No. 1480.

JANUARY 10, 1852.

Clinical LectureON

INJURIES OF THE KNEE-JOINT.Delivered at St. Thomas’s Hospital.

BY SAMUEL SOLLY, F.R.S.(Continued from page 2.)

THE next case in illustration of these injuries to the knee isdeeply interesting, and I will only remark, before reading it,that it forms a pleasing contrast to the last as regards theresult.

It is true that the subjects were men of very different

habits, and that life was not endangered in this case by intem-perance. But the delirium from constitutional irritation ex-cited by severe local injury, made its appearance, and the

amputation was only performed just in time to save life. Ihave no hesitation in saying that if it had been postponed anylonger, that a fearful delirium similar to that of delirium

tremens, but not like that, controllable, would have beenestablished, and must have carried my unfortunate patientinto his grave.The subject of it is a gentleman, aged forty-seven, whose

horses ran away as he was driving home from a railroadstation in the evening. The turning into his grounds was asharp angle, and the off wheel caught the right-hand gate-

post with such violence as to upset the phaeton and fling outboth him and the coachman. Unfortunately for my patienthis right leg was fixed between the carriage and the postwhile the impulsive force was expended on the whole body,which was twisted backward, so that the thigh was bentnearly to a right angle outwards from the knee-joint, and he’was hung up by the back of his coat to the rails on a linebehind the post by which his leg was fixed. When heattempted to stand, on being extricated from his dangerousposition, the leg bent in the same direction at the time somuch that he told me afterwards it was like leaning on abroken walking stick, and that his own impression was, thatthe limb must be broken in four or five places. He wasseen within a quarter of an hour of the accident by his usualmedical attendant, to whom I am indebted for the account ofhis case previous to my seeing him. He was lying on thesofa complaining of the most intense pain, which was greatlyaggravated by the slightest movement. There was a smallcontused wound over the inner condyle, with so much effusionover the bone that it could not be felt on a careful examina-tion, but with the slightest effort the limb could be moved toany extent outwards, from which I concluded that the internallateral ligament was torn through, and in all probability thecrucial ligaments also. On being put to bed he was laid on hisright side; the limb was laid on the outer side. Twenty-fourleeches were applied over the joint; a quarter of a grain ofmorphia every six hours. His diet was low, without stimulants,and the leeches, twenty-four in number, repeated every dayuntil seventy-two were applied. I saw him first on the Sunday,the fifth day after the accident. I examined the limb verygently, but quite sufficiently to convince me that the internallateral and crucial ligaments were torn through. The patientbeing apparently a healthy man in the prime of life, and asthere was not much constitutional disturbance, I thought itTight to try and save the limb, though I did so with muchanxiety.We placed the limb in an antero-posterior, semi flexed

position, keeping the foot upright by means of pillows: con-tinuing the spongio-piline, applied warm. I suggested thepossibility of being able to apply a pasteboard splint on theouter side in the course of a day or two, to support the limband prevent any motion in the joint. A pasteboard splintwas put on by Mr. D--, on the Thursday, and forty minimsof Battley’s solution given about three o’clock. Shortly after-wards some men of business came down to see him, and hewas excessively annoyed and excited. Up to this time hispulse had remained steady, about 80,Mr. D- saw him after this had occurred, about eight, P.M.;

he was then quite delirious. Skin hot. Pulse 120.Mr. D- at once examined into the condition of the joint,

and he states that there was no tension in the bandages

or increased heat in the limb. It appeared therefore mostprobable that the delirium arose from the opium, he havingbeen disturbed just at the time the sedative action ought tohave been induced.March 7th.-:N ine A.M.: The pulse has sunk to 100; but h&

has been talking all night, not having slept at all. Skin moist;.great thirst; tongue dry and furred; great flatulency. Hethen complained of having a sensation of a hundred-weightpressing down the upper part of the tibia. Mr. D. removedthe splint and one of the bandages, which change he saidrelieved him. But up to this time, Mr. D. states there was no<increased heat in the joint, or tenderness, and that he bore-the movement of the patella from side to side without anyfeeling of pain.

