ABNORMAL CONDITIONS OF THE KNEE-JOINT. 



51 



are usually ushered in by a severe rigor followed 

 by perspiration. The patient is remarkably 

 restless and depressed in mind. If the phle- 

 bitis be external, as in that occasionally succeed- 

 ing to venesection, which has preceded the acute 

 arthritis, the inflammation along the course of 

 the wounded vein will be observed for several 

 days before the attack of arthritis shall come on. 

 Whatever may have been the cause of the 

 inflammation of the joints, the disease does not, 

 as in rheumatic fever, pass successively from 

 joint to joint, completely leaving one joint 

 to visit another. Although varieties may of 

 course be noticed in the local symptoms which 

 this dangerous disease presents, it very con- 

 stantly happens that a joint once visited by it 

 seldom or never completely recovers its effects. 

 Usually many joints are successively or simul- 

 taneously affected, and we very generally dis- 

 cover that one or more of the internal organs is 

 also implicated. Whatever joint is attacked in 

 the course of the disease, it presents the ordinary 

 characters of an acute arthritis. The integu- 

 ments covering the articulation sometimes wear 

 a pink hue, and always have an elevated 

 temperature. The affected limb is powerless. 

 The patient complains of very considerable 

 pain, more particularly, as it appears to us, in 

 puerperal arthritis than in the affections of the 

 joints which attend on the ordinary forms of 

 diffuse inflammation. The swelling, when first 

 examined, is soft and fluctuating. After a time 

 the effusion of synovial fluid and pus increases, 

 giving rise to the distension of the synovial sac. 

 If at this advanced period we carefully examine 

 the parts immediately surrounding the inflamed 

 joint, we can discover that the integuments and 

 subjacent parts feel somewhat indurated and 

 cedematous, reminding us of the hardened basis 

 which we find circumscribing an abscess. It is 

 probable that this condition of the surrounding 

 parts arises from diffuse inflammation and the 

 infiltration of its digested purulent matter. 

 The arthritis in these cases is seldom the cause 

 of death ; either some internal vital organ be- 

 comes violently inflamed by which the death of 

 the patient is accelerated, or abscesses form in 

 the subcutaneous or intermuscular cellular 

 membrane in various parts of the body, which, 

 although more slowly, as certainly lead to a 

 fatal issue, for when the evacuation of the pus 

 takes place, the quantity of matter which is dis- 

 charged and continues to be secreted is so 

 excessive as greatly to reduce the patient's 

 strength, and the exhaustion from this source 

 and from the diarrhoea which usually attends are 

 sufficient to prostrate the powers of the youngest 

 and strongest individuals. Most writers indeed 

 have observed that in the majority of cases the 

 subjects of this disease had been in a bad state 

 of health at the time the exciting cause came 

 into action, a cachectic condition produced by 

 over-exertion of mind or body, and that from 

 these circumstances the susceptibility or pre- 

 disposition to this disease most probably 

 arose.* These observations are, we believe, 

 fully borne out by experience, and it may not 



* See Dr. Beatty, Dublin Journal, &c. 



perhaps be uninteresting to adduce some 

 remarks published by an author nearly forty 

 years ago, which prove that he was practically 

 acquainted with the complaint denominated by 

 the moderns puerperal rheumatism or puerperal 

 arthritis, and that he took a similar view of the 

 predisposing causes of this disease. Mr. 

 Russell in his work on the knee-joint, in treat- 

 ing of acute cases of what he calls white 

 swelling, says : " in those cases which proceed 

 most rapidly, the disease will reach its acme" in 

 the course of a few weeks." The very rapid 

 and acute cases seem to be connected with some 

 state of great relaxation and weakness. He 

 adds, " the most remarkable instances of this 

 variety which have fallen under my observation, 

 have occurred in the cases of women in child- 

 bed." In the Richmond Hospital (Dublin) 

 we had had many cases of this form of acute 

 arthritis, from which we select the two following 

 as serving to illustrate some of the foregoing 

 observations. Both these individuals were in a 

 delicate state of health when the disease attacked 

 them, and the swelling of the knee-joints and 

 other articulations formed a very small part of 

 their diseases. 



Andrew Turner, 28 years of age, was ad- 

 mitted into the Richmond Hospital on the 

 7th of May, 1836. He had much abused his 

 health and constitution. Five days after having 

 been bled in the right arm to relieve the con- 

 sequences of a severe beating, a superficial dif- 

 fused redness appeared on the skin of the fore- 

 arm ; the venesection wound was swelled and 

 inflamed ; a severe rigor occurred, followed by 

 profuse perspiration and fever ; erratic erysipelas 

 characterized by a faint red mottling of the skin 

 in patches appeared ; a blush of inflammation 

 in the form of a patch showed itself on the 

 shoulder, but not continuous with that on the 

 fore-arm ; a pink patch next appeared over the 

 right knee, then on the left arm, and afterwards 

 on the left lower extremity ; and while this dis- 

 ease invaded the body part after part, those 

 once occupied remained engaged as before. 

 On the 15th May, the ninth day from his ad- 

 mission, there was observed effusion into the 

 right knee and into the bursa which is subjacent 

 to the cruroeus muscle. Although considerable, 

 this effusion escaped the patient's attention ; he 

 complained of no pain, and to our enquiries 

 always replied that he was going on " gaily." 

 On the 18th the left knee-joint was tumefied, 

 but not to the same extent as the right. He 

 died on the 26th, his death being preceded 

 by the ordinary symptoms of pneumonia, pleu- 

 ritis, &c. On the post-mortem examination the 

 anatomical appearances of pneumonia, pleuritis, 

 and bronchitis were seen ; there was also effu- 

 sion into the cavities of the pericardium and 

 peritoneum. In the right knee-joint and sub- 

 cutaneous bursa, which freely communicated 

 with it, there was a large quantity of yellowish 

 green fluid, which seemed to be formed of the 

 mixture of purulent matter with the synovial 

 fluid : flakes of lymph floated in it. The syno- 

 vial lining of the subcruroeus bursa was very 

 red, as was also that of the joint itself. The 

 synovial membrane was elevated above the level 



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