50 
head of the tibia, instead of amputation of the 
thigh, where it was found impracticable to re- 
move the leg at the ordinary place of election— 
four inches below the knee-joint. But Larrey 
made an addition to this operation, namely, the 
extraction of the head of the fibula. He says, 
“‘ when the fibula is left short, which is usually 
the case, it is to be extirpated as useless, and 
troublesome in the application of the artificial 
leg, and the skin is to be left as long as pos- 
sible, to cover the stump.” Mr. Guthrie gives 
Larrey much praise for drawing the attention 
of the profession to this “ great improve- 
ment,” and adds the weight of his high autho- 
rity by recommending the removal of the head 
of the fibula. In alluding to this subject we 
may appear to be departing from the proper 
object of this article,—the abnormal appear- 
ances presented by the knee-joint; but having 
known some melancholy examples of acute in- 
flammation of the knee-joint to follow the 
operation here recommended, we take this op- 
rtunity of warning the profession against it. 
r. Guthrie himself says, it is possible, how- 
ever, that a case may occur (perhaps one in a 
thousand) in which the head of the fibula com- 
municates with the general cavity of the knee- 
joint; in such a case amputation must be done 
above the knee.” Independently of this com- 
munication between these two contiguous joints 
which Mr. Guthrie considers so rare, we have 
found, by repeated anatomical examinations of 
the relation existing between the synovial sacs 
of the knee-joint and that of the superior tibio- 
fibular articulation, that these two sacs are so 
close as to have but a thin transparent wall 
separating them. We consider it, not abso- 
lutely, but very nearly impracticable to cut out 
the head of the fibula in the living subject 
without making a communication with the pos- 
terior and back part of the synovial membrane 
of the knee-joint, so delicate is the thin trans- 
parent membrane which is interposed between 
the synovial sac of the knee-joint and the little 
synovial sac which partially envelopes the head 
of the fibula. Besides, in the living subject 
it must always prove to be a difficult matter 
to remove the head of the fibula without in- 
terfering with the tendon of the popliteus’ 
muscle, as we know the tendon to be enve- 
loped by a synovial production sent down 
along it, like that which in the shoulder-joint 
invests the tendon of the biceps. This synovial 
production is not confined to the tendon of 
the popliteus, but is also reflected over the 
groove formed for the reception of this tendon, 
and must be in danger of being opened in 
every operation which we can devise for the 
removal of the head of the fibula; and conse- 
quently, although there may be many cases in 
which it may be advisable to amputate the leg 
a little below the tubercle of the tibia, in no 
case, in our opinion, should the surgeon attempt 
to extirpate the head of the fibula. The idea 
that this small portion of bone, when left, is 
“useless and troublesome in the application of 
the artificial leg,” may be true, but it is not the 
less true that in the-majority of cases acute 
arthritis of the knee-joint wil! be very likely to 
ABNORMAL CONDITIONS OF THE KNEE-JOINT. 
succeed to this operation ; and we feel satis! re 
that, as soon as these anatomical relations | 
tween the synovial sac of the knee-joint an 
that of the superior tibio-fibular articulation a 
“eri on, this modern proposal will be 
jected. : 
Among the causes of acute arthritis gen 
exposure to cold is very frequently referred 
4 the patient, and apparently with 
he knee-joints being less covered by mu: 
parts than any other of the large articulation 
are more subjected to the influences of 
and on this account are perhaps more gene a 
affected by acute and chronic inflammation th 
other articulations. It must be admitted, ho 
ever, that we have met with cases of 
inflammation of the knee-joint for the origin 
which we could assign no cause, having cor 
on, as we are accustomed to say, spontaneous 
Acute arthritis genu sometimes arises as 
symptom in the course of different disease 
us in diffuse inflammation and in phlebit 
it is quite usual to find the joints visited | 
most severe attacks of inflammation. We ha 
seen examples of acute arthritis supe 
suddenly in the course of a severe attack 
erysipelas ;* and in rheumatic fever and put 
ral rheumatism we can see little else than ; 
inflammation of the joints, the nature of the: 
flammation in these cases, however, being vé 
different. 
Although we have here spoken of th 
different forms of disease, diffuse inflammati 
phlebitis, and puerperal rheumatism, we 
ourselves long entertained the opinion expres 
by Mr. Arnott, Velpeau, Dance, Cruveilhi 
our friend Dr. Beatty, and others,+ that 
three forms of disease in which the acute arth 
tis we are here treating of occurs, are the sam 
and that the arthritis in all three is similar, a 
proceeds from the same common cause, 
phlebitis and its consequences. a 
The peculiar form of acute arthritis” 
adv to has in almost all cases been fou 
to have been preceded by phlebitis. This m 
have come on spontaneously, or in consequet 
of a wound, or of the vessel having been 
cluded in a ligature. The form of acute ar 
tis which has been called puerperal rheum 
has also been found, in many cases, coinei 
with or preceded by phlebitis of the veins ¢ ; 
uterine system, or of some other veins.[ 
We have seen many cases which we con 
dered to be examples of diffuse inflan 
in very young subjects, engaging the peric 
of the em and tibia, and terminating im 
complete destruction of the bone, in the sl 
space of three days. Sometimes the perioste 
of the femur, for example, formed a comp 
cylindrical sac containing the detached shaft 
the bone. 
The symptoms of acute arthritis which 0 
in the course of a case of diffuse inflam 
fe. 
@ 
* See Dublin Journ. vol. xvii. p. 336, and in 
article p. 55. a 
+ See Dublin Journ., and Mr. Arnott’s valu 
observations in the Med. Chir. Trans, 4 
t See Dance’s, Beatty’s, and Mr, Harrison’s¢ 
Dublin Journ. > 