8th.-Very little change. Pulse 80; skin moist; still com-plaining of pain in the leg, but not in the joint.. 9th.-I received a telegraphic message requesting my im-mediate attendance. I found the limb much altered, thepatella, elevated, the whole joint fearfully swollen, but pro-jecting principJ.l!y on the inner side, in which situation theskin was red, teuse, and vesicated, pointing at one spot, onwhich there was a black slough about the size of a sixpence.He stated that his sufferings were extreme, that his leg for thelast twenty-four hours had felt as if it were in a vice. It wasevident there was no time to be lost in making an opening.This I did to the extent of half an inch, when nearly a pintof discoloured pus, mixed with synovia, flowed rapidly out ofthe wound. He expressed himself a little relieved. Theformidable nature of the case was but too obvious. An openknee-joint in a state of suppuration ! i Again we had to meet.The momentous question was whether it would be possibleto save both life and limb. I confess that I felt little doubtof the necessity of immediate amputation, but I thought itright to give him the benefit of another opinion; and Sir B.Brodie saw him with me at nine o’clock the same evening.He considered that I was justified in making the attempt tosave the limb. eve therefore determined to do so.

I 10th.-Eight A.M.: Has passed a tolerable night; slept atintervals; is easier this morning. The inflammation of theskin has not extended upwards, but the skin is very tense, andinclined to slough at points. To relieve the tension, I passeda director from the wound about an inch under the skinupwards, and divided it with a bistoury. I then applied againa large linseed-meal poultice, and placed the limb more on-the outer side, which he says is the most easy position.&mdash;Eight P.M : Rather less redness of the skin; tension relieved;.but the matter burrows and bags below the wound. Passeda director downwards under the skin, and divided it about aninch. These incisions gave a free exit to the matter, and-relieved all tension.llth.-Eight A.M.: Has passed a tolerable night without

taking any morphia. Countenance rather anxious; pulse-rapid, 112; not feeble; tongue a little furred; inflammationof skin decidedly less; wound looks very healthy. Orderediron and citrous quinine, five graius, ia an effervescingdraught, twice a day.-Eight P 1B1.: Has passed a quietday; the limb lying on the outer side, the foot turnedcompletely outwards. Appetite improved; takes nourish-ment well; wound looks remarkably healthy; less in--flamm.tion of the surrounding skin; cheerful and sanguine.I have more hopes than I have had yet of a successfulissue.12th.-Eight A.M.: Very restless night. The wound does

not look worse, but his tongue is not so clean; appetite in--different ; skin relaxed and perspiring. Ordered him quininetwo grains, sulphuric acid ten minims, compound tincture ofcardamoms, infusion of roses.-Eight P.M.: Has not sleptduring the day. About nine A.M., we transferred him to a couchon the plan of Earle’s fracture-bed. The movement was effectedin the following way : Four men, each holding a corner of thesheet and blanket, then carrying him off his bed, and two mengoing on either side of the couch, he was quietly lowered onto it. I took charge of the leg myself, carrying it on a pillow.The change was effected easily, and without giving him anypain, but it made him very nervous.13th.-Has passed a restless night; but he did not take any

morphia. Pulse-84; skin cool. The wound looks healthy;but there is quite a large teacupful of fluid, apparentlysynovia, mixed with pus, in the poultice. I also observed athin discharge of the same kind run rapidly from the jointinto the popliteal space. This free discharge of synovia is themost unfavourable symptom now.15th.-Eight P.M.: Looks cheerful; complexion good; tongue-

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moist and clean, particularly healthy, not red or glazed; skinmoist; pulse variable, between 100 and 86; fair volume; appe-tite has been good; had eaten a portion of a beef-steak and twosmelts for his dinner, with two glasses of home-brewed beer.The wound is cleaning rapidly and granulated; looks perfectlyhealthy, cannot detect any synovia running from the joint,but the sponge placed to catch the discharge during the day,contains three or four ounces of fluid. I considered his con-dition very favourable, and I have great hopes of his completerecovery. Compound colocynth, ten grains.16th.-Had three-quarters of a grain of morphia at half-

past twelve, went to sleep immediately, and slept withoutinterruption till half-past five; he then took a cup of tea,and feel off to sleep again, and slept till half-past seven.The best night he has had yet. Tongue clean and moist;pulse between 88 and 70; countenance cheerful; wound per-fectly healthy; less discharge of both pus and synovia; shiftedhim a little in his bed. Ordered, morphia, three quarters ofa grain at night, sulphate of magnesia, half a drachm, twice aday, in the infusion of roses.17th.-Much the same; a little heat on the outer side of the

patella.18th.&mdash;Not had a very good night, complains that the limb

started a good deal and woke him. Six P.M.: Visited him;found him comfortable; countenance good; pulse ranging be-tween 80 and 90; skin moist and appetite good; wound re-markably healthy, contracting; very little synovial discharge;but there is a decided increase of heat on the outer side ofthe patella, and rather more tenderness. Mr. D- thinksthat there is not quite so much heat as in the morning.Carried the poultice more completely round the joint, anddecided that if it were not relieved by the morning we wouldapply some leeches. Ordered, compound colocynth pill, fivegrains, morphia, three quarters of a grain.19th.-Not had a very good night; pain and heat increased

during the day, though the bowels have been freely relieved;twenty leeches applied in the evening; felt much relieved bythem.20th.-Has had a better night, the knee rather easier this

morning; perspires a good deal.20th.-Six A.M.-Saw him again; decided that the leeches

need not be repeated. Ordered, colocynth, two grains; aloes,five grains; morphia, three quarters of a grain.21st.-Not much sleep; but quiet during the night; pulse

