under the care of Mr. HAWKINS and Mr. HEwETT.)

William M—, a gamekeeper, aged thirty years, whohad apparently lived rather freely, and looked older,came to the hospital Jan. 5, 1853. The patient presented inthe vicinity of the right knee, a fluctuating swelling, whichhad existed for about nine months, the exciting cause beingunknown. The tumour was circumscribed and situated overthe head of the tibia; but the joint was not obviously in-volved, as the patient complained of no pain, and the synovialcavity did not seem enlarged, though the knee was stiff. Itwas at first a question whether the swelling was the result ofa collection of purulent fluid, or was owing to the distensionof a bursa situated in this neighbourhood. An exploratorypuncture was made into the tumour, and as the liquid whichescaped was quite clear, it was determined to give the patientthe benefit of the latter view of the case, and to excite theabsorption of the fluid by blisters and solution of iodine.

This course was persevered in for about two months, butthe swelling did not diminish; it was then again punctured,and this time evidently contained pus. The tumour wastherefore laid open, and as the knee-joint was still apparentlysafe, it was hoped that the disease might be so cured withoutextending to the articulation. The abscess had ir. the mean-time increased a good deal in size, the affected limb wasmuch larger than its companion, and the patient’s appearanceconsiderably worse than on his admission.The sac was at first thought to be superficial to the joint,

and was opened by a small incision almost two months afterthe first examination; but soon after this the collection ofmatter increased rapidly; the patient was seized with intensepain in the knee, he had startings in the limb, and slept verybadly. He was now noticed to have a slight cough, but nodisease of the lung was detected. The urine was high-coloured, but healthy; the abscess extended to a great depth,and bone could be felt by the probe, apparently close to thehead of the tibia.

After about three weeks, as the patient’s health was evi.dently suffering, and there seemed to be no chance of hissurviving the process of anchylosis, it was determined to am-putate. On April 14, 1853, a little more than three monthsafter admission, this operation was performed by Mr. Hewett,in the absence of Mr. Hawkins. The incision was circular,and made about the lower third of the thigh; it ran throughthe cavity of the abscess, this course being considered pre-

I ferable to amputating above the end of the sinus, which ar-

Supposed Bursal Inflammation over the Head of the Tibia;extension of the Morbid Action to the Knee-joint; Abscess;Articular Disorganization; Amputation; Death; Autopsy.(Under the care of Mr. HAWKINS and Mr. HEWETT.)

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rangement would have placed the incision at the upper thirdof the thigh, and rendered the operation much more severeas the patient was a stout man. The anterior portion of thestump was much thickened by serous infiltration, giving thesoft parts a brawny consistence, and rendering it impossibleto bring the margins of the wound into apposition immediatelyafter the operation. This state of things also prevented thesmall vessels from retracting, so that almost thirty ligatureswere required.On examination of the joint, its cavity was found to com-

municate freely with that of the abscess, the cartilages werealmost destroyed, and the exposed surfaces of bone cariousand partly united by soft anchylosis.The patient progressed extremely well for sixteen days;

his health and expression of countenance improved most re-markably; his appetite, before almost gone, became hearty;and he was profuse in his expressions of relief. But on the iseventeenth day, he had a severe rigor, followed by an abun-dant perspiration, and the usual symptoms of purulent infectionbecame manifest. The face turned very yellow; rigors andperspiration recurred at intervals; the bowels became veryweak; the tongue foul; and after a few days delirium set in.Still the stump looked healthy; there was plenty of soft partsto cover the bone, and they did not retract. The patient died,however, on May 8, 1853, seven days after the first symptomof purulent infection, and twenty-four days after the ampu-tation.

Post-mortem examination.-The body was enormously obese,the integuments very yellow, and two openings for venesectionexisted at the right elbow. The left leg had been amputatedabove the knee, the stump was well formed, and the flapsuniting well, but not quite cicatrized. On exposing the dividedbone, the muscles around were found very soft and paÏe;dark-looking purulent fluid enclosed about three-fourths ofthe circumference of the femur, the periosteum beingdestroyed to a corresponding extent; the bone itself, as wellas the medulla, were, however, healthy.The superficial veins of the thigh were natural, but the

femoral and tributary branches full of discoloured red andbrown pus-like fluid, and coagulated fibrin adherent and non-adherent to the coats of the vessels. Some of the smallerveins, near the lower part of the thigh, contained pure, light-coloured, yellow pus. The lower part of the vena cava in-ferior, as high as within two inches of the diaphragm, as alsothe left common iliac, the left internal and external iliacveins, all contained similar material to that within the leftfemoral vein. The right common iliac and sub-divisions werenatural. Nothing worthy of remark was noticed in the ab-dominal viscera; the pleural cavities were also healthy, butthe lungs were congested; and in the lower part of one of themwas a small yellow deposit of fibrin, surrounded by firmerstructure than the rest, and beginning very slightly to soften.There was also secondary lobular pneumonia, and it wasnoticed, that the blood was generally very fluid.

