Continued from page 961.1 I PROCEED, tlherefore, to the narration of further cases, exhibiting, some of them, the ordinary, and others, the least frequent complications, attending this operation. CASE II. G. W., aged 7, a pale, fair-haired, delicate-looking child, was admitted into the General Hospital, Birmingham, on June 8th, 1857, under my care, with disease of the left knee-joint. History. The knee has been diseased for the last two years; and on two occasions during that period he has'

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... a hospital patient. The disorder commenced after a slight injury occasioned by a fall. His parents are living, and his brothers and sisters are in good health. He has not had glandular enlargements, nor have the lungs shown symptoms of disease. Present State. The left knee is enlarged and rounded. There is an elastic elevation, corresponding to the synovial spaces by the sides of the patella. The inner condyle is much larger than natural, as is also the head of the tibia. The leg is semiflexed, and admits of very slight motion, which produces acute pain. The integuments are not ulcerated, and are free from pain, with the exception of the spaces by the sides of the patella above referred to. The muscles of the limb are much wasted, but the bones correspond in length to those of the opposite limb. The treatment, continued for several months, consisted in the careful adaptation of gutta percha splints to the joint, whilst a splint was also applied to the whole length of the limb, and was furnished.with a foot-piece and screw, so as gradually to straighten the extremity; at the same time, codliver oil and a nutritious diet were prescribed, with a view to the improvement of his general health. At this time the child suffered but little pain, though it was evident, no less from the increased size of the knee than from the wasting of the patient's frame, that the disease was making a gradual progress. In September, there appeared a swelling above the patella, apparently outside the joint, and situated amongst the tendons of the quadriceps. There was an obscure sense of fluctuation about this, but it was entirely fiee from pain. Soon after this time, I was desirous to excise this patient's knee, as I was satisfied of the presence of very extensive dis. organisation of the joint, and was of opinion that further delay would not prove advantageous. In consultation, however,with my colleagues, the symptoms were not deemed sufficiently urgent to render immediate operative interferenc'e expedient; and consequently, the treatment by rest and general means was continued. Finding that no improvement had manifested itself, either in the part affected or in the constitution, I resected the joint on December 16th. Operation. The patient being placed under the influence of chloroform, the usual semicircular incision was carried from one condyle, across the ligamentum patellae, to a corresponding point on the opposite side. The termination of the incision opened the abscess in the quadriceps, and gave exit to a large collection of pus; the soft parts were then cleared, and the ligamentous tissues divided. Before I was aware of it, the knee had been forcibly bent, and the remains of the crucial ligaments were torn through. This proceeding compelled me to saw off and remove the articular ends of the femur and tibia separately instead of in their connected state. The bones were sawn through with an ordinary amputation saw, and no spatula was introduced. The patella was not removed, No vessel required a ligature at the time of the operation. Two hours subsequently, the limb was accurately adjusted, and a modification of the Macintyre splint applied, which admitted of the wound being dressed without disturbance, and the boy being placed on a water-pillow, the extremity was lightly suspended in a swing-cradle. A small vessel proving troublesome during the dressing, it was tied, and the edges of the wound were closed by sutures. Examination of the Resected Bones. About three quarters of an inch of the femur, and rather less than half an inch of the tibia, were removed. The synovial membrane was everywhere in a condition of scrofulous degeneration. The cartilages covering the prominent surfaces of the condyles were almost entirely destroyed, large pieces being separated or only loosely connected with the bone beneath. The head of the tibia on the inner side was in the same condition in regard to its coverings. The bones themselves were filled with scrofulous matter. December 17th. He passed a restless night. This morning the pulse was 150. Dec. 18th. He had a better night; but was restless since morning; and had disturbed the splint. There was a free discharge from the wound. Dec. 19th. I was compelled to readjust the splint. Thc sutures were removed. The wound was looking healthy. Dec. 20th. The child was low and feverish. The pulse was rapid; the countenance pinched; the position of limb was good. I could not learn that he had had a rigor. Dec. 21st. Prostration was not so great. He had pain in the left elbow-joint, and was sick. Dec. 22nd. Suppuration was copious from the wound. He had pain in the right knee as well as in the elbow. Dec. 25th. He had a rigor whilst being dressed. The discharge from the wound was copious. From this date, he gradually sank, and died on January 4th, 1858, nineteen days afterthe operation. Dissection twenty-four hours after death. The brain was healthy. The lungs were remarkably small in size. The apex of the left lung was studded with a few tubercular deposits ia an unsoftened state. Small masses of purulent deposit were scattered throughout both lUDgS ; their size varied from a millet-seed to that of a pea or bean. The heart was healthy. In the pericardium was a large quantity of clear serum. The liver was natural in size: its surface was sprinkled by numerous purulent deposits, of the size of split-peas; and deeply seated in the upper part of the right lobe was a deposit of the size of a hazel-nut, of a similar character. The remainder of the abdominal viscera were natural. In the resected joint, the union of the flap in front was firm and satisfactory. The ends of the bones were in perfect apposition. On separating their surfaces, they were seen to be covered with imperfectly organised lymph. The textures adjacent were not infiltrated or in any way altered from the natural condition. The femoral vein was next traced carefully upwards from below the popliteal; it was healthy, until within a short distance from Poupart's ligament; at this point was located a plug of lymph, of two inches in extent. The plug imperfectly adhered to the coats of tlle vein, and was brokeni up in parts by bloody infiltration. The femoral and popliteal veins of the opposite limb were natural; so also were the iliacs and vena cava inferior. The cavity of the left elbow-joint waas filled up with a thin, dirty coloured pus. The left shoulder was healthy. The right shoulder had a quantity of pus within its cavity, whilst the right elbow was healthy. The right hip was filled with pus; the left was healthy. In the several joints occupied by pus, the cartilages and synovial membranes were unaffected. CASE III. G. A., aged 8, a delicate strumous looking boy, presented himself to my notice in Mlarch 1858, suffering from a long standing disease of the left knee. History. Six years since, after a fall, the joint first began to give pain, and after much suffering in the earlier stages of his complaint, the malady subsided to its present condition. Present State. His knee is now semiflexed, partially moveable. The tibia is thrown backwards, and thie patella rests firmly on the outer condyle. There is general enlargement of the articular extremities, and the entire aspect of the joint presents a globular appearance. He suffers no pain on movement or on pressure; but the limb is useless, is wasted, and he walks on cruitches, and has done so for years. It was evident in this case that all acute disorder had subsided; consequently, any treatmernt contemplated was with the view of, if possible, remedying the inutility of the limb. At the urgent request of the boy's friends, and after consultation with my colleagues, I determined to excise the joint, in the hope of obtaining a linmb more useful than the one just described. Accordingly, on March 24th, under chloroform, I operated in the ordinary way. Thin slices of the femur and tibia were removed, altogether, rather less two inches, and the patefla was likewise taken away. There was smart hsemorrhage, and two small vessels required ligature. The child seemed more than usually depressed after the operation, before 977 Dice. 3, 1859.] [BWTIM MEDICAL JOURNAL.