52 



ABNORMAL CONDITIONS OF THE KNEE-JOINT. 



of the cartilages by subsynovial infiltration. 

 The ligamentum mucosum, as it is called, was. 

 very vascular. The capillary system of the 

 semilunar cartilages was injected with minute 

 red vessels. The left knee-joint, which had 

 been but lately attacked, contained an inordinate 

 quantity of synovial fluid, of a greenish-yellow 

 hue, and of a thicker consistence and a deeper 

 colour than natural. The synovial membrane 

 was pale, and there was no infiltration in its 

 subsynovial structure. The vein in which 

 venesection had been performed was contracted 

 in the neighbourhood of the wound, and lymph 

 adhered to its lining membrane. Above the 

 right elbow-joint and internal to the course of 

 the vein, there was a small collection of matter 

 between the skin and fascia. 



Susan Brett, aet. 24, was brought into the 

 Richmond hospital on 26th February in great 

 distress and pain. On the 14th February she 

 was suddenly seized with convulsions, being 

 seven months pregnant. She was bled in the 

 right arm and her head shaved. Two days 

 after the operation the arm became very painful 

 and swollen. The pain increased, and on the 

 21st labour-pains came on and continued 

 during the day. In the evening she was again 

 attacked with convulsions, and blood was 

 drawn from the left arm. The child (her first) 

 was not expelled until early the next morn- 

 ing ; the evening of the same day she had a 

 severe rigour, which lasted half an hour, and 

 was succeeded by profuse perspiration ; this 

 soon went off, but she remained cold and 

 chilly for the remainder of the night. On the 

 following morning (23d) she was seized with 

 what she called severe rheumatic pains in her 

 hips and right shoulder, which left her " all 

 sore" and completely powerless. On the 24th 

 the pain in the right shoulder-joint became 

 most intense, and a severe stitch seized her in 

 the same side, which prevented her drawing 

 her breath. The pain in the arm also was now 

 very severe, extending upwards from where ve- 

 nesection was originally performed. The wound 

 was found not yet healed. 



When brought to the hospital, the fifth day 

 from her lying-in, she was in great distress and 

 pain. Her pulse was 140, with some fulness, 

 but still compressible. She preferred lying on 

 her right side bent forwards, with her knees 

 drawn up. Her respirations were fifty-two in a 

 minute, and greatly oppressed. At each effort 

 of inspiration the alae nasi were much dilated. 

 Her countenance was anxious, and there was a 

 bright circumscribed flush on each malar emi- 

 nence. For the last week she has raved con- 

 stantly at night, and has been more ill at cer- 

 tain hours of the day, very early in the morn- 

 ing, and again at half-past five, P.M. At the 

 latter hour she was generally found perspiring 

 copiously. Her bowels were too free. She 

 complained of pain chiefly in the right shoulder 

 and the lower part of the back ; also in both 

 her knees and metacarpal joint of the index- 

 linger of the left hand. She also complained 

 of her left hip. The right arm was swollen 

 but not discoloured, cedematous, and pitting on 

 pressure. The original wound made for vene- 



section was gaping, with unhealthy everted 

 edges ; no matter exuded from it. She kept 

 the arm in the flexed position ; to herself it felt 

 quite powerless, and when the least movement 

 was communicated to it, she suffered great tor- 

 ment. There was a hard line up the arm cor- 

 responding to the course of the basilic vein, 

 and when even the slightest pressure was made 

 in this line, she suffered pain. Immediately 

 above the elbow-joint the skin was hard ; the 

 subcutaneous cellular structure seemed more or 

 less cedematous as if infiltrated with fluid ; the 

 skin and subjacent parts seemed to be matted 

 together and somewhat cedematous, and pres- 

 sure here also gave the patient much uneasiness. 

 There was a suffused pink blush on the skin 

 covering the metacarpal joint of the index 

 finger; the joint was much swollen, and she 

 complained of much pain in it. Her princi- 

 pal suffering was fiom dyspnoea. An exami- 

 nation of the chest by auscultation and percus- 

 sion furnished all the evidence of extreme 

 bronchitis in both lungs, pleuritis with inci- 

 pient pneumonia : it was also inferred that 

 effusion had taken place into the right side of 

 the thorax. 



On the 28th February some of those deceit- 

 ful appearances of amendment not unusual in 

 the course of acute disease discovered them- 

 selves. It was reported that she had passed a 

 better night ; her pulse fell to 128; her respi- 

 ration was reduced to forty in the minute ; but 

 in the evening a pain, which she referred to 

 the situation of the diaphragm, came on with 

 great severity. Her cough was troublesome 

 and in paroxysms ; she expressed great anxiety 

 about herself, inquiring whether there were any 

 hopes for her, and complained of pain in her 

 left elbow, where, however, there was no- 

 swelling. The original wound made in the 

 right arm for the first venesection was still 

 open, but there was no inflammation about it. 

 The wounds made in the left arm for two sub- 

 sequent bleedings healed perfectly. She now 

 had pain in all her joints, particularly in the 

 metacarpal joint of the index finger of the left 

 hand. The shoulder-joints were swelled, and 

 she could not bear the slightest movement of 

 them. Her knees were very painful, chiefly 

 the left, which was greatly swollen, but its in- 

 teguments were not discoloured. Diarrhoea 

 was very troublesome. 



On the 2d of March profuse perspiration 

 broke out over the whole body, and oedema 

 of the feet came on. The next morning her 

 pulse was 128; respiration was jerking and 

 very much hurried ; and her countenance be- 

 trayed great internal distress. She had raved 

 alf night. There was complete orthopnoea, and 

 the swelling of the knees increased. She died 

 at four o'clock. 



On an examination of the body twenty-two 

 hours after death, the shoulder-joints were 

 found to contain a viscid greenish imperfectly 

 formed pus. Matter of the same appearance, 

 but less viscid, was met with on cutting down 

 to the right shoulder-joint among the muscles 

 external to it. The cartilages in both these 

 articulations had lost their colour and seemed 



