62 
influence on the constitution: it is not until it 
arrives at the second or third stage that it pro- 
duces any very remarkable alteration in the 
health ; but the pain about the commencement 
of the third stage is sometimes so violent as 
to deprive the patient of sleep and appetite. 
When the part is distended by abscesses, the 
pain is increased, but when these open or are 
opened, although temporary relief follows, 
slow fever supervenes, the discharge becomes 
Sanious and fcetid, and nocturnal sweats and 
colliquative diarrhoea shew themselves, together 
or alternately. 
Anatomical characters of the chronic stru- 
mous arthritis of the knee——The anatomical 
examination of a limb which has been ampu- 
tated on account of a white swelling, or after 
the death of the patient, demonstrates different 
alterations which disease produces in the struc- 
ture of the soft parts surrounding the diseased 
articulation, and in that of the bones, synovial 
membranes, and cartilages which compose it. 
The skin and subcutaneous cellular tissue are 
not greatly altered from their natural condition, 
except that the latter is usually infiltrated with 
a gelatinous matter, as is also the cellular struc- 
ture, which lies deeper, viz. that which unites 
the femur with the inferior part of the crureus 
muscle, as well as that behind the ligament of 
the patella, and that also which occupies the 
intervals between the condyles of the femur 
behind the crucial ligaments. These parts are 
equally infiltrated by a gelatinous fluid, of 
more or less density. The whole of this cel- 
lular structure presents the appearance of a 
soft, spongy, homogeneous mass. The liga- 
ments which secure the junction of the bones 
of the joint seem themselves involved in this 
morbid change of the surrounding cellular 
Structure, so that the tumefied ligaments and 
other structures seem to be confounded toge- 
ther, and to present an appearance almost like 
a fibro-cartilaginous mass. “ Thus have we 
seen,” says Boyer,* “ the fatty cellular tissue 
which is placed behind the ligamentum patella, 
so dense and thickened that it formed Dat one 
mass in which ligament and cellular tissue 
seem confounded together.” All these ap- 
Pees are present even before suppuration 
as occurred. If the disease had existed for 
any length of time so as to have arrived at the 
period of suppuration, we find, among the 
Structures thus altered, that symptomatic chro- 
nic abscesses have been formed. One extre- 
mity of them we observe usually communicat- 
ing with the knee-joint, while the other reaches 
the surface, and presents one or more openings 
which had become fistulous. These abscesses 
and fistulous canals we find always lined by a 
false membrane. The muscles which surround 
the diseased joint are pale and wasted, and the 
cellular tissue which is found in their thickness 
is ordinarily more or less infiltrated with the 
peculiar glairy matter above alluded to. The 
tendons of the flexor muscles are generally re- 
tracted and preserve their normal ap ce. 
The nerves we have had occasion to observe to 
* Maladies Chirurgicales, 
ABNORMAL CONDITIONS OF THE KNEE-JOINT. 
be thicker than natural. These are the alte 
tions which are noticed in the soft , as. 
—_ an anatomical examination down to’ 
nes and ultimate structures of the joint 
self. It is probable, however, that the 
changes will not be found to have occur 
unless the disease has existed for some t 
previously in the centre of the bones thi 
selves. Sir B. Brodie, Lloyd, and othe Ss 
of opinion that this strumous disease be gins 
the centre of the heads of the bones of 
knee-joint, in the cancellous structure ; 
Rust has satisfied himself that the memk 
nous tissue which lines the cancellous str 
ture of the bones is the seat of the first mor 
action. They have found the interior of 1 
spongy tissue of the bones more vascular tl 
natural, and with much apparent justice 6 
ceive them to be inflamed. These char 
then, in the interior of the bone they belie 
to constitute the anatomical charaeters of f 
first period of the disease, and that when 
arts external to the joint become swelled a 
infiltrated by the gelatinous matter above allu 
to, the second period is fully established. — 
When the second period has commence 
and the soft parts are excited into irritat 
if opportunities occur of examining the in 
rior of the bones, they will be found to be st 
tened and easily penetrated by a knife. T 
synovial membrane contains an unusual qua 
tity of fluid, and the bones will undergo fi 
ther changes as the disease grows worse. Th 
structures become still softer, their eancelle 
structure is found filled with a yellowish chee: 
like matter. The bones, which in the first) 
riod were in an hyperemic condition, a 
now found to be less vascular, and _portiol 
even become necrosed, so that it is not 1 
common in advanced cases to find in the 
terior of the joint portions of dead bone. ~ 
these cases the spongy portion of the be 
seems so altered in structure as to appear hi 
dissolved, and to contain a sanious and feetit 
matter in its substance. The periosteum | 
vesting the bones in the neighbourhood of t 
diseased knee is very much thickened a 
easily detached. It is surprising to what 
extent this strumous disease may have ¢ 
vanced in the bones and in the external p 
around the joints while the synovial structu 
and cartilages remain but partially engag 
The wniter has lately been compelled to am 
tate a thigh for this disease of the knee in et 
sequence of the constitutional symptoms 
it excited in the system. In this case he ¢ 
covered that while the bones and soft p. 
externally were far advanced in the sect 
stage of the disease, the synovial membr 
and cartilages were perfectly natural. 
however, the disease has advanced far, 
the fistulous orifices are found to commit 
cate with the interior of the joint, we 
that the synovial membrane presents appe 
ances of morbid action having gone on imi 
and when the puriform fluid contained in it 
wiped away, that the surface of this m 
* Russel entirely differs from them. | 