100. He does not look so well. The knee is more swollenand rather more tender; decided that if the pain increasedduring the day, fresh leeches should be applied. The painand swelling of the joint increased during the day, andtwelve leeches were applied at night; the application relievedthe pain, and he had a better night. Took morphia, threequarters of a grain; Dover’s powder, three grains; colocynth,one grain.22nd.-Six P.M., not so well; the knee is more swollen, and

is becoming more painful. The whole is much more swollen, Iand slightly cedematous; pulse smaller, 26, 27, 26, 26. Has I

been wandering in his mind; after waking from his sleep,com-plained that two men had been admitted into his room, sentfor his housekeeper and complained to her of having so acted.The discharge is very abundant; I examined the limb at

six, and again at half-past eight; during this interval, Ifound that at teast two ounces had been discharged. Thetongue is a little dry, but not furred; the appetite not quite sogood; bowels a little irritable. The nurse reports that thelimb has started more than usual during the day. Nine P.M.:Morphia, one grain. In about half an hour he sent to sayhe was very sleepy, and anxious to know if he might have hismilk; he did so, but as he was restless at half-past eleven, and Icomplaining, I gave him half a grain more morphia. Thismade him quiet, but he did not get to sleep till two; then heslept till four, and was dozing again during the night, so muchso, that in the morning he said it was the best night he hadhad, and that he felt less anxiety regarding the dressing of thelimb. jm,&: Discharge more profuse; leg more swollen; skinover the inner side of the knee rather tense and shining; thighmore swollen; tongue much the same; pulse 27, 26, 25, 26;countenance much the same. Seven P.M.: Has passed a tran-quil day; appetite rather better; leg uncomfortable; kneemore swollen; lays on the outer side; nothing like so muchdischarge; not more than an ounce in the poultice; it has notrun down along the leg. Pulse 120; tongue clean and moist;perspires profusely; bowels not open. Morphia, one grain.24th.-I have slept in his house every night since my con-

sultation with Sir B. Brodie, and watched his progress withgreat anxiety; has had a pretty good night, but occasionally

delirious; slept at intervals; countenance tranquil; skin verymoist; joint rather painful. Pulse 10,30,26,25, small; tongue,a brownish fur at the back, moist, and clean at the tip. Thegeneral condition of his nervous system, and the enormousdischarge, confirm my fears that amputation must be had re-course to.25th.-Has had only two hours’ sleep during the night. He

is anxious regarding the amputation, and has made up his mindto the necessity; says he feels that the limb can never again beof use to him. Seen again by Sir B. Brodie, who confirms myopinion.-Five P.M.: Removed it by a double flap operation inthe thigh. He lost five or six ounces of blood.-Ten P.M.:Gave him a grain of morphia, which was repeated twice beforehe had any sleep; he rambled a good deal in the evening, buthad a pretty good night, becoming quiet about twelve. Ap-plied ice to the stump.26th.-Eight A.M.: Quite rational and quiet this morning;

some bleeding about seven, but the reapplication of the icerestrained it.

Examination of the Limb.-Cellular tissue under the quadri-ceps femoris in the vicinity of the joint infiltrated with pus;large quantity of pus in the joint; the posterior crucial liga-ment torn through; an extensive abscess in the poplitealspace. In examining the head of the tibia we found a fissureextending through cartilage and bone on the internal condy-loid surface; the fissure extended through the centre of thisspace from before backwards, and down the shaft of the bone;ulceration of the cartilages, but without the formation of anyfalse membrane. The portion thus split from the rest of thebone was still so firmly bound to it that I could not moveit so as produce crepitus, using as much force as I could exert.Through this fissure the synovial fluid drained into thepopliteal space communicating with the abscess above re-ferred to.

April 9th.-He has been going on well since the last report;there has not been any union by the first intention, but it hasbeen granulating kindly. I found both the ligatures floatingin the pus, at the edge of the wound, so that I conclude theyseparated yesterday, the fourteenth day from the operation.The stump healed well, forming a large fleshy cushion, and hehas since walked about with great activity on an artificiallimb made by Mr. Gray, of Cork-street.

