ABNORMAL CONDITIONS OF THE KNEE-JOINT. 
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 
_ eourse 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- 
_ over 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, 
' iving 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 
‘edematous, reminding us of the hardened basis 
which we find circumscribing an abscess. It is 
_ probable that this condition of the surrounding 
erie 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 diarrhea 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 
i * See Dr. Beatty, Dublin Journal, &c. 
51 
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 acmé 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 crureus 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 pneumouia, 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 subcrurceus bursa was very 
red, as was also that of the joint itself. The 
synovial membrane was elevated above the level 
E 2 
