We consider the observations and experience of Mr. Guthrie on the subject of wounds of the knee-joint to be too valuable to be here passed over. " Wounds of the knee-joint," he remarks, " however simple, should always be considered of a dangerous nature, infinitely more so than of the shoulder, the elbow, or the ankle." " I could," he adds, " relate an infi nite number of cases on these points, termi nating fatally or in amputation, where the in jury was severe, or apparently at first but slight, and but few cases where the capsular ligament was opened' into by a musket-ball, where the patient has preserved the use of the limb. In every case where the wound was known to be serious, I have invariably been disappointed in the hope of saving the limb." He then adduces the following case as an instance of apparent simple injury that frequently occurs. "This ease," he adds, " will shew the danger of all these wounds, and the very great care and at tention that are necessary for their cure. Co lonel Donellan, of the forty-eighth regiment, was wounded at the battle of Talavera in the knee-joint by a musket-ball, which gave him so little uneasiness, that when a roller had been put on his leg, with some simple dressing, he could scarcely be persuaded to proceed to the rear. At a little distance from the fire of the enemy we talked over the affairs of the mo ment, when, tossing his leg about on the saddle, he declared he felt no inconvenience from the wound, and would go back, as he saw his corps was very much exposed. I explained to him the dangerous nature of the wounds of the knee-joint, and after he had staid with me a couple of hours, I persuaded him to go into the town. This injury, although at first to all appearance so trifling, and under the best sur gical care, caused the death of this officer in a very short time, and proceeded so rapidly as to prevent any relief at last being obtained by am putation." Some years ago MM. Larrey and Garriques, in France, recommended the amputation of the leg immediately below the tuberosity of the head of the tibia, instead of amputation of the thigh, where it was found impracticable to re move the leg at the ordinary place of election— four inches below the knee-joint. But Larrey made an addition to this operation, namely, the extraction of the head of the fibula. lie says, " when the fibula is left short, which is usually the case, it is to be extirpated as useless, and troublesome in the application of the artificial leg, and the skin is to be left as long as pos sible, to cover the stump." Mr. Guthrie gives Larrey much praise for drawing the attention of the profession to this " great improve ment," and adds the weight of his high autho rity by recommending the removal of the head of the fibula. In alluding to this subject we may appear to be departing from the proper object of this article,—the abnormal appear ances presented by the knee-joint ; but having known some melancholy examples of acute in flammation of the knee-joint to follow the operation here recommended, we take this op portunity of warning the profession against it. Mr. Guthrie himself says, " it is possible, how ever, that a case may occur (perhaps one in a thousand) in which the head of the fibula com municates with the general cavity of the knee joint ; in such a case amputation must be done above the knee." Independently of this com munication between these two contiguous joints which Mr. Guthrie considers so rare, we have found, by repeated anatomical examinations of the relation existing between the synovial sacs of the knee-joint and that of the superior tibio fibular articulation, that these two sacs are so close as to have but a thin transparent wall separating them. We consider it, not abso lutely, but very nearly impracticable to cut out the head of the fibula in the living subject without making a communication with the pos terior and back part of the synovial membrane of the knee-joint, so delicate is the thin trans parent membrane which is interposed between the synovial sac of the knee-joint and the little synovial sac which partially envelopes the head of the fibula. Besides, in the living subject it must always prove to be a difficult matter to remove the head of the fibula without in terfering with the tendon of the popliteus muscle, as we know the tendon to be enve loped by a synovial production sent down along it, like that which in the shoulder-joint invests the tendon of the biceps. This synovial production is not confined to the tendon of the popliteus, but is also reflected over the groove formed for the reception of this tendon, and must be in danger of being opened in every operation which we can devise for the removal of the head of the fibula; and conse quently, although there may be many cases in which it may be advisable to amputate the leg a little below the tubercle of the tibia, in no case, in our opinion, should the surgeon attempt to extirpate the head of the fibula. The idea that this small portion of bone, when left, is "useless and troublesome in the application of the artificial leg," may be true, but it is not the less true that in the majority of cases acute arthritis of the knee-joint will be very likely to succeed to this operation ; and we feel satisfied that, as soon as these anatomical relations be tween the synovial sac of the knee-joint and that of the superior tibio-fibular articulation are reflected on, this modern proposal will be re jected.
Among the causes of acute arthritis gem, exposure to cold is very frequently referred to by the patient, and apparently with reason. The knee-joints being less covered by muscular parts than any other of the large articulations, are more subjected to the influences of cold, and on this account are perhaps more generally affected by acute and chronic inflammation than other articulations. It must be admitted, how ever, that we have met with cases of acute inflammation of the knee-joint for the origin of which we could assign no cause, having come on, as we are accustomed to say, spontaneously. Acute arthritis genu sometimes arises as a symptom in the course of different diseases.