This concludes the examples of extension of the morbidprocess of bone into the knee-joint which we have latelyobserved in the hospitals of London, and we now pass toanother class of cases wherein the inflammation began in thejoint itself, mostly in the synovial membrane, in which casesamputation was performed with varying results.

Inflammation of the Synovial Membrane of the Knee-joint; sub-sidence of Acute Symptoms; Anchylosis prevented by neglect;renewed Inflammation of Synovial Membrane, Bones, andLigaments; Amputation; Recovery.

(Under the care of Mr. HAWKINS.John W-, aged fourteen years, was admitted for the

second time, Dec. 8, 1852.It appears that the patient had, about a twelvemonth

previous to his present admission, been received into the I

hospital for acute inflammation of the synovial membrane ofthe right knee-joint. He remained several months undertreatment, the inflammation was subdued by appropriatemeans, and he was discharged in a favourable condition witha partially anchylosed knee. The boy was desired to wear asplint for some time, so that the process of anchylosis mightbe favoured; but he unfortunately did not attend to thedirections which were given to him, the splint was soon castoff, the limb freely used? and new inflammation excited in thearticulation.He was re-admitted, as stated above, and it was soon

observed that pus had formed in the joint. The abscess wasopened some time after admission, to give the patient a chanceof anchylosis forming again; but the system now gave way

under the irritative action of the articular suppuration, and itsoon became clear that the limb must be sacrificed to savelife. Amputation above the knee was performed on the 17thof March, 1853, almost three months after the boy’s re-

admission.Mr. Hawkins laid open the knee-joint after the operation,

and found a small quantity of pus within it; the cartilagesboth of the articulating surfaces of the femur and tibia wereabsorbed, a granulating surface appearing in their stead. Thelatter circumstance showed very clearly that nature was insome degree preparing for anchylosis, which would probablyhave taken place if the patient’s strength had not given way.

This boy progressed very well, all the usual healthy changestook place in the stump, and the latter was, on the 10th ofMay, completely cicatrized.Of cases like the present we have seen many for the last

few years. Here and there anchylosis has taken place; but,as a rule, amputation was found necessary to save life, whichwas ebbing fast under the influence of the irritation caused bythe articular affection.We now come to the consideration of another set of cases,

in which the inflammation remained extra-articular, andterminated in recovery.

-

ST. MARY’S HOSPITAL.

Large extra-articular Abscess near the Knee; Recovery withoutthe implication of the Joint.

(Under the care of Mr. COULSON.)MARY B , a laundress, aged nineteen, stout and healthy-

looking, was admitted, Dec. 3, 1852. The patient, who doesnot kneel down for her work, had enjoyed excellent healthuntil a fortnight before admission, when she felt pain in theright knee. She went on with her occupation for threedays afterwards, but was then compelled to desist, from thesuffering caused by a hard, red swelling near the knee-joint.She stated that this " small boil" burst, and that half a pintof purulent matter escaped ten days before admission.On examination the knee was found enlarged, the outline

of the joint being indistinct, the skin was red in patches, andthere was an opening over the patella, from which issued asanious discharge. The bending of the leg gave much pain,and there was a tender spot on the external side of the knee.Mr. Coulson made an opening into the swelling, freed a

quantity of grumous matter, and ordered poultices andaperients.On the thirteenth day a probe could be passed upwards and

backwards in the wound for about four inches; the sinus waslaid open, and lint inserted to excite the healing from thebottom.Four days afterwards the girl became feverish, and lost her

appetite; fluctuation was detected on the inner side of theknee. Mr. Coulson opened this abscess in the most dependentpart, and ordered the leg to be placed upon a back-splint.Poultices, saline medicines.

Suppuration continued from both openings for a week, whenthe patient was ordered bark and nutritious diet. She like-wise had brandy; and on the fifth week after admission thepatella could be made out, and there was less pain thanformerly. The sinuses went on gradually contracting, andthe parts were quite healed up on the 18th of March, 1853,fourteen weeks after admission, the joint not having materiallysuffered during the protracted extra-articular suppuration.

It is not uninteresting to compare this case with those of £Middlesex and St. George’s Hospital, and one cannot helpremarking how readily joints become affected in some

patients, and how they resist with others. It is true that inthe cases which were related bone was affected in the vicinityof the joint, but the bursal inflammation, which was theprincipal symptom in Mr. Coulson’s patient, was quite severeenough to run on to the joint, had the constitution been in aless healthy condition.The next case is likewise remarkable, as showing that

necrosis of the patella may take place and the joint not beattacked with inflammation. It will form an instructivecontrast with the first case of this day’s " Mirror."

Necrosis of the Patella ; Removal of Dead Bone; Becovery.(Under the care of Mr. COULSON.)

Charles B-, a tallow-chandler, aged forty years, was:

admitted December 24,1852.The patient has had gleet for the last two years, and has

been subject to pains in the bones. About four monthsbefore admission hp noticed hard resisting tumours on the

Necrosis of the Patella; Removal of Dead Bone; Recovery.(Under the care of Mr. COULSON.)