This case was a painfully interesting one to me, and Iwatched night and day, with great anxiety, from the momentI first found that suppuration had occurred in the joint. I donot believe that any plan of treatment could have preventedthis action. The injury to the internal ligaments was such,that a certain amount of pus must have been secreted in theprocess of reparation, even if the inflammation had not ex-ceeded what may be called its conservative action. Thefriends of this patient, when I first saw him, hearing thatthere was no wound, were surprised when I stated the seriousnature of the injury, and the fear I entertained for the preser-vation of the limb. Indeed, I was obliged to intimate as muchto the patient himself, in order to keep him quiet, as he hadnot kept his limb perfectly at rest. In fact he expected to goto town in a few days, and was much disappointed when I toldhim he must not think of such a thing for some weeks to come.With regard to the application of a splint in such cases, it

must be done with the greatest care, and removed immediatelythere is any increase of pain or inflammation. You must notsuppose that the mere fact of suppuration having taken placein a joint, is sufficient to justify amputation. You must putinto the balance the age and general constitution of yourpatient-whether he is a fat and flabby subject, without muchpower, or whether he is thin and muscular; whether he isirritable, nervous, and excitable, or calm, tranquil, andsanguine.With regard to the local treatment, I have no hesitation in

recommending a free opening into the joint, where there isextensive suppuration, and much constitutional irritation inconsequence; and on this subject I think the opinion of Mr.Rutherford Alcock of infinite value, from his great experience.He says:*-"The great object, then, is, firstly, to prevent the deposit

and accumulation of matter in the articulation, which, not-withstanding all that has been said of its bland, innocuousnature, previously to the admission of atmospheric air, quicklyerodes all the articulating surfaces, in the generality of cases;I have seen exceptions, but they are few; and, secondly, toprevent the matter from burrowing among the muscles ex-

* Med. Chir. Trans., vol. xxiii, p. 268.

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tending upwards and downwards, thus involving the whole Ilimb in a suppurative and disorganizing disease. i" No sooner, therefore, is suppuration established, than it

becomes necessary to devise the best means of obtaining itsevacuation, and to secure its draining off, in proportion, or asfast as it forms. Any fears of the contact of air, I cannot butthink, are out of place. The matter will do more mischief bybeing allowed to lodge. Counter openings in pendent posi-tions, and free incisions, either in the vicinity, or, if necessary,through the capsule, should be promptly and boldly practised,together with such regulated pressure, above and below thearticulation, as the state of the limb may indicate and allow,in order to counteract the tendency to spread and burrow."

Sir A. Cooper relates a case in his work on dislocation whichin some respects resembles the preceding case. There was a

compound fracture of the condyles into the joint, but thepatient went on well for twenty days. On the evening of thetwenty-first day, he was found much heated, with a veryfrequent pulse, dry tongue, and a tendency to delirium. Hedied on the twenty-fourth day.The limb on examination after death exhibited great signs

of inflammation; a considerable quantity of matter was foundbetween the muscles of the thigh, a part of which was dis-charged by the external wound. It would seem from theaccount that the delirium and fever came on too rapidly togive time for amputation.Of fractures into the joint, those of the tibia are, as far as

my experience goes, the most dangerous. I have seen severalsimple fractures of the os femoris into the knee-joint, and theygenerally do well, but not always. Compound fracture ofthese parts is very rare. Mr. Travers relates a very in-teresting case, in Sir A. Cooper’s work. It occurred in a boy,though his age is not mentioned. There was much dis-placement of the fractured bone, and a small wound communi-cating. The fracture extended nearly in the direction of theaxis of the bone, in addition to a transverse fracture of theshaft of the bone above the joint; the external condyle wasmovable, and thrown out of its place during the accident, asif it had been drawn by the leg, and twisted inwards. Therewas very little constitutional disturbance. The fracturedportion of bone ultimately protruded, and became detached.The accident occurred on the 17th of September, and he wasdischarged from the hospital on the 6th of December, beingable to bend the joint and walk tolerably well with a stick.In the following February he had the free use of the joint.

(To be concluded in our next.)

ON IMPROVING THE CONDITION OF THEINSANE,

BY INCREASED REPORTS ON PRIVATE ASYLUMS.

BY HENRY MONRO, M.B. Oxon., F.R.C.P., Author of"Remarks on Insanity," &c.

(Continued from p. 4.)

SECTION I.

On Increasing the Means of Information as to the Conditionof Private Lunatic Asylums.

