60 
He found it necessary, however, after the lapse 
of three years, to seek re-admission into the 
hospital, where he now is. The right knee- 
joint is now enlarged, and in a condition simi- 
lar to that of the left on his first admission. 
The latter, on the contrary, has nearly resumed 
its normal condition; the dropsical effusion of 
synovia has disappeared; he does not com- 
plain of pain in it; but if the joint be accu- 
rately examined, the bony irregularities which 
were noticed on the head of the tibia will be 
found, as might be expected, still to exist. If 
we move the patella transversely, an articular 
crepitus is perceived, plainly shewing that the 
cartilages have been removed from the patella 
and corresponding trochlea of the femur. The 
edges of the trochlea can also be felt through 
the skin to be elevated into rising crests. The 
peculiar crackling noise which is elicited when 
the joint is flexed and extended is infinitely 
more remarkable in the left knee-joint now, 
when it is comparatively well, than formerly, 
when it was much swollen, and when the syno- 
vial membrane was in what has been called a 
dropsical condition. 
Anatomical characters—When we have an 
opportunity of making an anatomical examina- 
tion of a knee in which the disease had been 
fully established, we find the synovial fluid 
increased in quantity, and but little altered in 
its sensible qualities. The membrane is thicker 
than natural, and opaque. Sometimes vascular 
synovial fimbriz are formed, and hang into the 
synovial sac.* We also find moveable carti- 
laginous bodies in the interior, similar to those 
noticed in the elbow-joint.t (See Exzow, 
ABNORMAL CONDITIONS OF.) 
In the line of flexion and extension we 
observe narrow sulci formed by the removal of 
the cartilages. On examining the popliteal 
tumour, we find it to be, what we might have 
surmised, an enlargement and dropsical condi- 
tion of the bursa, which naturally exists at the 
point of decussation of the semi-membranosus 
tendon with the tendon of the internal head of 
the gastrocnemius. This bursa communicates 
normally with the synovial sac of the knee- 
joint by a very small circular aperture. It is 
not an uniform ovoid sac, but evidently has 
semilunar septa irregularly thrown across its 
interior, making the bursa a small multilocular 
cavity. When the joint is much distended by 
synovial fluid, the bursa admits some of this 
fluid, and takes upon itself the same morbid 
rocess which affects the proper synovial mem- 
lieias of the joint itself. As we examine the 
disease when it has existed for some time, we 
find that the cartilage has been removed in 
grooves, and its place supplied by a porcelain- 
ous or ivory deposit. e bones of the knee- 
joint, however, present appearances charac- 
teristic enough: they generally appear to be 
enl This is obviously the case with the 
patella: it is broader than natural, excavated, 
and grooved vertically. All the bones seem 
enlarged and porous on all those parts of the 
* See Cruveilhier, liv. 9. pl. 6. 
t See Morgagni's case, in note above, 
ABNORMAL CONDITIONS OF THE KNEE-JOINT. 
articular surfaces which have not been worn | 
use into porcelainous polished surfaces and st 
The cavities of the head of the tibia for dl 
reception of the condyles of the femur ; 
much deepened, and exuberant nodules 
vegetations of bone are thrown out around f 
circumference of this head. When we exan 
the femur, we find here also bony vegetati 
arranged along the lateral margins of the 
dyles, similar to those which we noticed aro 
the corona of the head of the femur.* © 
on Ped bone called the trochlea, u 
which the patella moves, is also grooved ye 
cally, and Che trochlea has rising edges t 
oa — which will be found to correspon 
the lateral margins of the la when 
bone is laid stock the troctlon of tie em 
The anatomical characters of this disease w 
it has existed long, will of course be still 
strongly marked. However, the dropsi 
effusion into the synovial sae will be found 
be much less as the disease is of longer dui 
tion. The joint becomes more and more flex 
the tibia has a tendency to be partially 
placed outwards, and the toe is everted: | 
patella under such circumstances is disloca 
on the external condyle, giving us ane 
example of this luxation from disease. Int 
interior of the joint foreign bodies are fout 
while the articular and semilunar cartilage 
altogether absorbed. . 
White swelling, or chronic strumous arthr 
of the knee—The knee-joint is more liab 
e disease commonly called white swe 
than any other articulation. This disea 
though utterly insidious in its attack and s 
in its progress, nevertheless presents some 
the characters of an inflammatory compl 
during its whole course. The first ; 
generally is reported as a deep-seated dt 
heavy pain unattended by swelling and 
increased by motion, but in children the swe 
ing is often the first symptom noticed. This 
followed by pain, which, although it ec 
only occasionally, is severe, and is re’ 
almost uniformly to the inside of the kn 
Some increase of temperature of the affect 
joint on comparison with the other knee, ¢ 
be ceiertiined 7 
The swelling does not at first encompass t 
whole joint, but first appears on the anteri 
and lower of the knee, occupying 
general the two little hollows on the differ 
sides of the ligament which joins the patella 
the tibia. This swelling is elastic, and 
examination by the finger conveys a sense 
softness and fluctuation, as if it containe 
fluid, although no fluid to any amount tea 
exists. The skin over the knee becomes p 
and shining, as if thinned. The subcutanes 
veins dilate and become very evident. 1 
muscles of the ret waste, so that the volu 
of this portion of the affected extremity is e 
widerihdpstekincdd: and the inferior part of 
thigh just over the knee suffers a characterist 
diminution in the measure of its circumference 
W 
+ 
* See HIP, ABNORMAL CONDITION OF, ff 
also Cruveilhier, liv. 9. pl. 6. fig- 2. 
¥ 
