IlIichael Smith, 58 years of age, was admitted into the Richmond Hospital in 1838,1abouring under erysipelas of the head. During the course of the disease, one of his knee-joints became hot and swollen, the patella seemed to float, and on each side of it a fluctuation be came evident. He was more or less insensible from the erysipelas of the head, but when the knee-joint was moved, he exhibited signs of suffering. On the eighth day after the knee joint was first affected, be died of the erysipelas of the head. The knee-joint was carefully inspected, fine red injection having been previ ously thrown into the femoral artery. The synovial sac of the articulation was distended by a turbid yellowish-green fluid, apparently composed of a mixture of pus and synovia. When this was washed away, the synovial membrane was found not so much thickened as in the former case, nor had it so much of the vivid scarlet colour as the last specimen alluded to ; and reminded those who examined it of the appearance which the conjunctiva presents in subacute conjunctivitis. This membrane ap peared to be thickened and pulpy where it had already advanced somewhat over the external condyle of the femur. The subsynovial tissues were more or less infiltrated. The cartilages had lost their normal whiteness and brilliancy, and were of a murky yellowish hue ; they were somewhat softened in their substance, and the cartilaginous covering of the patella was slightly elevated, in patches, and one spot of ulceration was seen at the circumference of its external edge. The cartilage covering this bone was so soft that the blunt probe easily penetrated into its structure. Many would call this a case of simple-synovitis genu, but it is manifest that, although the acute disease in the knee originated in the synovial membrane, the other structures of the joint very soon became implicated, and that, at the period of the patient's death, which was only a few days after the first attack of the joint, the term of synovitis of the knee-joint was not sufficiently comprehensive. We have had many opportunities of examining the knee joints of those who have died of diffuse inflam mation, which has occurred in females some short time after parturition, and in those cases denominated puerperal rheumatism, and in cases where the arthritis of the knee or other joints was concurrent with phlebitis ; and in such cases we have found the most remarkable phenomena to be,—great effusion into the knee joint of a fluid which would seem to be com posed of equal parts of pus and synovial fluid. This was viscid, of a sea-green colour, and of the consistence of honey. In cutting down to the joint in these cases we frequently met with ill-digested matter in and amongst the muscles surrounding the affected articulation. The synovial membrane was of a pink colour. The articular cartilages presented an appearance which was rather peculiar. We have found them generally to preserve their normal adhesion to bone, to be smooth on their surface, but to be evidently thinned, and so reduced as to form a stratum covering the condyles of the femur scarcely half a line in thickness. The inter-articular cartilages externally preserve their normal appearance, but we can occasionally discover that after an attack of acute arthritis of the description now under consideration, these structures shew that they are permeated inter nally by capillary vessels containing red blood. We have had many,—too many examples lately verifying the above description of the anatomical appearances presented on the examination of the knee-joints of those who have died of dif fuse inflammation.
Simple chronic arthritis of the knee.—The symptoms which denote the existence of simple chronic inflammation of the knee-joint are very similar to those belonging to the acute affection of this articulation, being only slower in the different stages of their developement and milder in their character.
The simple chronic arthritis genu commences with a pain which the patient usually refers to the inner side of the joint. -This pain is not • sufficient to prevent him from following his ordinary occupation, and is at first usually un accompanied by swelling, or if swelling exist at this early period, it is inconsiderable. There is 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 nor part of the joint arouna the ilgamentum patella' : in the strumous also the ham is sooner filled 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 simple 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 sleep 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, oedema 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.
The two following cases may serve as exam ples of the simple chronic arthritis gene. The tirst presented us a rare opportunity of witness ing the anatomical characters of the disease in 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 larded 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. lie was ordered twenty-four leeches and fomentations to the knee-joint, and to take three times a day a pill containing two grains of calomel and half a grain of opium. On the fourth day of this treatment he complained of scalding when passing urine, and of acid eruc tations from his stomach. For the latter mag nesia and lime-water were given. On the fifth day diarrhtea, probably mercurial, set in, which was very severe and did not yield to the treat ment, which consisted in the administration of an emollient enema containing forty drops of tincture of opium, and of a pill every third hour, containing two grains of acetate of lead and one grain of opium ; and warm fomenta tions with turpentine to the abdomen. After the fourth pill had been taken the diarrlitra ceased. It is proper to mention that the fore going symptoms were accompanied at the com mencement by a good deal of fever of the sthenic type ; the patient's face was greatly flushed, his eyes glistened, the lips were ver million red, the pulse was one hundred and strong, and there was much increase of heat of the surface. ‘Vhen the diarrhoea ceased, a new phenomenon, hxmaturia, presented itsel f,accom pan ied by great pain across the lumbar region, 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 would pass, which had not any urinous odour. These calls became less frequent, but the fluid passed became more and more red ; his countenance changed, and he had the general symptoms of loss of blood. Added to this his stomach was in a continued state of erethism; he had urgent desire for cold drinks, but nothing, not even cold water, would for one moment remain on his stomach. His countenance was sunken and exsangueous ; his pulse, one hundred and forty, could scarcely be counted. His surface became cold, and he complained of the greatest sense of exhaustion. At this period most urgent singultus set in and added much to his other sufferings. The hmmaturia continued, the sto mach rejected every species of nutriment, and medicine failed altogether to relieve his symp toms. He died exhausted on the fourth day from the diarrhoea setting in, and on the seventh from his admission into hospital. It is remark able that during the last three days of his illness he did not feel any uneasiness in his knee, and the swelling of the joint had greatly dimi nished.