ABNORMAL CONDITIONS OF THE KNEE-JOINT. 



57 



of the femur was superficially removed for the 

 size of a sixpence. To this softened, ulcerated, 

 or abraded point the principal pain was referred, 

 by the patient during life. There were not any 

 loose and vascular synovial fringes hanging into 

 the interior of the joint, but examining at the 

 circumference of the cartilage, where it invests 

 the external condyle of the femur, this mem- 

 brane and its subsynovial tissue were very red, 

 vascular, and villous-looking. The outer edge 

 of the cartilaginous covering of the femoral 

 condyle was thin and minutely serrated, and the 

 eye of the probe could be placed under this edge. 

 John Nugent, set. 19, was admitted into the 

 Richmond Hospital, January, 1839. He had 

 been under treatment in the country for six 

 months for a disease of the left knee-joint, which 

 originated in a blow on the joint from the handle 

 of a printing-press. He fainted at the time of 

 the accident, and the pain never ceased from that 

 day up to this period of his admission. He 

 was reduced a good deal in flesh. He had 

 occasional perspirations during the night, parti- 

 cularly about the head, and starting pain shoot- 

 ing up and down the leg. He could not bear 

 the joint to be moved but kept it semiflexed, 

 and the limb lying on the outside. He stated 

 that before his admission he had never been 

 altogether confined for the complaint. There 

 was some little swelling of the knee, which was 

 tender on pressure. There was no swelling in 

 the ham, nor enlargement of the inguinal glands. 

 The calf of the leg was wasted, and the thigh 

 also was less than the other by an inch in the 

 measure of its circumference above the knee. 

 He remained much in this state until March 14th, 

 when he complained of suffering a constant 

 " dead pain" across the joint below the patella ; 

 besides this there was occasionally a throbbing 

 sensation which was more distressing to him 

 than any other, even than the spasmodic starting 

 of the limb. On the 2nd of April a valvular 

 opening was made with caution into an abscess 

 on the inside below the articulation; thin curdy 

 matter came away. This gave him some relief. 

 On the 4th another opening was made in the 

 outside above the joint, where also the abscess 

 showed itself: matter of a similar description 

 came away. Previous to these punctures hav- 

 ing been made, amputation was proposed to 

 the man as the only means of escape from this 

 disease, but he preferred to have tl.e abscesses 

 opened. Fever did not follow upon this first 

 or second operation, but subsequently it set in, 

 and ran very high for four days, during which 

 he perspired largely and had much pain and 

 starting of the limb, with head-ache and anxiety 

 of manner, and for two days he was in a con- 

 fused stale bordering on delirium. Nor did the 

 evacuation of the purulent matter prevent the 

 enlargement of the cavities of the abscesses 

 connected with the diseased joint, as appears 

 by the following report, dated May 10th, made 

 by our clinical clerk, Dr. Bradshaw. " The 

 abscess has ascended up the thigh, running- 

 high up the popliteal region. The hectic fever 

 is severe; his pulse in general 120, small and 

 compressible; emaciation had advanced and is 

 still advancing ; his strength is giving way 



under the disease, and he must soon sink if 

 amputation be not consented to." On the 

 10th May the report was, " Diarrhea still con- 

 tinues, but without abdominal pain or tender- 

 ness. The emaciation is very great. Pulse 120, 

 small, and compressible. Tongue red, moist, 

 and morbidly clean. The flexion of the leg on 

 the thigh becomes every day more and more 

 considerable, so that the angle becomes daily 

 more acute." On the following day amputation 

 high up was performed. The disease of the 

 knee had much affected the cartilaginous struc- 

 tures of the joint, the absorption of which seemed 

 to have been effected by a vascular pulpy mem- 

 brane. The parts that had suffered most were 

 the external condyle of the femur, the inner 

 head of the tibia, and the inner and posterior 

 surface of the patella. Along the trochlea of 

 the femur there existed longitudinal grooves or 

 furrows in the cartilage, which was not removed. 

 A highly vascular and pulpy membrane was 

 found filling the parts wherever the cartilage 

 had been absorbed, and this membrane could 

 be traced insinuating itself beneath the edge of 

 the remaining portions of the cartilage, by which 

 means the process of absorption seemed to have 

 been effected. In the interior of the joint there 

 were much pus and flakes of lymph, and where 

 the cartilages had been removed the porous 

 surface of the bones had been covered by soft 

 layers of lymph of very recent formation. 



Chronic rheumatic arthritis of the knee. 

 In the articles HA.ND, HIP, ELBOW, &c. in this 

 work we have treated of a chronic disease 

 affecting other articulations, which we have 

 denominated chronic rheumatic arthritis; we 

 shall, now give an account of the symptoms 

 and anatomical characters of this disease as we 

 have found it in the knee-joint. \\ hen this 

 articulation is affected with it, other joints in 

 the same individual will also be found more or 

 less implicated. The commencement of this 

 disease of the knee is marked by evidences of 

 subacute inflammation, such as pain, heat, con- 

 siderable swelling. This is followed by a 

 second period, in which the heat and swelling 

 diminish, but the pain continues. This pain 

 is usually referred to the inner condyle of the 

 femur and tibia. The patient may for a long 

 period be able to walk, but every movement 

 produces considerable pain, and at length he 

 becomes incapable of walking or even of stand- 

 ing. The limbs diminish in size, but become 

 remarkably firm to the feel. The patient having 

 at last lost (he power of flexing or extending the 

 limb, the hamstring muscles gradually become 

 more lense. The knee-joints from the com- 

 mencement incline slightly inwards, and the 

 tibia oi'twards, and this bone is at the same 

 time roiated in this Inst direction, so that the 

 foot is everted ; if the limb then be kept in 

 the semi-flexed position, and the tibia be thus 

 rotated outward, carrying with it the ligamentum 

 patellae, it. is easy to account for the circumstance 

 which we have in some examples witnessed in 

 the disease, viz. that the patella leans towards 

 the outer condyle, and further, that it is then 

 sometimes thrown completely over it, so as to 

 represent the external dislocation of this bone. 



