56 
ordinary ion, and is at first usually un- 
accompanied by swelling, or if swelling exist 
at this early period, it is inconsiderable. There 
18 more pain and less swelling than in the ordi- 
nary case of scrofulous white swelling. The 
swelling, too, is different, that in the strumous 
being more elastic, more of a globular form, 
and situated at first more at the lower and ante- 
rior of the joint around the ligamentum 
ae #: in the strumous also the ham is sooner 
led up. Moreover, the simple chronic ar- 
thritis of the knee is a disease of adult life, and 
the strumous of the younger subject. As the 
— chronic arthritis of the knee proceeds, 
the limb wastes somewhat, a preternatural effu- 
sion of synovial fluid into the joint takes place, 
and pain on motion becomes so severe as to 
confine the patient to the house ; he complains 
of a constant, deep, boring pain, which is usu- 
ally referred to the inner condyle of the femur 
or tibia, and is accompanied by some spasmodic 
starting of the muscles of the limb, by which 
his “ri is disturbed. When pressure is made 
on the knee over the situation where uneasiness 
is experienced, the pain is increased; and the 
integuments of the affected articulation have a 
higher temperature than natural. In the early 
stage of the disease the popliteal space is not 
filled up. As the inflammatoryaction proceeds, 
the patient’s strength and spirits become ex- 
hausted by continued pain and confinement; 
the constitution becomes engaged, suppuration 
occurs in the interior of the joint, and matter 
makes its way to the surface, edema of the 
instep manifests itself, and the disease now runs 
very much the same course as does the chronic 
strumous white swelling, partial dislocation of 
the tibia outwards or backwards occurring, and 
amputation becoming necessary to save life. 
e two following cases may serve as exam- 
ples of the simple chronic arthritis genu. The 
first haere us a rare opportunity of witness- 
ing the anatomical characters of the disease ia a 
very early stage ; the second in the advanced 
form, as amputation could no longer be deferred 
with safety. 
J. M‘Cann was admitted into the Richmond 
Surgical Hospital on the 13th Dec. 1836, for an 
affection of his left knee-joint. The attack 
was about six weeks coming on, but he remem- 
bered that about.ten years previously he had 
fever, and that the left knee-joint was at that 
time severely visited by inflammation. Since 
that period, however, he remained well until 
he got cold, which ended in the present attack 
of the knee, and at this time no other joint was 
affected. The joint appeared to be much en- 
larged when compared with the right and 
healthy knee; the prominences of the bones 
were no longer evident ; the swelling was soft 
and fluctuating, and extended up the front of 
the thigh, but the ham was not in the least filled 
up; the knee was slightly flexed, and the ten- 
dons of the hamstring muscles were remarkably 
tense; he referred the pain to the internal side 
of the joint. Hoping to be released of these 
symptoms he sought admission into the hospi- 
tal. He was ordered twenty-four leeches 
and fomentations to the knee-joint, and to take 
ABNORMAL CONDITIONS OF THE KNEE-JOINT. 
three times a day a pill containing two grail 
of calomel and half a grain of opium. On th 
fourth day of this treatment he complained ¢ 
scalding when passing urine, and of acid ere 
tations from his stomach. For the latter may 
—_ and lime-water were ae On the fifi 
ay diarrhea, probably mercurial, set in, whit 
was very sive’ and did not yield to the tre 
ment, which consisted in the administration 
an emollient enema containing forty d 
tincture of opium, and of a pill every 
hour, containing two grains of acetate of 
and one grain of opium ; and warm fom 
tions with turpentine to the abdomen. 
the fourth pill had been taken the diarrh 
ceased. Itis proper to mention that the fo 
going symptoms were accompanied at the con 
mencement by a good of fever of | 
sthenic type; the patient’s face was g 
flushed, his eyes glistened, the lips were vi 
million red, the pulse was one hundred an 
strong, and there was much increase of heat 
the surface. When the diarrhea ceased, a ne 
phenomenon, hematuria, presented itself, accon 
panied by great pain across the lumbar regio 
along the course of the ureters, and in the testi 
cles. The calls to pass water occurred hourly 
and half a pint of urine and blood mixed 
pass, which had not any urinous odour. Th 
calls became less frequent, but the fluid pas: 
became more and more pei countenan 
changed, and he had the ge 
loss arg ee) Added to this his romana 
in a continued state of erethism; he had urge 
desire for cold drinks, but nothing, not evi 
cold water, would for one moment remain 0 
his stomach. His countenance was sunken 
exsangueous ; his pulse, one hundred and forts 
could scarcely be counted. His surface becam 
cold, and he complained of the greatest sens 
of exhaustion. At this period m 
singultus set in and added much to his othe 
sufferings. The hematuria continued, the sto 
mach rejected every species of nutriment, and 
medicine failed altogether to relieve his sym 
toms. He died exhausted on the fourth di 
from the diarrhea setting in, and on the sevent 
from his admission into hospital. It is remar 
able that during the last three days of his illne: 
he did not feel any uneasiness in his. knee, an 
the swelling of the joint had greatly ¢ 
nished. 3 
On a post-mortem examination the kidr 
were found much enlarged and friable, 
some purpuric spots (petechia hemorrhagic 
on their surface. The spleen was very smi 
and of a healthy consistence. On openin 
the bursa beneath the rectus and vasti, it ¥ 
found to be distended with synovial fluid 
the ordinary character; no communicati 
existed hetween this bursa and the knee-jo 
When the proper synovial membrane 
joint itself was opened, the quantity of syno’ 
fluid was found to be very scanty. The sem 
lunar cartilages were normal, but the articular 
cartilages which invest the tibia and femur we 
of a yellowish hue, and here and there appeare¢ 
softer than natural. In one spot the ca 
covering the convexity of the internal cond 
OT 
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m7 
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