ABNORMAL CONDITIONS OF THE KNEE-JOINT. 



63 



brane, instead of being white, is red and vil- 

 lous, and much like mucous membrane in a 

 high state of inflammation. We can frequently 

 ascertain that this membrane has superadded 

 to it layers of newly deposited lymph, which 

 have become highly organized. Mr. Russell 

 says, that in his dissections of white swelling 

 of the knee, he has found the inside of the 

 synovial membrane covered with a layer of a soft 

 substance, of a pale yellowish colour, and semi- 

 transparent; that this substance was nearly 

 one-eighth of an inch in thickness, softer in its 

 inner concave surface, and firmer on the outer 

 convex part, where it adhered to the inside of 

 the synovial capsule of the joint with a con- 

 siderable degree of firmness. In many places 

 he observed on it a very beautiful plexus of 

 vessels ; and at the interstices between the sur- 

 face of the femur and tibia, he states that he 

 generally found an appendage full of blood- 

 vessels which had insinuated itself to the dis- 

 tance of nearly half an inch. It very fre- 

 quently happens that the cartilages and crucial 

 ligaments are completely concealed from our 

 view by a membrane, in some places of one- 

 quarter or even one-half of an inch in thick- 

 ness, presenting a loose cellular structure, 

 highly vascular, occupying the intervals be- 

 tween the condyles, and hanging into the in- 

 terior of the joint; and we have usually found 

 this newly-formed structure to be superadded 

 to the original synovial membrane, and to 

 establish adhesions between the bones of the 

 articulation, and we find bands of organized 

 lymph stretching from the femur to the tibia. 

 When this condition of the synovial membrane 

 existed, we have usually found the cartilages 

 remaining; but in other cases the synovial 

 membrane itself has been found to be but little 

 altered ; and yet the cartilages have been re- 

 moved partially or completely, the porous sub- 

 stance of the bone having been found exposed, 

 or covered by recent deposits of soft pultaceous 

 lymph. 



Such are the organic changes which usu- 

 ally produce white swellings. These changes 

 present numerous varieties, but it is sufficient 

 to notice the principal ones, and to observe 

 that there are scarcely two patients in whom 

 they are perfectly alike. 



Sir Benjamin Brodie, in his work on the 

 joints, has remarked that when acute inflam- 

 mation attacks the shaft of a cylindrical bone 

 and the periosteum covering it, the disease is 

 usually limited by the epiphysis, so that, not- 

 withstanding the extensive abscesses and exfo- 

 liations which frequently ensue, the neighbour- 

 ing joints are not affected by it. Although we 

 have seen numerous specimens proving the ge- 

 neral truth of this observation, yet on the other 

 hand we have witnessed exceptions to it: in- 

 deed Sir Benjamin Brodie has further observed 

 that a few instances occur in which acute in- 

 flammation attacks the epiphysis itself, termi- 

 nating also in exfoliations, &c. more or less ex- 

 tensive. 



In very young subjects we occasionally see 

 examples of diffuse inflammation which has 

 engaged the periosteum of the femur or tibia, 



and the epiphysis of one or both of these bones, 

 the inflammation extending to the knee-joint. 

 These cases are usually rapid in their course, 

 and too frequently terminate fatally, the ordi- 

 nary symptoms of diffuse inflammation being 

 exhibited in their progress. In the post-mortem 

 investigations of these cases we find that the 

 periosteum is extensively separated from the 

 bones by purulent matter ; that the epiphyses, 

 detached from the shafts of their respective 

 bones, are loose in the interior of the joint; 

 and that the synovial membrane is dis- 

 tended by matter. In the serous and mu- 

 cous membranes of the chest also we generally 

 find evidences of acute inflammation having 

 existed. The origin of these violent attacks is 

 sometimes referred to a fall or other accidental 

 injury, sometimes to a cold which commenced 

 with a rigour. We have sometimes known 

 this severe form of disease to succeed imme- 

 diately to attacks of small-pox, and also of 

 scarlatina. Dr. M'Dowel, in the third and 

 fourth volumes of the Dublin Journal, has de- 

 scribed this disease under the heads Periostitis 

 and Synovitis ; and the museum of the Rich- 

 mond hospital contains many specimens of 

 these unhappy results of diffuse inflammation. 

 Cases of diffuse inflammation are not the 

 only ones in which we have seen matter, 

 formed beneath the periosteum of the tibia, 

 passing the epiphysis and getting into the 

 cavity of the knee-joint ; we have known in- 

 stances of such occurrences in cases of acute 

 necrosis of the tibia, in which the disease in its 

 commencement had been exclusively confined 

 to the one bone. Mr. Smyly, one of the sur- 

 geons to the Meath Hospital, presented to the 

 museum of the College of Surgeons in Dublin, 

 a specimen, the result of an acute necrosis of 

 the tibia. The following is the history of this 

 case, which he kindly communicated to the 

 writer. James Jarman, set. 9, was admitted 

 into the Meath Hospital the 5th October, 1837. 

 Sixteen days previously he had suffered a very 

 severe contusion on the front of the left tibia 

 by the accidental falling of an iron bar; there 

 was, however, no breach of the skin, and the 

 boy was able to walk about as usual for two 

 days, when acute inflammation attacked the 

 contused part, and daily increased for a fort- 

 night. On the 4th of October he applied for 

 relief at the dispensary. At this time a large 

 and tense swelling extended from above the 

 knee to the instep; a fluctuation was evident 

 the whole way down the front of the leg. An 

 incision was made into this swelling, which 

 gave exit to a considerable quantity of thin 

 discoloured pus, and the tibia was found quite 

 denuded of periosteum. Great relief followed 

 the opening of the abscess, but on the 10th of 

 October there was much tumefaction observa- 

 ble at each side of the patella, and redness, as 

 if the joint were in a state of suppuration. 

 The boy suffered much from irritative fever and 

 occasional diarrhoea : his pulse became very 

 frequent, and his tongue red and dry. The ope- 

 ration of amputation at the lower third of the 

 thigh was now the only resource, and it was 

 accordingly performed. 



