ABNORMAL CONDITIONS OF THE KNEE-JOINT. 
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, 
B wascular, 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 “esi et. 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-joimt which 
originated in a blow on the joint from the handle 
_ of aprinting-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 remaimed much in thisstate 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 the 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 state 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 
57 
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 teoder- 
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 inver 
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.— 
Tn the articles Hann, Hip, Etzow, &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.. When 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 the power of flexing or extending the 
Jimb, the hamstring muscles gradually become 
more tense. The knee-joints from the com- 
mencement incline slightly inwards, and the 
tibia outwards, and this bone is at the same 
time rotated in this last 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 
patellz, 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. 