Thus in diffuse inflammation and in phlebitis it is quite usual to find the joints visited by most severe attacks of inflammation. We have seen examples of acute arthritis supervening suddenly in the course of a severe attack of erysipelas;• and in rheumatic fever and puer peral rheumatism we can see little else than an inflammation of the joints, the nature of the in flammation in these cases, however, being very different.
Although we have here spoken of three different forms of disease, diffuse inflammation, phlebitis, and puerperal rheumatism, we have ourselves long entertained the opinion expressed by Mr. Arnott, Velpeau, Dance, Cruveilhier, our friend Dr. Beatty, and others,-} that the three forms of disease in which the acute arthri tis we are here treating of occurs, are the same, and that the arthritis in all three is similar, and proceeds from the same common cause, viz. phlebitis and its consequences.
The peculiar form of acute arthritis here adverted to bas in almost all cases been found to have been preceded by phlebitis. This may have come on spontaneously, or in consequence of a wound, or of the vessel having been in cluded in a ligature. The form of acute arthri tis which has been called puerperal rheumatism has also been found, in many cases, coincident with or preceded by phlebitis of the veins of the uterine system, or of some other veins.: We have seen many cases which we consi dered to be examples of diffuse inflammation in very young subjects, engaging the periosteum of the femur and tibia, and terminating in the , complete destruction of the bone, in the short space of three days. Sometimes the periosteum of the femur, for example, formed a complete cylindrical sac containing the detached shaft of the bone.
The symptoms of acute arthritis which occur in the course of a case of diffuse inflammation are usually ushered in by a severe rigor followed by perspiration. The patient is remarkably restless and depressed in mind. If the phle bitis be external, as in that occasionally succeed ing to venesection, which has preceded the acute arthritis, the inflammation along the course of the wounded vein will be observed for several days before the attack of arthritis shall come on. Whatever may have been the cause of the inflammation of the joints, the disease does not, as in rheumatic fever, pass successively from joint to joint, completely leaving one joint to visit another. Although varieties may of course be noticed in the local symptoms which this dangerous disease presents, it very con stantly happens that a joint once visited by it seldom or never completely recovers its effects. Usually many joints are successively or simul taneously affected, and we very generally dis cover that one or more of the internal organs is also implicated. Whatever joint is attacked in the course of the disease, it presents the ordinary characters of an acute arthritis. The integu ments covering the articulation sometimes wear a pink hue, and always have an elevated temperature. The affected limb is powerless. The patient complains of very considerable pain, more particularly, as it appears to us, in puerperal arthritis than in the affections of the joints which attend on the ordinary forms of diffuse inflammation. The swelling, when first examined, is soft and fluctuating. After a time the effusion of synovial fluid and pus increases, giving rise to the distension of the synovial sac. If at this advanced period we carefully examine the parts immediately surrounding the inflamed joint, we can discover that the integuments and subjacent parts feel somewhat indurated and edematous, reminding us of the hardened basis which we find circumscribing an abscess. It is probable that this condition of the surrounding parts arises from diffuse inflammation and the infiltration of its digested purulent matter. The arthritis in these cases is seldom the cause of death ; either some internal vital organ be comes violently inflamed by which the death of the patient is accelerated, or abscesses form in the subcutaneous or intermuscular cellular membrane in various parts of the body, which, although more slowly, as certainly lead to a fatal issue, for when the evacuation of the pus takes place, the quantity of matter which is dis , charged and continues to be secreted is so excessive as greatly to reduce the patient's strength, and the exhaustion from this source and from the diarrhcea which usually attends are sufficient to prostrate the powers of the youngest and strongest individuals. Most writers indeed have observed that in the majority of cases the subjects of this disease had been in a had state of health at the time the exciting cause came into action,—a cachectic condition produced by over-exertion of mind or body, and that from these circumstances the susceptibility or pre disposition to this disease most probably I arose.* These observations are, we believe, fully borne out by experience, and it may not perhaps be uninteresting- to adduce some remarks published by an author nearly forty years ago, which prove that he was practically acquainted with the complaint denominated by the moderns puerperal rheumatism or puerperal arthritis, and that he took a similar view of the predisposing causes of this disease. Mr. Russell in his work on the knee-joint, in treat ing of acute cases of what lie calls white swelling, says : " in those cases which proceed most rapidly, the disease will reach its acme in the course of a few weeks." The very rapid and acute cases seem to be connected with some state of great relaxation and weakness. He adds, " the most remarkable instances of this variety which have fallen under my observation, have occurred in the cases of women in child bed." In the Richmond Hospital (Dublin) we had had many cases of this form of acute arthritis, from which we select the two following as serving to illustrate some of the foregoing observations. Both these individuals were in a delicate state of health when the disease attacked them, and the swelling of the knee-joints and other articulations formed a very small part of their diseases.