THE questions which I would now ask are,--What meansare at present available to the friends of patients for ascer-taining the condition of a private lunatic asylum ? Are theysufficient for the just wants of friends or patients i If theyare not, how can a sufficient remedy for these just wants beobtained a

On the means existing at present.-I am willing to acknow-ledge that manypersons, particularly those in the upper classes,have comparatively easy access to good information on thesematters. They may be acquainted with respectable pro-prietors, personally or indirectly; they have the best advicewithin their reach, especially those living in large towns; andthey live so much in society as to know the world’s opinion ofdifferent establishments, which is, after all, one of the bestcriterions of practical truth. But there are many not so hap-pily circumstanced when a member of their family becomesinsane; it is for these that I now specially speak, and as theyare many in number, their wants have a claim to be heard.At the same time I would not be understood to infer that eventhose who have all the advantages which society can offer,would not derive much benefit from the existence of moreample and accessible means of information on this head.But let us suppose a case where this need is felt. A family

is living in the country, with only their neighbouring medicaladviser, to consult with. A child or parent is observed to showsigns of incipient insanity, by altered manners, perverted affec-tions, strange conduct, and that mysterious look which is sub-stituted for the habitual happy expression of health. Keenanxiety is felt; perhaps a knowledge that insanity is heredi-tary in the family increases this anxiety, which, as days go by,ripens into the conviction that the mind is diseased. Thematter is hardly mentioned at first, so great is the dread.Soon, however, it is talked about, though the kindly voice issilent when the poor subject of this discourse appears. Thewrinkled brow, the startled look, the changed complexion,are watched, with a desire to avoid the notice of the sufferer,and an anxiety which none can know but those dependentupon one thus afflicted. Friends now talk apart in retiredrooms. Some overt act committed, or some increase ofinsane phenomena, compel the family into action. The patientknows now that he is suspected and watched, and difficultiesincrease immediately a hundred-fold; for the interests of thepatient and his friends are divided; the one believing that hismind is right, and that he is the victim of an extraordinaryand unprovoked persecution; the others knowing that life,property, and respectability call for their interference. Re-straint is at last imposed. The kindly feelings of the familysuggest home treatment at first; the expression is, "Everythingbefore an asylum." The medical man is in attendance, andprobably begins a course of depletion and blistering, whichsoon increases all the symptoms of excitement, &c. The vio-lence of the patient becomes insupportable in a small house,and it is observed that the presence of friends always increasesthis furor.Those who know anything of insanity will now acknowledge

that an asylum is necessary,-that the presence of friends in.creases excitement,-that patients cannot endure resistanceto their will from those they are in the habit of seeingobedient to them, though they may sullenly submit to it fromstrangers,-that the accommodation of a private house is notsufficient, for there are no airing grounds, no baths, no meansof seclusion, &c.,-that the family of brothers and sisters areexposed to injury, bodily and mental, by the presence of thisscene of distress, in the case of a member of their own family,-that the patient can no longer appreciate the affections ofhome, for bitter has become sweet, and sweet bitter,-thatchange alone will do good-change of associations, change ofattendants, change of air,-and that a great moral means ofinfluencing the patient is lost, if the prospect of release froman asylum upon amendment of conduct and discipline ofmorbid propensities, does not form a part of the treatment.These arguments at length prevail-the fondly-cherishedresolution to keep the patient at home is most unwillinglygiven up at the command of stern necessity: and now comesthat question, which a want of good system on the part ofthose in authority renders so difficult of solution-that is,How is an asylum to be obtained where the best treatment can beinsured That this question is not sufficiently studied, oranswered satisfactorily, we may judge a little by the motiveswhich actuate too many in their selection.On the ’motives which too often actuate friends in the choice of

an A sylum.-We have supposed the person asking this questionto be out of the reach of those means of information which

I many possess; we may rightly esteem him, in addition,ignorant of the importance of this question, ignorant of the.

difference between various asylums, and of the practical im-portance of this difference. Whether to suppose all this is agreat stretch of the imagination, I need only ask those whoare in the habit of receiving patients. Will the answer be,that friends, especially of the less educated class, receive, or

. see the necessity for receiving, sufficient information as to, these matters, before they commit their relatives into thehands of strangers ? I think the answer will be No,-espe-’ cially when we observe what motives and opportunities

dictate or compel the selection. Locality will influencel some. The asylum thought of is conveniently near, and canbe easily visited; no harm has been heard of it, and the more, affectionate family selects this one. Again: the asylum. thought of is conveniently at a distance, and removes the! subject of their anxiety further away from the associationsr of home, and the more prudent select that one. General. report of a most vague nature, the influence of a great name,l &c., will guide many in their choice. Where affection is not, sufficiently strong, or conscience keen enough, some less

worthy motive may, in the absence of accessible means of information, guide a person in a manner which shame might

hinder, were these means at hand. Bat if we suppose a more