The three following are cases of suppurative synovitis: CASE XI.-Margt. M., ætat 9, fell down on the 9th July, 1858, on a hand basin, which she was carrying; broke it and cut her arm inside the elbow; she bled a good deal, and when this was stopped the wound was closed. 10th.-Synovia was observed to escape, and on the 12th.-A rigor set in; the elbow became very painful and swollen. Ordered tartrate of potash and senna draught, immediately; ten drops of laudanum at bedtime. 13th.—The pain is most severe; there is much fluid in the joint, which can be felt through the thickened tissues; the opium has made her sleep. I laid the joint open, for a space of an inch and a-half, along the inner edge of the olecranon and triceps tendon; much pus escaped. To take the following, three times a day : 15th. She is less feverish; the wound discharges freely; the pus is healthy she could eat some chicken to-day. She is to have meat whenever she can eat it, and a glass of port wine, daily: strong broths. : 17th.-Is better; appetite improves; pain much less; diminish the laudanum to seven drops. 20th.-Allowed to get up for a few hours; discharge less; wound filling up. This patient got well: when the wound in the joint had healed, before the external one had skinned over, I had friction used over the rest of the joint, and then passive motion at the end of the following month, August. In a fortnight after, there was still a little thickening, and she could not quite straighten the arm; in all other respects she was well. CASE XII.-Charles Hudson, ætat 35, carpenter, came to me at the Charing Cross Hospital on account of a wound over the knuckle of the left ring-finger, 22nd June, 1860. On the 13th of that month he had hurt his hand, jamming it between a plank and the wall, and at the same time a rusty nail wounded it over that knuckle. The wound became, as he said, very bad; and is now very painful, the pain running up the arm; there are no red lines, nor any enlargement of epicondyleian glands. 22nd. There was a suppurating sore over the back of the metacarpophalangeal joint, with pale, flabby granulations. In its centre ran, directly down, a narrow sinus, into which, a probe being passed, came against no dead bone. When the phalanx was pressed against the metacarpal bone, without either flexing or straightening the joint in the least, pus flowed pretty freely from the sinus. There was evidently an opening into the joint, which was filled with matter. A free incision was made, laying the sinus and the joint open; a splint was placed in the front of the finger. The man was ordered to carry the hand in a sling, supinated, that the pus might flow out: to put a poultice upon the wound, and to take the following draught three times a day : 25th.-There has been a free discharge; pain less; wound looks healthier. 29th.-Wound seems inclined to heal; no pus now escapes on pressing the joint surfaces together; the man is in no pain; the wound appears healing from the bottom, and soundly. 2nd July. The wound is skinned over with a blue cicatrix; I am not quite confident of the soundness of the healing, as there appears to be fluid beneath the blue skin. Ordered to continue the medicine; to use passive motion. 10th.-The cicatrix has got hard; the healing is quite sound, and the joint enjoys perfect freedom of motion, except that he cannot quite straighten the finger by the muscles of the part, although there is no obstruction when it is straightened by another hand. CASE XIII.-George Balster, ætat 23, tailor, came among my out-patients to the Charing-Cross Hospital, 22nd June, 1859. A companion had, in fun, stabbed at him with a needle in the knee, on the 20th. He thought nothing of it, but the part is now painful. The joint is slightly swelled, and he has a good deal of fever: he was recommended to come into the hospital, but would not; says he can be nursed at home, and will come in a cab: the little puncture may just be seen as a dark spot on the inside of the patella. Ordered 8 leeches; to be followed by hot poultice; splint: calomel and opium pills, 2 grains; and grain night and morning. 24th. Came back: the limb is not better, rather worse; has much pain, and it is more swollen, more hot, and the skin is red: tried in vain to persuade him to come in: to continue the pills. To take the following draught three times a day :— 29th. His wife came to ask me to see him, as he is very ill found him in great pain; the joint much more swollen, not merely from fluid in the cavity, but from œdema; the surface red and hot. It seems that on the 27th, about midnight, he had two or three shiverings, and could not be made to feel warm; he afterwards was restless and in great pain: last night wandered a good deal, and slept hardly at all. Tongue, brown; pulse, low and quick. Ordered the following draught three times a day :— A grain of opium, as a pill, at night; brandy, four ounces a day; the joint to be covered by a large poultice. 