THE DUBLIN JOURNAL OF

M E D I C A L S C I E N C E .

M A R C H 1, 1884.

PART I.

O R I G I N A L COMMUNICATIONS.

ART. X.--Foreign Bodies in the Knee-joint. By SIR G~OROE PORTER, M.Ch., Univ. Dub., Honoris Causd; Fellow and ex-President, Royal College of Surgeons in Ireland ; Surgeon-in- Ordinary to Her Majesty the Queen in Ireland, Senior Surgeon to the Meath Hospital; Consulting Surgeon, Dr. Steevens' HospitalY

THE subject of foreign bodies, or loose cartilages, situated in the knee-joint, is one of great interest to the practical surgeon--first, as regards their presence in an articulation which, with reference to size and utility in locomotion, is the most important in the body ; and secondly, owing to the excruciating pain and oft.recurring attacks of inflammation their presence so frequently produces by getting locked between the articulating surfaces of the bones, ren- dering the life of the patient most miserable, and preventing his usual avocations, or his indulging in any form of active exercise. With respect to the formation of these loose cartilages several theories have been advanced, and although they have not been noticed by any of the very ancient writers, their presence is by no means un- common in the different ranks of life. Ambrose Par~ was the first who drew attention to the subject. He stated " that a hard, polished, white body, of the size of an almond, was discharged from the knee-joint of a patient in the year 1558," in which he made an incision for the purpr of removing therefrom a collection of fluid. The next surgeon who wrote concerning these bodies was Pechlin,

a Read before the Surgical Section of the Academy of Medicine in Ireland, Friday, February 8, 1884.

VOL. L X X V I L ~ N O . 147, T H I R D SERIES. O

194 Foreign Bodies in the Knee-joint.

in the year 1691, who published the full details of another case in which a cartilaginous body was successfully extracted from the knee-joint. Later on we find Dr. A. Monro, in 1726, dissecting the knee-joint of a woman who had been executed, and in the course of his dissections discovering a cartilaginous body of the shape and size of a small bean. Ten years later, in 1736, Mr. Simpson cut out of the knee-joint a similar substance, which at the time of the operation he believed was only underneath the sldu. From that period until now their presence and consequent effects seem to have been pretty well understood, and have been mentioned and described by nearly every surgical writer. The articulations in which these formations occur are--the wrist, elbow, shoulder, tem- poro-maxillary, knee, and ankle. They are met with, however, most frequently in the knee, and owing to the severe set of symp- toms they produce during locomotion, render their consideration interesting. These movable bodies are of two kinds--first, those described as round or fiat concretions, which are supposed to consist of fibrin; secondly, those which are irregular in shape, often nodu- luted, and formed of ossifying cartilage. They vary in number, size, and colour. One may be found in a joint, or many. Mal- gaigne found sixty in the elbow-joint, and Dr. Berry, of Kentucky, removed thirty-eight from the knee of a male negro. Their size varies from that of a millet-seed to that of a walnut. Their colour is sometimes white or whitish gray; others are of a Paint yellow tint. _As regards mobility, they may be completely isolated, and moving freely about the joint in every direction, or they may be attached by a slight band of fibrinous exudation or lymph to some point of the synovial membrane.

The loose cartilages belonging to the first or fibrinous variety are supposed to originate in different ways--viz., they may be formed out of the masses of fibrin which float about in the exuda- tion and effusion that accompanies an attack of synovitis; or they may arise in the synovial fluid, which has been changed in its constitution by inflammation; or again, they may arise by the concentration of fibrin around a mass of coagulated blood which has found its way into the joint by the rupture of a small vessel, the result of an accident.

Those bodies of the second variety mentioned are organised, and can be referred to one of four distinct sources.

Firstly, in the apices of the synovial fringes cartilage ceils are known occasionally to exist, which, under tile stimulus of inflam-

By Sn~ GEORGE PORTER. 195

matory action, undergo active proliferation and organisation, thus forming a cartilaginous nodule, which ossifies in the centre and by the movement of the joint becomes completely detached f~om the fringe of the synovial membrane it originally sprang from, and thus l~alls loose into the cavity of the joint and floats about in every direction.

