56 



ABNORMAL CONDITIONS OF THE KNEE-JOINT. 



ordinary occupation, and is at first usually un- 

 accompanied by swelling, or if swelling exist 

 at this early period, it is inconsiderable. There 

 is more pain and less swelling than in the ordi- 

 nary case of scrofulous white swelling. The 

 swelling, too, is different, that in the strumous 

 being more elastic, more of a globular form, 

 and situated at first more at the lower and ante- 

 rior part of the joint around the ligamentum 

 patellae : in the strumous also the ham is sooner 

 filled up. Moreover, the simple chronic ar- 

 thritis of the knee is a disease of adult life, and 

 the strumous of the younger subject. As the 

 simple chronic arthritis of the knee proceeds, 

 the limb wastes somewhat, a preternatural effu- 

 sion of synovial fluid into the joint takes place, 

 and pain on motion becomes so severe as to 

 confine the patient to the house ; he complains 

 of a constant, deep, boring pain, which is usu- 

 ally referred to the inner condyle of the femur 

 or tibia, and is accompanied by some spasmodic 

 starting of the muscles of the limb, by which 

 his sleep is disturbed. When pressure is made 

 on the knee over the situation where uneasiness 

 is experienced, the pain is increased ; and the 

 integuments of the affected articulation have a 

 higher temperature than natural. In the early 

 stage of the disease the popliteal space is not 

 filled up. As the inflammatoryaction proceeds, 

 the patient's strength and spirits become ex- 

 hausted by continued pain and confinement; 

 the constitution becomes engaged, suppuration 

 occurs in the interior of the joint, and matter 

 makes its way to the surface, oedema of the 

 instep manifests itself, and the disease now runs 

 very much the same course as does the chronic 

 strumous white swelling, partial dislocation of 

 the tibia outwards or back%vards occurring, and 

 amputation becoming necessary to save life. 



The two following cases may serve as exam- 

 ples of the simple chronic arthritis genu. The 

 first presented us a rare opportunity of witness- 

 ing the anatomical characters of the disease in a 

 very early stage ; the second in the advanced 

 form, as amputation could no longer be deferred 

 with safety. 



J. M'Cann was admitted into the Richmond 

 Surgical Hospital on the 13th Dec. 1836, for an 

 affection of his left knee-joint. The attack 

 was about six weeks coming on, but he remem- 

 bered that about ten years previously he had 

 fever, and that the left knee-joint was at that 

 time severely visited by inflammation. Since 

 that period, however, he remained well until 

 he got cold, which ended in the present attack 

 of the knee, and at this time no other joint was 

 affected. The joint appeared to be much en- 

 larged when compared with the right and 

 healthy knee ; the prominences of the bones 

 were no longer evident ; the swelling was soft 

 and fluctuating, and extended up the front of 

 the thigh, but the ham was not in the least filled 

 up; the knee was slightly flexed, and the ten- 

 dons of the hamstring muscles were remarkably 

 tense ; he referred the pain to the internal side 

 of the joint. Hoping to be released of these 

 symptoms he sought admission into the hospi- 

 tal. He was ordered twenty-four leeches 

 and fomentations to the knee-joint, and to take 



three times a day a pill containing two grains 

 of calomel and half a grain of opium. On tlie 

 fourth day of this treatment he complained of 

 scalding when passing urine, and of acid eruc- 

 tations from his stomach. For the latter mag- 

 nesia and lime-water were given. On the fifth 

 day diarrhoea, probably mercurial, set in, which 

 was very severe and did not yield to the treat- 

 ment, which consisted in the administration of 

 an emollient enema containing forty drops of 

 tincture of opium, and of a pill every third 

 hour, containing two grains of acetate of lead 

 and one grain of opium ; and warm fomenta- 

 tions with turpentine to the abdomen. After 

 the fourth pill had been taken the diarrhoea 

 ceased. It is proper to mention that the fore- 

 going symptoms were accompanied at the com- 

 mencement by a good deal of fever of the 

 sthenic type ; the patient's face was greatly 

 flushed, his eyes glistened, the lips were ver- 

 million red, the pulse was one hundred and 

 strong, and there was much increase of heat of 

 the surface. When the diarrhoea ceased, a new 

 phenomenon, haematuria, presented itself,accom- 

 panied by great pain across the lumbar region, 

 along the course of the ureters, and in the testi- 

 cles. The calls to pass water occurred hourly, 

 and half a pint of urine and blood mixed would 

 pass, which had not any urinous odour. These 

 calls became less frequent, but the fluid passed 

 became more and more red ; his countenance 

 changed, and he had the general symptoms of 

 loss of blood. Added to this his stomach was 

 in a continued state of erethism ; he had urgent 

 desire for cold drinks, but nothing, not even 

 cold water, would for one moment remain on 

 his stomach. His countenance was sunken and 

 exsangueous ; his pulse, one hundred and forty, 

 could scarcely be counted. His surface became 

 cold, and he complained of the greatest sense 

 of exhaustion. At this period most urgent 

 singultus set in and added much to his other 

 sufferings. The hsematuria continued, the sto- 

 mach rejected every species of nutriment, and 

 medicine failed altogether to relieve his symp- 

 toms. He died exhausted on the fourth day 

 from the diarrhoea setting in, and on the seventh 

 from his admission into hospital. It is remark- 

 able that during the last three days of his illness 

 he did not feel any uneasiness in his knee, and 

 the swelling of the joint had greatly dimi- 

 nished. 



On a post-mortem examination the kidneys 

 were found much enlarged and friable, with 

 some purpuric spots (petechise hremorrhagicse) 

 on their surface. The spleen was very small 

 and of a healthy consistence. On opening 

 the bursa beneath the reel us and vasti, it was 

 found to be distended with synovial fluid of 

 the ordinary character; no communication 

 existed between this bursa and the knee-joint. 

 When the proper synovial membrane of the 

 joint itself was opened, the quantity of synovial 

 fluid was found to be very scanty. The semi- 

 lunar cartilages were normal, but the articular 

 cartilages which invest the tibia and femur were 

 of a yellowish hue, and here and there appeared 

 softer than natural. In one spot the cartilage 

 covering the convexity of the internal condyle 



