UNIVERSITY COLLEGE HOSPITAL. Excision of the Knee-Joint

Erichsen
1854 The Lancet  
Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum et dissectionum historias, tam aliorum proprias, collectas habere et intel se comparare.—MORGAGNI. De Sed. et Caus. Morb. lib. 14. Procemium. THE readers of THE LANCET probably recollect the cases of -excision of the knee-joint which have been recorded in the I Mirror." The results obtained in the hospitals of London have not been favourable. There is one case, however, still 87Lb judice-namely, that of a girl operated upon
more » ... irl operated upon by Mr. Fergusson, at King's College Hospital. (THE LANCET, vol. i. p. 518, 1853. *) She was discharged, a few months ago, with an almost complete consolidation of the parts left after excision, the limb being steadied by an appropriate apparatus. Mr. Jones, of Jersey, seems to be the only surgeon who can bring forward patients making free use of their limbs after excision at the knee-joint. t Another attempt in the same direction has lately been made at University College Hospital, by Mr. Erichsen, and we take an early opportunity of mentioning the case. William S-, aged seven years, was admitted Feb. 3, 1854. When three months old he was weaned, owing to the illness of his mother; after this, he was very weakly, and when between two and three years of age an abscess formed and burst over the left sterno-mastoid muscle. At four and a half, the patient had measles very severely; at six, he had chicken-pox, and when the latter affection was going off his mother observed him to limp, and to walk and run on tiptoe. The knee at that time was rather swollen, but there was neither redness nor pain; the child, however, said that he felt as if something drew up his leg. Two practitioners were consulted ; one advised the mother to let the child run about, the other to keep the leg quiet. The boy became an out-patient of this hospital on the 4th of May, 1852, and remained so for about a twelvemonth. During this time antiphlogistic, derivative, and constitutional means were employed. The knee was at that period very much swollen, the oedema being principally confined to the parts around the patella. About April, 1853, an abscess formed in the outer and inner part of the knee; this was opened, and the Datient admitted into the house. Mr. Erichsen shortly afterwards made free incisions on either side of the joint, when a considerable quantity of pus escaped. Cod-liver oil, iodide of potassium, and iodide of iron were administered, and the leg was placed in splints whilst the patient was under the influence of chloroform. The limb was left thus controlled for four months; but when the splints were taken off, the leg became flexed as before. Neither the opening made for emptying the abscess, nor the wound on either side of the knee, had healed. The patient was now removed from the hospital for change of air, and readmitted, as above stated, on the 13th of February, 1854. He was then pale and thin, but cheerful; the knee was somewhat enlarged, but the health good. On the 15th of February, Mr. Erichsen performed excision of the joint whilst the patient was insensible from chloroform. A first incision was made an inch above the inner condyle of * Two other cases will be found in vol. i. p. 367 and 425, and vol. ii. p. 133. 1850. t See Report of a Meeting of the Medical Society of London, THE LANCET the femur, along the side of the joint, to about an inch below the patella; a second incision ran across the leg; and a third, parallel to the first, on the other side of the joint; the flap, including the patella, was then raised, and the lower two inches of the femur removed with the saw. The upper portion of the tibia was sliced off, and a portion of the outer part gouged away. The under surface of the patella was likewise scraped, the hæmorrhage being altogether very trifling. The parts have since been kept in apposition, and the patient, up to the 10th of March, was doing well. The question of excision of the knee-joint is so important that we shall make it a point to watch this case, which we sincerely hope will turn out well. ST. BARTHOLOMEW'S HOSPITAL. Encephaloid Disease of the Lower Part of the Femur; Amputation of the Thigh. (Under the care of Mr. LLOYD.) NONE but those who have opportunities of seeing hospital practice in a kind of synoptical manner, can be aware of a singular peculiarity—namely, the fact of the same affection being at one time more than another observed in the wards cf the various nosocomial institutions. These affections are far from being either endemic or epidemic, but depend on unknown, or at least very imperfectly known, causes. Take, for instance, encephaloid disease of bone. At one time, not far distant from this, one could hardly enter the surgical wards of our hospitals without being painfully struck with the aspect of sufferers who were labouring under malignant disease of bone of either the upper or lower extremity. But for some time past we have not met with any; and even supposing some cases to have escaped our vigilance, there must be decidedly fewer now than for the last three years. Mr. Lloyd's case, which we put this day upon record, presents this consoling feature, that the disease has not recurred, and that in this respect it offers a fortunate excention. Mary W—, aged thirty-one years, married, and has had only one child, now eighteen months old, who is in pretty good health. The patient's father and mother are both dead; the father was ill ten months with cancer of the face, which, before his death, destroyed the eye, nose, and mouth. The mother died in confinement. The patient has been living in Hackney all her life; she had no hard work, is of temperate habits, and does not remember having hurt the knee in any way. Twelve years before admission, the woman went into the London Hospital for the affection called housemaids' knee ; it got well in a month, but the joint remained weak, and she used to wrap it up in flannel in the winter. The patient had no uneasiness or inconvenience with the knee until three months before she was received into this hospital, when she felt a weakness in the joint, but not very severe pain, especially when carrying her little boy. Small tumours now formed in the upper part of the popliteal space; these increased in size, and others formed on the lateral parts of the joint, but the growths did not extend to the front of the articulation. She showed the latter to a surgeon, who told her she had varicose veins, and should bandage up the joint. The swelling increased; the pain became very intense, and she tried many remedies, until advised to go to St. Bartholomew's H o s p i t a l , after having kept her bed for three weeks at home. On admission, a tense elastic swelling was discovered around the left knee-joint, not very tender on pressure, the articulation being about twice the size of the other. The principal part of the swelling was in the upper portion of the popliteal space. Mr. Lloyd ordered sedatives ; but it was plain that the patient was labouring under malignant disease of the lower part of the femur, and amputation was proposed. The poor woman consented, and on the 10th of January, 1853, the operation was performed in the usual way, at the lower part of the thigh. The knee joint, on a section being made, presented the usual appearances of encephaloid disease. The patient progressed pretty favourably, yet she was very weak, and on the fourth day Mr. Lloyd allowed a chop and wine. She required also some sedatives, but on the fifth day after the operation almost the whole line of incision had adhered. Twelfth week.-Has remained to this day in hospital ; yesterday an abscess was opened by Mr. Lloyd in the stump ; the latter is quite healed, but large; the collection of matter & m i d d o t ; was on the external part of the thigh. The woman's health , is pretty good. ' This patient was discharged with a good stump in June,
doi:10.1016/s0140-6736(00)45884-8 fatcat:qi5nsbb2vzaxrltdx2w75qsfjy