58 



ABNORMAL CONDITIONS OF THE KNEE-JOINT. 



When the distension of the synovial sac of 

 the articulation is at its maximum, we usually 

 notice in this disease a prominent tumour about 

 the size of a small hen's egg projecting into 

 the popliteal space (jig. 3). This tumour 

 leans towards the inner head of the gastro- 

 cnemius; it disappears when the knee is flexed, 

 and becomes more tense and hard when the 

 limb is in the extended posture, as when the 

 patient stands erect. We have known several 

 cases of this disease of the knee-joint, where 

 the synovial sacs of the knees have. been much 

 distended, and have on these occasions almost 

 uniformly observed this popliteal tumour formed. 

 From its situation, and from negative evidence, 

 we can readily infer that the swelling consists 

 of synovial fluid contained in a bursa, which 

 has a communication with the interior of the 

 knee-joint. 



We have witnessed very many cases of this 

 chronic rheumatic arthritis of the knee, in which 

 this dropsical condition of the popliteal bursa 

 existed, and some of these having had this 

 chronic disease in both knee-joints, the bursse 

 were seen in both popliteal spaces, presenting 

 in these cases on a superficial inspection the 

 resemblance to a case of double popliteal 

 aneurism. 



We have also enjoyed an opportunity of 

 ascertaining by anatomical examination the real 

 condition of this synovial sac in this disease, 

 and its relation to the synovial membrane of 

 the joint itself, to which we shall have occasion 

 just now to revert. 



When the palm of the hand is applied over 

 the patella in the early stages of the affection, 

 a sensation of a preternatural degree of heat is 

 felt ; and when pressure is made on the patella, 

 and a lateral movement across the condyles is 

 communicated to it, a very evident roughness 

 is perceived, either on the articular surface of 

 the patella itself, or the corresponding surface 

 of the trochlea of the femur ; and when the 

 knee-joint is fully flexed, a characteristic arti- 

 cular crepitus becomes manifest. In the later 

 stages of the disease, the subacute inflamma- 

 tion, with the phenomena which it presents, 

 subsides, the synovial fluid becomes absorbed, 

 and the patella falls down on the trochlea of 

 the femur ; the popliteal bursa also disappears, 

 and the grating produced by rubbing surfaces 

 is perceived by the patient himself in all his 

 movements, and can even be heard by the by- 

 standers. If the joint be now examined care- 

 fully by the surgeon, he feels satisfied that the 

 smooth cartilage has been removed, either par- 

 tially or completely, from the articular surfaces. 

 Crests of ossific deposit may even be per- 

 ceived, and, almost invariably, foreign bodies 

 may be felt in the interior of the joint. Some 

 of these are superficial, small, and moveable ; 

 others are evidently situated more deeply in 

 the interior of the joint. Some are small, 

 some large, and we have known one case, 

 which we learned to be of forty years standing, 

 in which numerous bodies* of this description 



* The case mentioned by Morgagni in which he 

 saw twenty-five of these bodies in the left knee- 



could be felt, some literally as large as the 

 patella, floating about in the interior of the 

 knee-joint, and which, we doubt not, were 

 exactly of the same nature as those we have 

 described in the elbow-joint. 



The prognosis in this disease must be un- 

 favourable, as it seldom yields to medicine, but 

 it does not appear to us to shorten life. We 

 have seen an example in which the knee-joints 

 had been affected with this disease, as the 

 patient herself reported, for forty years. We 

 are not prepared to say, however, that medicine 

 and proper treatment may not occasionally cut 

 short the disease, and we are sure the sufferings 

 of the patient may be palliated at least by 

 appropriate treatment. The following case is a 

 good example of this disease. 



Case of chronic rheumatic arthritis. Patrick 

 Donohoe, aged 38, a carter, admitted into the 

 Richmond Hospital, (Dublin,) Nov. 24, 1836, 

 complained of chronic pains in all his joints, 

 but the principal source of his uneasiness was 

 the diseased condition of his knee-joints, which 

 prevented his earning his livelihood. Both 

 knee-joints were greatly swollen ; he com- 

 plained of stiffness of them, and of some pain 

 at the inner condyle of the tibia, which in- 

 creased when he stood up ; yet he was able to 

 walk a considerable distance. The limbs could 

 be fully extended, and when in bed he kept 

 them pretty constantly in this position. He 

 could not fully flex them backwards. The 

 swelling of the knees differs from that of an 

 ordinary white swelling, although it might cor- 

 respond much to the characters which a case 

 of chronic synovitis of the knee might present, 

 or to a case which the older writers denominated 

 hydrops articuli. The swelling viewed in front 

 is of an irregular globular form, involving the 

 patella, its ligament, and the hamstring ten- 

 dons in one uniform tumour; on the contrary 

 the ligamentum patellae can be felt, with its 

 edges as yet sharp and well defined, when the 

 patient is desired to exert the extensor muscles 

 of the leg. The tibia at the side of the liga- 

 ment, as far as the insertion of the internal 

 lateral ligament, can be plainly felt through 

 the skin to be rough and scabrous, and it can 

 be perceived that this part of the bone is beset 

 with bony vegetations. The breadth of the 

 head of the tibia is increased ; the synovial 

 membrane contains a redundant secretion, which 

 elevates the vastus internus and forms a swelling 

 here which measures about seven inches in its 

 vertical diameter, and which seems to be some- 

 what constricted transversely in its centre (/?g.2). 

 The swellingof the knee on the outside is evident 

 enough, but is not so well marked as that on 

 the inner side. It presents no transverse band, 

 subdividing it into two tumours. The out- 

 line of the hamstring tendons is seen, when 

 the joint is viewed in profile, either from 

 without or within, and a very well defined ovoid 

 projection from the popliteal space is observed 

 (Jig. 3). Its centre is on a level with the up- 

 joint of an old woman who died of apoplexy, we 

 think must have been a case of the chronic disease 

 we are now describing. 



