Two Singular Cases of Diseased Knee-Joints Successfully Treated. The First by Topical Applications; The Second by Operation. By Mr. Joseph Warner, F. R. S. Surgeon to Guy's-Hospital

I have had an opportunity lately of examining this curious, fleshy, coral-like figure in the microscope, and find, that all the interstices between the stars are fill'd with eggs of different sizes, each adhering by one end to a very fine capillary filament. The smallest eggs are globular, and as they advance in size, change to an oval figure; from thence they assume the shape of one of the radii of the stars. In several of these stars I have observed a smaller radius, as it were, endeavouring to get into the circle; and notwithstanding their seeming connection in the center as one animal, I believe I shall soon be able to shew you, in a drawing from the microscope, that each radius is a distinct animal by itself. I am, Dear Sir, Lawrence-lane, Jan. 22, 1756. Your most affectionate Friend, John Ellis. LXII. Two singular Cases of diseased Knee-joints successfully treated. The first by topical Applications; the second by Operation. By Mr. Joseph Warner, F. R. S. Surgeon to Guy's-Hospital. Read Jan. 22, 1756. Diseases of the larger joints of the extremities have always been look'd upon by surgeons of the greatest eminence in their pro- profession, to be attended with considerable danger to the patient; and with the greatest reason, since they have been convinced from much experience, that these maladies are too often the consequences of depraved habits of body, arising from scrophulous, scorbutic, or some other general cause. But tho' we are sufficiently apprized of these facts, and that they too often baffle the greatest skill in physic and surgery, we are nevertheless not to infer from hence, that every disorder of this kind is attended with the like bad circumstances; since it is well enough known to the experienced, that diseases of the joints, particularly those of the knee, are sometimes merely local complaints, which may not only be assisted by surgery, but perfectly cured. These species of tumors I now hint at, are those, which are distinguished by the name of hydrops articuli, or the dropsy of the joint; of which there are, as I have often observed, two different kinds. The one, wherein the disease is situated in the membrana adiposa, and neighbouring parts on this side the capsular ligament. The other is that species of disease, wherein the fluid is contained within the capsular ligament, betwixt the extremities of the thigh-bone, and the largest bone of the leg. The first species of tumor may be distinguished from the second by the touch; from the appearance of the tumor of the first kind, which is pale and uniform; from a want of fluctuation; and from the little or no degree of pain attending it. The repeated use, for some weeks, of emollient fomentations, mercurial frictions, and gentle purges, has been often known to remove this disorder. At other times it has been found, that these applications have had little or no effect, but that the disease has given way to, and been totally removed by the use of perpetual blisters to the part affected; which should, in most instances, be continued for several weeks. At other times, I have known the Pisseleon Indicum, in English called the Barbadoes tar, to have so good an effect, by being applied every day to the joint, for some weeks, even after every other remedy had failed, as to cure such a disorder of the knee-joint, as had hitherto been judged desperate: in which case there plainly appeared to be an enlargement of the bones, as well as a very considerable one of the integuments, and of the tendinous and ligamentous parts, but without any apparent inflammation. In this instance there was no extravasated fluid could be discover'd; however, there was an immobility of the joint, and a considerable contraction of the hamstrings. The pain was extravagantly great, which the patient described as shooting thro' the ligaments of the joint, the kneepan, the extremities of the thigh-bone, and those of the leg. He had a severe symptomatic fever, which had been of many weeks continuance, and was become greatly emaciated thereby. The reason for my giving so particular a relation of the circumstances attending this fact proceeds from my desire of recommending a tryal of the same remedy, in the like cases; which, as far as I can judge from my own experience, may always be safely done, where there is no degree of inflammation already formed upon the integuments. And I am farther induced to communicate a short history of the case to this Society, as it is an application I never saw made use of before, in the like like case, tho' the use of it has not been uncommon in old sprains of the joints; wherein it has oftentimes been found to be of singular service, even when other remedies have been ineffectually tried. The second species of hydrops articuli, or that wherein the extravasated fluid is contained within the capsular ligament, may be distinguished from the first, from its deep situation; from the fluctuation, which is felt upon patting the knee on one side, while the other hand is held immovably on the opposite side; from the degree of pain arising from the distension, which the capsular ligament suffers, in consequence of its contents; from the incapacity of bending the joint; and from the circumstance of its being attended with no general complaints