ABNORMAL CONDITIONS OF THE KNEE-JOINT. 
Patients under an incipient attack of white 
swelling first experience inconvenience in walk- 
ing from weakness of the joint, a symptom 
which is more especially troublesome after 
exercise. But as soon as the pain becomes 
constant, the patient is no longer able to rest 
the weight of his body upon the affected limb 
without a great increase of uneasiness. On 
_ this account he is willing to save the limb as 
‘much as possible; he touches the ground, 
_ therefore, merely with his toes, trusting the 
_ support of his body chiefly to the other limb. 
_ In walking in this way the knee necessarily 
_ becomes bent, and what is thus begun becomes 
_ permanent from other causes; so that after a 
_ certain period the joint continues permanently 
in a state of flexion. 
___ Although we occasionally see cases in which 
the leg remains extended on the thigh, they 
_ must be considered rare, for in general the leg 
is in a more or less forced state of flexion on 
the thigh, and such is the patient’s apprehen- 
sion of pain he will not on any account extend 
‘the leg voluntarily, nor allow it to be extended 
by others. 
_. The earlier period of the disease is succeeded 
by a second stage,* in which the patient usually 
_ submits to the adoption of active and energetic 
_ treatment. The pain now not unfrequently 
diminishes, but the swelling continues in- 
creasing, the ham becomes fully occupied by 
it, the extremities of the bones appear to 
enlarge, and become more prominent as the 
flexion increases. Attacks of inflammation 
* ensue, accompanied by pain starting up and 
down the limb, by which sleep is interrupted. 
_ These attacks are usually succeeded by effusion 
of fluid into the synovial sac of the joint and 
_ cellular interstices around : abscesses form, and 
some fluctuation may now be discovered in 
different parts of the swelling. If at this 
period, which may be called the third or sup- 
purative stage of the disease, the bones be 
_ moved laterally, it will be perceived that the 
ligaments permit an unnatural degree of motion 
‘between them, and now, as in other articula- 
tions, ial or complete luxation may occur. 
Such, however, is the breadth of the surfaces of 
‘contact of the bones of the knee-joint, that 
‘complete luxation seldom happens. The limb 
at this period is usually found lying powerless 
_ On its outer side and in the semiflexed position ; 
and after some time a partial displacement of 
the leg outwards on the femur occurs: under 
_ other circumstances a partial or complete luxa- 
_ tion backwards happens. Although the disease, 
_ arrived at this stage, seldom terminates favour- 
ably, still instances do occur of unexpected 
improvement of the general health, of the 
_ Tesdlution of the swelling, of the absorption of 
‘Matter, and of one of the forms of anchylosis 
taking place. But usually the matter formed 
in and around the joint goes on accumulating, 
_ ™ Mr. Lloyd divides scrofulous white swellings 
into three stages ; the first being that in which the 
affection is confined to the bone; the second that 
in which the external parts become thickened and 
swelled; and the third what he denominates the 
sub-acute stage.—Lloyd on scrofula. 
61 
the tension of the knee-joint increases, and 
now in most cases an accompanying cedema of 
the foot is observed, a symptom than which 
there can be none more unfavourable. The 
nocturnal startings of the limb, disturbing the 
patient’s rest, become more painful and urgent, 
and abscesses communicating with the interior 
of the articulation open externally by one or 
more orifices, and give exit to a quantity of 
matter, which rarely has the quality of laud- 
able pus; on the contrary, it is for the most 
part a sero-purulent liquid, of a yellowish 
green colour, like whey, in which curdy mat- 
ters are found floating. It is remarkable that 
little diminution in the size of the swelling 
follows the escape of this matter. 
We have stated that the pus is seldom lau- 
dable. On some few occasions, however, its 
consistence may be that of good pus; but even 
then it soon degenerates into a thin fetid sa- 
nies of bad quality. The openings giving exit 
to the discharge sometimes close very speedily, 
and new collections form in different parts of 
the tumour. This, however, is unfortunately 
rare, for generally the openings degenerate into 
fistule. A probe introduced into one of these 
penetrates, if the route be not long and cir- 
cuitous, into the interior of the joint, and dis- 
covers the internal parts to be carious and dis- 
organised ; and if the bones of the articulation 
be now pressed together, a crepitation, arising 
from the friction of the carious and ulcerated 
surfaces, is perceived, furnishing unequivocal 
evidence of the last stage of disorganization of 
all the structures of the articulation. This is 
the most common course of the disease, but in 
some cases there are varieties to be observed. 
For example, the suppuration of the soft parts 
and ‘of the cartilages, and even caries of the 
bones, may occasionally precede the displace- 
ment of the bones; and all the parts of the 
articulation may be destroyed without the oc- 
currence of any displacement; but if, in this 
case, we move the bones of the articulation in 
opposite directions, we easily ascertain the re- 
laxation of the uniting ligaments, and that 
many of the conditions necessary to the dis- 
placement exist, although, from some cause not 
easily explained, it has not occurred. 
As to our prognosis we should remember 
that the age and constitution of the patient 
have considerable influence on the ulterior pro- 
gress of the disease, and our knowledge of this 
must control our anticipations as to the result 
to be expected, ceteris paribus. The disease 
in the truly strumous subject is very rebellious, 
and has a disposition to terminate in suppu- 
ration which it is difficult to baffle. In young 
subjects it is in general more acute, or the suc- 
cession of the different orders of symptoms is 
more rapid; but in young persons there is 
much more hope of cure than in the old and 
exhausted. We agree with Mr. Russell in 
opinion that it is in the cases of infants that 
the formation of anchylosis may be expected as 
the termination of a case of white swelling, 
though even with these true bony anchylosis 
must be considered as a very rare occurrence. 
In the beginning the disease has but little 
