62 



ABNORMAL CONDITIONS OF THE KNEE-JOINT. 



influence on the constitution : it is not until it 

 arrives at the second or third stage that it pro- 

 duces any very remarkable alteration in the 

 health ; but the pain about the commencement 

 of the third stage is sometimes so violent as 

 to deprive the patient of sleep and appetite. 

 When the part is distended by abscesses, the 

 pain is increased, but when these open or are 

 opened, although temporary relief follows, 

 slow fever supervenes, the discharge becomes 

 sanious and foetid, and nocturnal sweats and 

 colliquative diarrhoea shew themselves, together 

 or alternately. 



Anatomical characters of the chronic stru- 

 rnous arthritis of' the knee. The anatomical 

 examination of a limb which has been ampu- 

 tated on account of a white swelling, or after 

 the death of the patient, demonstrates different 

 alterations which disease produces in the struc- 

 ture of the soft parts surrounding the diseased 

 articulation, and in that of the bones, synovial 

 membranes, and cartilages which compose it. 

 The skin and subcutaneous cellular tissue are 

 not greatly altered from their natural condition, 

 except that the latter is usually infiltrated with 

 a gelatinous matter, as is also the cellular struc- 

 ture, which lies deeper, viz. that which unites 

 the femur with the inferior part of the crurseus 

 muscle, as well as that behind the ligament of 

 the patella, and that also which occupies the 

 intervals between the condyles of the femur 

 behind the crucial ligaments. These parts are 

 equally infiltrated by a gelatinous fluid, of 

 more or less density. The whole of this cel- 

 lular structure presents the appearance of a 

 soft, spongy, homogeneous mass. The liga- 

 ments which secure the junction of the bones 

 of the joint seem themselves involved in this 

 morbid change of the surrounding cellular 

 structure, so that the tumefied ligaments and 

 other structures seem to be confounded toge- 

 ther, and to present an appearance almost like 

 a fibre-cartilaginous mass. " Thus have we 

 seen," says Boyer,* " the fatty cellular tissue 

 which is placed behind the ligamentum patellae, 

 so dense and thickened that it formed but one 

 mass in which ligament and cellular tissue 

 seem confounded together." All these ap- 

 pearances are present even before suppuration 

 has occurred. If the disease had existed for 

 any length of time so as to have arrived at the 

 period of suppuration, we find, among the 

 structures thus altered, that symptomatic chro- 

 nic abscesses have been formed. One extre- 

 mity of them we observe usually communicat- 

 ing with the knee-joint, while the other reaches 

 the surface, and presents one or more openings 

 which had become fistulous. These abscesses 

 and fistulous canals we find always lined by a 

 false membrane. The muscles which surround 

 the diseased joint are pale and wasted, and the 

 cellular tissue which is found in their thickness 

 is ordinarily more or less infiltrated with the 

 peculiar glairy matter above alluded to. The 

 tendons of the flexor muscles are generally re- 

 tracted and preserve their normal appearance. 

 The nerves we have had occasion to observe to 



be thicker than natural. These are the altera- 

 tions which are noticed in the soft parts, as we 

 pursue an anatomical examination down to the 

 bones and ultimate structures of the joint it- 

 self. It is probable, however, that these 

 changes will not be found to have occurred 

 unless the disease has existed for some time 

 previously in the centre of the bones them- 

 selves. Sir B. Brodie, Lloyd, and others are 

 of opinion that this strumous disease begins in 

 the centre of the heads of the bones of the 

 knee-joint, in the cancellous structure ;* and 

 Rust has satisfied himself that the membra- 

 nous tissue which lines the cancellous struc- 

 ture of the bones is the seat of the first morbid 

 action. They have found the interior of the 

 spongy tissue of the bones more vascular than 

 natural, and with much apparent justice con- 

 ceive them to be inflamed. These changes, 

 then, in the interior of the bone they believe 

 to constitute the anatomical characters of the 

 first period of the disease, and that when the 

 parts external to the joint become swelled and 

 infiltrated by the gelatinous matter above alluded 

 to, the second period is fully established. 



When the second period has commenced, 

 and the soft parts are excited into irritation, 

 if opportunities occur of examining the inte- 

 rior of the bones, they will be found to be sof- 

 tened and easily penetrated by a knife. The 

 synovial membrane contains an unusual quan- 

 tity of fluid, and the bones will undergo fur- 

 ther changes as the disease grows worse. These 

 structures become still softer, thei~ cancellous 

 structure is found filled with a yellowish cheese- 

 like matter. The bones, which in the first pe- 

 riod were in an hypersemic condition, are 

 now found to be less vascular, and portions 

 even become necrosed, so that it is not un- 

 common in advanced cases to find in the in- 

 terior of the joint portions of dead bone. In 

 these cases the spongy portion of the bones 

 seems so altered in structure as to appear half 

 dissolved, and to contain a sanious and foetid 

 matter in its substance. The periosteum in- 

 vesting the bones in the neighbourhood of the 

 diseased knee is very much thickened and 

 easily detached. It is surprising to what an 

 extent this strumous disease may have ad- 

 vanced in the bones and in the external parts 

 around the joints while the synovial structures 

 and cartilages remain but partially engaged. 

 The writer has lately been compelled to ampu- 

 tate a thigh for this disease of the knee in con- 

 sequence of the constitutional symptoms which 

 it excited in the system. In this case he dis- 

 covered that while the bones and soft parts 

 externally were far advanced in the second 

 stage of the disease, the synovial membrane 

 and cartilages were perfectly natural. When, 

 however, the disease has advanced far, and 

 the fistulous orifices are found to communi- 

 cate with the interior of the joint, we find 

 that the synovial membrane presents appear- 

 ances of morbid action having gone on in it, 

 and when the puriform fluid contained in it is 

 wiped away, that the surface of this mem- 



Maladies Chirurgicales. 



Russel entirely differs from them. 