of body, as well as from the sudden enlargement of the tumor; upon the increase of which depends the degree of uneasiness in the part. This is very far from being the case, in that kind of disease called the spina ventosa, which arises originally from the medulla and bone itself being diseased; from whence proceed grievous pricking and throbbing pains, that come on previously, in general, to any visible enlargement of the part affected, or any discoverable quantity of fluid deposited in the joint; the difference of which symptoms resulting from the different diseases may be learned from the succeeding case, wherein it was judged necessary to cut more than once thro' the capsular ligament, in order to evacuate its contain'd, extravasated fluid; which, contrary to the common received opinion of wounds of the ligaments being attended with certain destruction to the limb, should always be done under the like bad circumstances, in reasonable expectation of of removing a complaint, which totally disables the patient, and too frequently terminates in the loss of the limb, when neglected. And I am more particularly inclined to recommend this practice, as I am convinced, that this disease is out of the reach of such applications, as are of service in other diseases of these parts, whose situation is more superficial; that is, on this side the ligament, in which is contained the synovia. William Drury, aged 28, by business a porter, was put under my care, on the 5th of September, 1754, for a disorder in his knee. Upon enquiry, it appeared greatly swelled, was attended with excessive pain, which was continual: there was not the least degree of inflammation upon the integuments; the patient was incapable of bending his knee in the least degree, or of setting his foot to the ground. He could get no rest. The disorder arose without any accountable cause, and had been only of three weeks standing. Upon placing one hand on the outside of the knee, and by patting with the other on the inside, it was easy to discover a fluctuation; on which account I judged it adviseable to make an opening into the tumor, which I did by incision on the upper and inside of the knee-pan, as this was the most prominent part; upon which, a thick, gelatinous fluid, deeply tinged with blood, was discharged in a full stream to the quantity of fourteen ounces. After the whole of it was evacuated, I passed a probe thro' the wound, which went under the knee-pan: the wound was superficially dress'd with lint, and the whole of the knee was covered with a pulstice of strong beer-grounds and oatmeal. The patient complain'd of considerable pain for about four hours afterwards, when he grew easy, and so continued till the second day after the operation, when the knee became a good deal painful: there was no discharge from the wound. Upon enquiry I found he had not been at stool for three days, which occasioned the administration of a clyster, by which stools were procured, and the pain became considerably abated. On the third day from the operation there appeared a considerable discharge, and his knee was quite easy, which continued so till the sixth day, when the discharge was much abated. The pain returned and continued till the eighth day, when the discharge returned again, and the pain was removed. Observing from this time, that the discharge increased, and so continued easy till the eleventh day, which proceeded altogether from within the joint, I dilated the wound, that the matter might have a more ready issue. This answered my expectation, and the patient continued easy till the fifteenth day, when he complained of a return of pain. Upon examination, I perceived the outside of the knee was swelled, and upon pressure I discovered a fluctuation; which induced me to make an incision thro' the integuments and capsular ligament, on this side; which, I discovered, by the use of the probe, that passed under the knee-pan, to have a communication with the wound on the inside. From this time the patient went on very well, without any farther complaints; and in about twelve weeks from the first operation, he became perfectly well, and still continues so, without any other complaint than that of a small degree. degree of stiffness in the joint, as I have very lately had an opportunity of informing myself. During the whole time of the cure, I made use of emollient fomentations, dressed the wounds superficially, and continued the pulstice of strong-beer grounds and oatmeal, which were the only methods taken in surgery for his relief. Hatton-Garden, Jan. 31, 1755. LXIII. Extract of a Letter from Mr. William Pye, dated Manilla, Oct. 1st, 1754, to his Brother in London. Communicated to Mr. Benj. Wilson, F. R. S. by the Hon. Mr. Barrington. Read Jan. 29, 1756. I Will now give you some description of this place. Manilla is one of the largest of the Philippine islands, and the city is much larger than Oxford, and has two universities in it, and is inhabited only by Spaniards. The houses are large, and built very strong; the ground-floor is stone; the walls of a prodigious thickness; all above is wood, and so contrived, that every piece of timber has a connection with each other, all over the house: they are let into one another, and joined together, that the earthquakes, which are very terrible and frequent, may not throw them down. The convents are likewise very strong and handsome. The suburbs are very extensive, and well inhabited.