Secondly, one or more of the edges of the synovial membrane may become pinched or squeezed between the articulating surfaces of the bones, giving rise to local and inflammatory infiltration, and thickening of small portions of the membrane. In due course these become crushed off or detached from their connexion with the rest of the synovlal sac, and drop freely into the joint.

Tfiirdly, these bodies may arise outside the synovial sac in the periosteum or sub-synovial connective tissue as osteophytes, and in time, by excessive movement, may be forced into the cavity of the articulation.

Fourthly, they may arise, as Mr. Tealc has suggested, as the result of fragmentary exfoliations, or separations, of small portions of the cartilages composing the joint itself.

The late Mr. Adams, of Dublin, considered their presence was due to an osteo-arthritic origin. The symptoms attending the pre- sence of these bodies are so well known that it is hardly necessary to mention them. Suffice it to say--The patient, when walking or in some movement of the joint, is suddenly seized with a most violent pain, and is unable to move the joint in any direction. The pain at times is so great that he becomes sick and faint, and is compelled to grasp the nearest object to prevent himself from fall- ing. When the position of the limb is changed the cartilage slips from between the articulating surfkees, the pain instantly subsides, and the function of the joint is immediately restored. These attacks of pain occur as often as the body gets between the bones, and according to the amount of exertion the patient has been subjected to. The frequency of the attacks would also depend whether the foreign body was entirely free, or its range of mobility limited in its extent by a small attached pedicle, or band of lymph.

It is most likely that during some movement slight inflammation may set in, causing the pouring out of lymph which makes the body become adherent to some part of the synovial membrane, in a situation that would not interfere with motion; or else it may fall into some little pocket or recess formed by the folds of the synovial membrane, in.which it becomes temporarily fixed. This

196 Foreign Bodies in tt~e Knee-joint.

accounts for the absence o pain, inconvenience, and disappearance of the body for intervals of weeks, and the return of the symptoms would prove that it has again been detached or dislodged.

The treatment for these loose cartilages, or foreign bodies of any kind finding their way into the knee-joint, may be divided into the palliative and the radical. The former consists in the wearing of a well-fitting laced knee-cap, or other mechanical appliance for the purpose of fixing permanently the body in a situation that will not interfere with the free motion of the joint. Some patients are quite satisfied with this form of treatment.

Cases, however, will occur, owing to constant attacks of pain and inflammation, when it becomes necessary to recommend the removal of the foreign body. In adopting the radical treatment the surgeon has the choice of two operations : - -

1. The direct incision. 2. The indirect or subcutaneous incision, as practised by Syme

and Goyrand. As two remarkable cases of foreign bodies in the knee-joint have

very recently come under my observation, I will briefly give the history, progress, and successful result of the direct method of operation, as performed under the spray and other antiseptic pre- cautions : -

Removal of a Loose Cartilage from the Knee-joint.

CASE I.--J . H., aged twenty-six, a private in the 5th Dragoon Guards, stationed at York, was admitted into the Meath Hospital on January 7th, 1884, suffering from a loose cartilage in his left knee- joint.

History.--He stated that in July, 1883, whilst riding through the streets of York, his horse became restive and backed against a passing cab. His knee was squeezed. After this accident he was confined to the Military Hospital at York for a fortnight, and although he suffered much pain he did not observe the small body moving about in his knee- joint until September, 1883, when Dr. Riordan, of the Army Medical Department, detected it. For weeks he felt no inconvenience from its presence, being able to walk about and attend to his military duties. At other times he was seized with a most violent pain in his knee rendering him unable to stand, walk, or move the joint in any direction.

He was now invalided by a medical board from the service, and my friend, Dr. Riordan, gave him a letter to me asking that he should be admitted to the Meath Hospital, where he was taken in on January 7th, 1884.

By SIR GEORGE PORTER. 197

State on admission.--His left knee-jolnt being carefully examined, a loose cartilage was discovered moving about in several directions. Sometimes it was difficult to ascertain its exact position. The man, however, by different movements of his joint, could always manage to find it.

