REMARKS ON PRE-SYSTOLIC CARDIAC MURMUR
353 cut with the knife. Over the internal condyle is some ab. sorption of cartilage, as also over the corresponding part of the inner tuberosity of the tibia. Elsewhere they are normal, or nearly so. The section of the bones shows slightly increased density near to the articular surface; otherwise they are healthy. A large collection of pus existed immediately above and to the outer side of the, patella. This appeared to be in a synovial cavity, but not in the general joint cavity; probably
... avity; probably some adhesions had shut off a pouch at this part, in which the fluid had accumulated. In the soft parts around the joint several sinuses existed; one of which communicated with the joint by an aperture in the popliteal space; whilst a second passed through this region, and ran down the calf of the leg behind the tibia, forming a wide channel, which terminated about two inches from the heel: all communicated with the exterior by the opening on the outer side of the thigh. In this case you will see, if you look well at the section of the joint, that, as in the first case, the disease is one oj the synovial membrane chiefly, but that the bone also is attacked, and that in a way not to be easily recognised by the eye, though quite capable of manifesting itself by symptoms before the removal of the parts. The report says the bones show slightly increased density, and this, when attention is drawn to it, is quite apparent. Now, what does this mean ? P Well, I take it that it is the expression of inflammatory mischief, which has gone on to the formation of new bone. You may, perhaps, think that the bone looks healthy enough, and so it is. There is nothing in these parts not quite consistent with a good and useful limb; nevertheless, as we know that inflammation has existed here, and as, when contrasted with normal bones, we find these thicker and heavier, we are justified in concluding that they have suffered the same process, though, perhaps, to a less extent than the synovial membrane-that they have, in fact, under the stimulus of inflammation, undergone a nearly normal process, and have become hypertrophied. You will also notice as a feature of the case the very extensive disease of the soft parts which existed, one sinus being very wide and extending from the lower third of the thigh nearly to the heel. CASE 4.-Lpdia M——, aged twenty, was admitted Nov. 16th, 1871. Her family history is good. She is married, and has had one child eight months ago, which died three months after birth. She is now two months advanced in pregnancy for the second time. Fifteen years ago she had a fall on her right knee. It immediately became much swollen, but without pain or redness. The swelling has never since then quite gone down, neither has she ever been free from pain in the joint when exercised in the slightest degree by walking. She has, however, managed to get about with the aid of a stick. Eight years ago it became rather more than usually painful, and she was in another hospital for six weeks. The knee was lanced over the inner part of the head of the tibia, but no matter came away, and the opening quickly healed up. For four weeks the limb was put on a splint and painted, but this treatment was entirely discarded on her leaving. Thus she went on till eighteen months ago, when she slipped on some orangepeel, and fell on the bad knee. This caused her much pain, and the swelling increased. It has continued more painful ever since, and she has ceased to be able to walk on it. During the last fortnight, without any additional blow, she has had much more pain, especially on the outer side of the joint. On admission her general health is good. The diseased knee measures 13 inches, the sound one only 12 inches in circumference. The right knee is bent at an angle of 113", and cannot be straightened more. There is much thickening, and the skin is white and shiny. On manipulation there is no fluid in the joint, but exceeding tenderness over the external tuberosity of the tibia and head of the fibula,. The patella lies on the outer articular surface of the femur. The long axis of the tibia runs up behind the long axis of the femur, and considerably to its outer side, so that the condyle of the femur is prominent on the inner side, and the outer tuberosity of the tibia on the outer side. Since her admission her one continuous complaint has been of pain, especially over the outer side of the joint. She sleeps hardly at all during the night, according to her own statement, and the sister of the ward confirms this. In consequence of this severe pain, she was very desirous of having her leg off, and I therefore, after consultation with my colleague, Mr. Birkett, decided upon amputation. That operation you have just seen me perform ; it was done in the usual way in which I perform all amputations in this region when possible. I now pass you round a section of the joint, and you will see that there is no fluid in the cavity, but that the small interval between the bones is filled up by a soft pulpy material, which forms a uniting medium between the tibia and femur. The patella is pushed entirely on to the external condyle, and between it and the femur adhesions have formed round the margin of the patella, leaving the greater part of its articular surface free to form the wall of a small cavity in conjunction with the opposing surface of the condyle. This space contains some blood and lymph. The cartilage of all the bones is very nearly, though not quite destroyed, and the bone surfaces beneath are tough. The epiphyses are united, but distinct. For two or three inches above and below the joint the bones are soft, and have undergone some amount of interstitial absorption. In other words, they have become atrophied from disease, and the cancellous spaces are filled up with an opaque fatty material, such as used to be called strumous deposit. You will see that both in the femur and tibia the epiphysis easily breaks down, and is bloodless; while at the junction of the epiphysis with the shaft the bone is, on the contrary, very vascular, though the latter is also in a commencing state of the same degeneration. The special point in this case that may here be remarked upon is, that our patient was two months advanced in pregnancy, and thus the question naturally arose as to whether she was in a fit state for operation. Many would have decided this in the negative, but I have seen so many facts which point in another direction that it seemed to me that her condition was no bar to operative measures. Bear in mind that she is at a very early period of utero-gestation, and if I had decided to wait she would have been committed to much pain and suffering for the remaining seven months of her pregnancy, and probably for some six or seven months longer till she had weaned her child. I had then to put the shock of the operation and the suppurative drain, but an immediate decrease of pain, on one side of the scale, and much and prolonged anguish on the other; to form, if possible, some estimate as to the probable results on her general health in either case, and to select that method of procedure which promised most favourably. You know how it was decided, and for the reason, as I tell you, that during gestation the reparative powers of a woman are very great. A most apt illustration of this point has only lately been in the same ward with this patient, in the case of Ellen N-, aged twenty-four, who was admitted on October 24th, being then five months pregnant, with an oblique fracture of the femur just above the knee-joint. We had much difficulty in getting and maintaining apposition of the fragments. However, this was accomplished, and she left the hospital walking on the limb on December lst, or rather under six weeks from the date of her admission. Such cases as these are by no means unfrequently seen, and upon the like are founded the observations that have been made.