64 



ABNORMAL CONDITIONS OF THE KNEE-JOINT. 



On examination, the knee-joint was found 

 distended with purulent matter. The syno- 

 vial membrane was covered in patches by a 

 vascular pulpy membrane ; the cartilages were 

 removed in several places. An opening was 

 found in the inner condyle of the tibia, which 

 perforated the spongy substance of this bone, 

 and thus established a communication between 

 the interior of the knee-joint and a large 

 abscess as it were which had formed under 

 the periosteum of the tibia. The shaft of the 

 tibia was detached from the epiphysis and the 

 periosteum, and was surrounded by matter. 

 The periosteum was thickened, vascular, rough, 

 and gritty from minute particles of bone depo- 

 sited in it. The ankle-joint was free. The boy 

 recovered his health. 



Acute arthritis of the knee may be com- 

 bined with acute osteitis of the bones of this 

 articulation, and without any discoverable com- 

 munication between the cavity of the arti- 

 culation and the interior of the bones. On the 

 21st March, 1840, Mr. Smith presented to the 

 Pathological Society the following case. Susan 

 Christie, set. 56, an inmate of the House of In- 

 dustry, and for a long period disabled by the 

 affection of the knee-joints which we have 

 described as chronic rheumatic arthritis, was 

 removed to the Whitworth Hospital, where she 

 died of a most acute attack of inflammation of 

 the right knee-joint. On the post-mortem exa- 

 mination old adhesions were observed in the 

 chest. The right knee-joint presented the ex- 

 ternal appearances noticed as belonging to the 

 chronic rheumatic arthritis in a somewhat ad- 

 vanced stage ; moreover, it was greatly swollen, 

 and when the synovial membrane was opened 

 purulent matter escaped ; organizable lymph 

 lined this membrane and the cartilages generally. 

 These structures, however, were in some places 

 removed altogether, their place being supplied 

 by a porcelaiuous deposit, grooved in the line 

 of flexion and extension. From the condyles 

 of the tibia the cartilage was raised up from the 

 bone, apparently stretched out, and converted 

 into a thin, flexible, and soft yellow membrane, 

 difficult to be distinguished, except by its si- 

 tuation, from a deposit of lymph the produce 

 of recent inflammation. 



But the interior of the head of the tibia, 

 its cancellated structure, the medullary mem- 

 brane lining these cancelli, and the membrane 

 of the medullary canal itself, all presented evi- 

 dences of their having been the seat of acute 

 inflammation. The purulent matter was dif- 

 fused through the cancelli of the tibia, from 

 the knee-joint, for one-third of its extent, but 

 was nowhere collected into any isolated cavity 

 or abscess, nor was there any communication 

 between the purulent matter which occupied 

 the synovial sac of the knee-joint, and that 

 which pervaded the medullary structure and 

 cancellated tissue of the tibia. In a word, the 

 anatomical characters of a true acute osteitis 

 of the bones entering into the formation of 

 the knee-joint coexisted in an advanced stage 

 with those of acute inflammation of all the 

 other structures of the articulation. 



The osteitis of the lower extremity of the 



femur or upper portion of the tibia sometimes 

 presents more of a chronic character. The in- 

 flammation of the interior of the bone may 

 proceed to cause the death of a portion, which 

 is converted into a sequestrum, the presence of 

 which becomes a source of irritation and in- 

 flammation of the surrounding bone and the 

 formation of an abscess. The following case 

 came under the writer's observation while under 

 the care of his colleague Dr. Hutton in the 

 Richmond Hospital. Thomas Conolly, set. 43, 

 was admitted in May, 1838, for a disease in 

 the lower extremity of the left femur, of many 

 years' duration. He had long suffered from a 

 deep boring pain in the interior of the bone. 

 At length an abscess formed, matter made its 

 way to the surface and was evacuated, and 

 two small fistulous openings remained, through 

 which a probe could be passed deep into the 

 interior of the enlarged femur. The man was 

 greatly exhausted by the quantity of the dis- 

 charge, by confinement, and hectic fever, and 

 amputation was performed in the femur just 

 above the diseased part. The femur was found 

 much enlarged near the knee-joint, and covered 

 by wasted muscles, which had undergone a 

 considerable degree of fatty degeneration. When 

 these were removed, the periosteum was found 

 thickened. A vertical cut from before back- 

 wards was made through the femur, knee- 

 joint, and tibia, by which section the cavity of 

 an abscess capable of containing a hen's egg 

 was exposed, which was placed transversely 

 between the condyles, having two open fistu- 

 lous orifices, one on the inner, the other on the 

 external condyle. This abscess was lined by a 

 thick membrane which by a fine injection was 

 proved to have been highly vascular ; villous 

 flocculi hung from it into the interior of the ca- 

 vity ; a dark-looking sequestrum of a cylin- 

 drical form, an inch and a half long and half 

 an inch thick, occupied the superior half of the 

 cavity; one end of the sequestrum was fixed 

 into the bony tissue of the femur, as if it 

 were on its way to present itself at the outer 

 fistulous orifice ; the remainder of it lay dia- 

 gonally across the cavity of the abscess, the 

 front wall of which was principally constituted 

 of soft parts, the femur having been absorbed 

 in this situation. In the vicinity of the ab- 

 scess, particularly above it, the bone was greatly 

 thickened, its cancellated structure solidified, 

 and rendered apparently as dense as ivory. 

 The interior of the joint was quite unconnected 

 with the cavity of the abscess, but the joint it- 

 self presented evidence of its having been at 

 one time the seat of some form of inflam- 

 matory action, because the shape of the con- 

 dyles of the femur was somewhat altered, and 

 at the same time thetibia was partially displaced 

 backwards, and ligamentous anchylosis had 

 taken place. The cartilage had been removed 

 somewhat from the ends of the bones, and its 

 place supplied in patches by a membrane like 

 periosteum, and in other situations by a dense 

 polished enamel. It was to be inferred from 

 the appearances which the 'bones and conti- 

 guous structures presented, that the knee-joint 

 had latterly been quite useless. 