Operation.--On January 17th, 1884, ether having been administered, I operated by the direct method, assisted by my colleagues, Messrs. Smyly, Ormsby, and Hepburn, under the carbolic spray. The cartilage was found to be extremely movable, and very difficult to fix in any one given position. I t was secured after several attempts by means of a needle at the outer and lower border of the patella. The needle was passed through the integument, and made to penetrate the body. An incision about two inches long was carried directly over the cartilage. A quantity of synovial fluid escaped through this incision. The cartilage was then extracted, and the edges of the wound brought together by means of two silver wire sutures, and dressed with full antiseptic precautions. The joint was also fixed by means of a well-padded posterior splint, and the patient removed to his bed.

After-treatment.--He suffered very little pain or uneasiness the night of the day of the operation. His pulse and temperature were normal, and remained so throughout his entire convalescence.

First dressS~g.--The wound was dressed under the spray on file 25th, eight days after the operation, and it was found aseptic. No appearance of pus. Its edges lying in perfect apposition. The sutures were re- moved, and it was covered with carbolic gauze.

Second dressing on 29th January, 1884, when it was found to be completely healed. Dressings were then discontinued, and merely a bandage applied. Four days later he was able to walk about the ward. He has now obtained almost complete use of his joint, and is most anxious to re-enter the service.

A Bullet removedfi'om the Knee-joint after a lodgment of Thirteen Years.

CASE II . - - -Whils t Mr. R. T., aged forty-five years, one of the most eminent gun-makers in this city, was holding a Derringer pistol, which he was about to discharge, it suddenly went off, and the ball struck him and entered about two inches above his left patella. This occurrence happened th i r teen years ago. He bled very little at the time, and was seen in about half an hour after the accident by tile late Mr. John Hamilton, who did not deem it prudent to explore the wound, but placed his limb in a fixed position, and applied a cold lotion.

The next day considerable inflammation was present in the knee-joint~ and in two days afterwards a slight discharge of pus flowed from the wound, which was supposed, at the time, to have taken a downward course. He was confined to bed for upwards of three months, and had a slow

198 Address in State Medicine.

convalescence for three months longer before he was able to resume his usual avocations. From this time to about seven years after the accident he remained well; then, whilst stepping off a car, the bullet suddenly came to the surface below the patella, but before he could obtain any surgical assistance it had disappeared again.

In the early part of December, 1883, his knee-joint became swollen and uncomfortable, but not very painful; and on the evening of the 24th of December last I received a note from his brother stating that the ball had come to the surface, and requesting me to see him at once. I saw him in about twenty minutes, bringing with me the necessary instru- ments and antiseptic dressings. I found that the ball had made its way to the inside of the patella, and was almost under the skin. Having fixed it with the thumb and fore-finger of my left hand, I cut down and exposed its surface. I attempted to seize it with a forceps, but the instrument slipped twice. I then passed beneath a small steel scoop, and thus extracted it with ease. The joint being opened, a large quantity of synovial fluid escaped at the moment the ball was removed. I, however, closed the wound immediately with a strip of salicylic plaister and applied the usual antiseptic dressings.

I need not weary you with the daily notes of this case, but state that it was treated throughout antiseptically, tn ten days the wound was healed, and the patient was allowed to sit up, and in three weeks from the operation he was walking about his room. These two cases I considered might be received with interest by the Academy, and I think are additional proofs (if such were required) of the great advantages of antiseptic surgery. In my student days a wound of the knee-joint, with escape of synovia, was often followed by amputation or death. Now, without fear, we cut into a knee-joint under the carbolic spray, thus stamping on " Lister ism" the verdict of almost universal success.

ART..XI.--Address in State Medicine to the State Medicine Sub- Section of the Academy of Medicine in Ireland. By THOMAS WRXOLZY GRIMS~AW, M.A., M.D.; Fellow of the King and Quoen's College of Physicians; Registrar-General for I reland; Chairman of the Sub-Section.

] ~IAVE to thank the Fellows for the high honour of being chosen Chairman of the Sub-Section of State Medicine of the Academy of Medicine in Ireland, the duties of which I shall endeavour to fulfil to the credit of this Academy and, I hope, to the advantage of State Medicine in Ireland.