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preside over the development of an attack of 

 an acute rheumatic arthritis, or of diffuse in- 

 flammation. 



Whatever may have been the specific nature 

 of the acute inflammation, there is soon no- 

 ticed, besides the pain felt through the carpal 

 region and the heat, that there is considerable 

 swelling. This last is more particularly ob- 

 served on the dorsum of the wrist and carpus 

 than elsewhere. An effusion, whether of 

 serum or pus, very soon takes place into the 

 interior of the synovial sac, which will always 

 have a tendency to distend this sac in all di- 

 rections ; but there can appear but little 

 swelling at the anterior part of the arti- 

 culation, because here a large fasciculus 

 of flexor tendons of the fingers passes, and 

 supports the synovial membrane. On the 

 lateral aspect of the wrist-joint, the tume- 

 faction, although sensible, is still limited by 

 the resistance which the lateral ligaments op- 

 pose to the distension of the capsule. Behind, 

 on the contrary, where the synovial membrane 

 is unsupported and but superficially covered, 

 the swelling, the result of the inflammation, 

 soon becomes much more manifest, and fluc- 

 tuation evident. 



We are not aware of any case recorded in 

 which complete dislocation of the hand, on 

 the back part of the forearm or of this last 

 forwards, had occurred as the result of acute 

 inflammation. The only luxation, the result 

 of acute arthritis in the region of the wrist, 

 which has been noticed hitherto, has been 

 that of the ulna backwards. 



This luxation is not an uncommon result 

 of an attack of acute arthritis of the wrist, by 

 which the ligament which connects the ulna 

 to the cuneiform bone becomes softened and 

 lengthened, and permits of the ulna being dis- 

 located partially or completely backwards. 

 Bonnet has commented on the frequency of 

 this backward displacement of the ulna, and 

 looks upon it as the smultaneous effect of 

 the facility with which the ligamentous ties of 

 this bone'become softened and elongated, and 

 of the faulty position in which the hand is 

 kept by the patient, who remains usually 

 in bed during these acute attacks, and pre- 

 serves the forearm and hand in a state of 

 complete pronation, a position which favours 

 the displacement of the ulna backwards. 



We have stated that acute arthritis of 

 the wrist and carpal joints may be the result 

 of inflammatory action, propagated from a 

 wounded tendon of one of the fingers. The 

 following is one of a few of those cases which 

 had been admitted into the Richmond Hospital 

 within a short period. 



CASE. John Murphy, a labourer, aet. 

 thirty-eight, while engaged in a fight with 

 another labourer, received from him a bite in 

 the little finger. The inflammation which fol- 

 lowed involved the tendons and their sheaths, 

 and spreading up the forearm, implicated in 

 its passage the carpal and meta-carpal joints 

 as well as the wrist and radio-ulnar articula- 

 tion, all of which became ultimately disorgan- 

 ised. The amputation of the forearm, below 



WRIST-JOINT (ABNORMAL ANATOMY). 



the elbow-joint, became necessary. On making 

 an anatomical examination it was found that 

 there was complete disorganisation of the wrist- 

 joint. All the bones of the carpus were loose 

 and bathed in purulent matter. 



Chronic Strumous Arthritis of the Wrist, or 

 White Sivelling. This is a disease which is 

 generally considered to have its origin in the 

 cancellous structure of the bones. It is fa- 

 miliarly designated by many English writers 

 by the well-known but somewhat equivocal 

 name of " white swelling." 



When we take into consideration that the 

 bones and the joints which compose the region 

 of the wrist are very superficially placed, and 

 that they are frequently subjected to sprains 

 and concussions from falls on the palm of the 

 hand, we need not be surprised to find that 

 these numerous injuries become so many de- 

 termining causes, giving rise to a chronic in- 

 flammation of the bones and articular textures 

 of the wrist, which frequently assumes the 

 strumous character. 



As to the symptoms of this disease, we 

 have to observe that the patient complains of 

 pain, sometimes in one point of the wrist, 

 sometimes in another, which is increased on 

 the slightest motion. Soon a swelling ap- 

 pears on the dorsum of the carpus, and the 

 hand, from day to day, becomes more flexed 

 on the forearm. After a time the region of 

 the wrist assumes a globular form. The fore- 

 arm, when compared with that of the opposite 

 side, has an emaciated and wasted appearance. 

 The patient usually has the hand supported 

 on its palm, in the prone position, on some 

 flat surface; the whole hand has a most 

 helpless aspect; the fingers are swollen at 

 their bases, and seem elongated and tapering 

 towards their extremities : they are straight 

 and motionless, and it is always with diffi- 

 culty and pain that the patient moves them, 

 a circumstance we can easily account for, by 

 recollecting that the inflammatory irritation 

 which affects the wrist-joint is readily propa- 

 gated to the tendons of the fingers which pass 

 so immediately in front of it. 



The synovial membrane in these cases is 

 early distended by an increased secretion into 

 the interior of the sac, and a fluctuating swell- 

 ing may be occasionally perceived posteriorly, 

 as in the case of acute arthritis ; but in the 

 case of white swelling, instead of true fluctua- 

 tion, there is in general nothing but a decep- 

 tive feeling of it, from the infiltration of the 

 tissues in the region of the wrist, by a glairy 

 gelatiniform structure, similar to that which 

 constitutes the chief bulk of white swellings in 

 general. 



During the second period of the disease, 

 the degree of flexion of the hand and of the 

 wrist-joint becomes increased, and the lower 

 extremity of the bones of the forearm, parti- 

 cularly of the ulna, becomes very salient pos- 

 teriorly. As the disease goes on, the bones 

 of the carpus become more deeply carious ; 

 chronic symptomatic abscesses form, and their 

 contents make their way to the surface, which 

 is frequently studded over, in advanced cases, 



