50 



ABNORMAL CONDITIONS OF THE KNEE-JOINT. 



head of the tibia, instead of amputation of the 

 thigh, where it was found impracticable to re- 

 move the leg at the ordinary place of election 

 four inches below the knee-joint. But Larrey 

 made an addition to this operation, namely, the 

 extraction of the head of the fibula. He says, 

 " when the fibula is left short, which is usually 

 the case, it is to be extirpated as useless, and 

 troublesome in the application of the artificial 

 leg, and the skin is to be left as long as pos- 

 sible, to cover the stump." Mr. Guthrie gives 

 Larrey much praise for drawing the attention 

 of the profession to this " great improve- 

 ment," and adds the weight of his high autho- 

 rity by recommending the removal of the head 

 of the fibula. In alluding to this subject we 

 may appear to be departing from the proper 

 object of this article, the abnormal appear- 

 ances presented by the knee-joint ; but having 

 known some melancholy examples of acute in- 

 flammation of the knee-joint to follow the 

 operation here recommended, we take this op- 

 portunity of warning the profession against it. 

 Mr. Guthrie himself says, '' it is possible, how- 

 ever, that a case may occur (perhaps one in a 

 thousand) in which the head of the fibula com- 

 municates with the general cavity of the knee- 

 joint ; in such a case amputation must be done 

 above the knee." Independently of this com- 

 munication between these two contiguous joints 

 which Mr. Guthrie considers so rare, we have 

 found, by repeated anatomical examinations of 

 the relation existing between the synovial sacs 

 of the knee-joint and that of the superior tibio- 

 fibular articulation, that these two sacs are so 

 close as to have but a thin transparent wall 

 separating them. We consider it, not abso- 

 lutely, but very nearly impracticable to cut out 

 the head of the fibula in the living subject 

 without making a communication with the pos- 

 terior and back part of the synovial membrane 

 of the knee-joint, so delicate is the thin trans- 

 parent membrane which is interposed between 

 the synovial sac of the knee-joint and the little 

 synovial sac which partially envelopes the head 

 of the fibula. Besides, in the living subject 

 it must always prove to be a difficult matter 

 to remove the head of the fibula without in- 

 terfering with the tendon of the popliteus 

 muscle, as we know the tendon to be enve- 

 loped by a synovial production sent down 

 along it, like that which in the shoulder-joint 

 invests the tendon of the biceps. This synovial 

 production is not confined to the tendon of 

 the popliteus, but is also reflected over the 

 groove formed for the reception of this tendon, 

 and must be in danger of being opened in 

 every operation which we can devise for the 

 removal of the head of the fibula ; and conse- 

 quently, although there may be many cases in 

 which it may be advisable to amputate the leg 

 a little below the tubercle of the tibia, in no 

 case, in our opinion, should the surgeon attempt 

 to extirpate the head of the fibula. The idea 

 that this small portion of bone, when left, is 

 " useless and troublesome in the application of 

 the artificial leg," may be true, but it is not the 

 less true that in the majority of cases acute 

 arthritis of the knee-joint will be very likely to 



succeed to this operation ; and we feel satisfied 

 that, as soon as these anatomical relations be- 

 tween the synovial sac of the knee-joint and 

 that of the superior tibio-fibular articulation are 

 reflected on, this modern proposal will be re- 

 jected. 



Among the causes of acute arthritis genu, 

 exposure to cold is very frequently referred to 

 by the patient, and apparently with reason. 

 The knee-joints being less covered by muscular 

 parts than any other of the large articulations, 

 are more subjected to the influences of cold, 

 and on this account are perhaps more generally 

 affected by acute and chronic inflammation than 

 other articulations. It must be admitted, how- 

 ever, that we have met with cases of acute 

 inflammation of the knee-joint for the origin of 

 which we could assign no cause, having come 

 on, as we are accustomed to say, spontaneously. 

 Acute arthritis genu sometimes arises as a 

 symptom in the course of different diseases. 

 Thus in diffuse inflammation and in phlebitis 

 it is quite usual to find the joints visited by 

 most severe attacks of inflammation. We have 

 seen examples of acute arthritis supervening 

 suddenly in the course of a severe attack of 

 erysipelas;* and in rheumatic fever and puer- 

 peral rheumatism we can see little else than an 

 inflammation of the joints, the nature of the in- 

 flammation in these cases, however, being very 

 different. 



Although we have here spoken of three 

 different forms of disease, diffuse inflammation, 

 phlebitis, and puerperal rheumatism, we have 

 ourselves long entertained the opinion expressed 

 by Mr. Arnott, Velpeau, Dance, Cruveilhier, 

 our friend Dr. Beatty, and others,+ that the 

 three forms of disease in which the acute arthri- 

 tis we are here treating of occurs, are the same, 

 and that the arthritis in all three is similar, and 

 proceeds from the same common cause, viz. 

 phlebitis and its consequences. 



The peculiar form of acute arthritis here 

 adverted to has in almost all cases been found 

 to have been preceded by phlebitis. This may 

 have come on spontaneously, or in consequence 

 of a wound, or of the vessel having been in- 

 cluded in a ligature. The form of acute arthri- 

 tis which has been called puerperal rheumatism 

 has also been found, in many cases, coincident 

 with or preceded by phlebitis of the veins of the 

 uterine system, or of some other veins. J 



We have seen many cases which we consi- 

 dered to be examples of diffuse inflammation 

 in very young subjects, engaging the periosteum 

 of the femur and tibia, and terminating in the 

 complete destruction of the bone, in the short 

 space of three days. Sometimes the periosteum 

 of the femur, for example, formed a complete 

 cylindrical sac containing the detached shaft of 

 the bone. 



The symptoms of acute arthritis which occur 

 in the course of a case of diffuse inflammation 



* See Dublin Journ. vol. xvii. p. 336, and in this 

 article p. 55. 



t See Dublin Journ., and Mr. Arnott's valuable 

 observations in the Med. Chir. Trans. 



i See Dance's, Beatty's, and Mr. Harrison's cases, 

 Dublin Journ. 