30th.-Worse; hardly knew what was said to him; or, at least, could hardly answer; delirious, and talked, not loudly, a good deal in the night; even now, wanders a little. Made a long incision, down to the joint, on each side, and in front of hamstring tendons; about three ounces of pus, altogether, came away, with flocculi in it. To go on in the same way. One vessel was tied: lost very little blood. 2nd July. He was a little better yesterday; the tongue was cleaner, and his manner less oppressed; he had a dose of castor oil: to-day he is evidently better; tongue cleaner; and he says he is easy: slept well last night without wandering. The wounds discharge freely. 5th. He may now be reckoned out of danger. 10th. Still goes on well; wounds granulating: substitute two pints of stout for brandy. The end of this case was tedious. It soon became evident that the best that could be hoped for was a partially anchylosed joint. The treatment, at last, became limited to passive motion, rubbing, &c.; and he recovered, ultimately, with some very fair power of moving the limb. ALTHOUGH acute rheumatism is a disease belonging to physicians I feel it necessary to enter somewhat minutely upon certain points connected with its pathology, because we shall then be able to trace therefrom the actions which take place in the chronic form of the disease, and because a very high authority has recorded his opinion that the local affection of the joints is not inflammatory. The order in which the symptoms of rheumatic fever occur is not always the same, but whatever it be they are generally preceded by a certain feeling of malaise and vague wandering pains in the limbs, such as are usual before the actual invasion of any febrile disease. After a certain period of this incubation there comes on a shivering fit, accompanied or followed by great heat of skin and perspirations, and by the whole train of symptoms which constitute the perfect disease, a great part of which is pain and swelling in one or more joints. The affected joints are very painful, enlarged, hot, and red, and when first swollen fluctuate; but the most remarkable part of their condition is, that a joint thus suffering and exquisitely painful shall in a few hours lose these signs of inflammation, which are transferred to another and distant articulation. A most important part also of the malady is the tendency exhibited by internal and vital organs to assume an inflammatory condition; thus, not only the peri- and endocardium, but the pleuræ, peritoneum, and the lungs themselves, become involved, moreover in the larger number of instances the inflammation proceeds rapidly to the deposition of lymph, producing thickening, adhesion, or consolidation, as the case may be. Now, the whole clinical history of this disease clearly demonstrates it to be a specific fever produced by some poison in the blood, like typhus fever or the exanthemata, and, like these, rheumatism, besides producing the general symptoms which constitute it by their very nature a fever, also sets up actions on particular parts or textures of the body. The poison producing typhus, or any one of the eruptive fevers, is more complicated than is probably that which produces rheumatism, it is not to be defined by any chemical language or test, and is introduced into the body from without. On the contrary, the rheumatic poison is in all probability lactic acid, and owes its presence in so great excess either to a check on its excretion, or to its superabundant formation in the body, or to both;* and it may well be that one cause shall give rise to, or rather a train of circumstances shall act as a cause determining, both this excessive production and diminished excretion of lactic acid. Although external circumstances may and do produce rheumatism, the poison itself of the disease is elaborated in, and not out of, the body. Dr. Todd observes that, "These causes must be admitted to be imperfect assimilation and vicissitudes of temperature, and hence the ill-clad and badly fed children of the poor are the most frequent victims of rheumatism. Hard work, exposure to cold and wet, bad food, are strongly contrasted with the ease, comfort, and excess, which give rise to the analogous one of gout. If, now, we remember, that the skin is the great emunctory of lactic acid, and that bad or too little food may give rise to its undue development as well as too much food, it is no wonder that as lactic acid is imperfectly excreted through its natural channel in consequence of the influence of cold in checking perspirations, and is too freely developed in the alimentary canal, it should accumulate in the blood. Moreover the long continuance of the causes which produce the defective cutaneous secretion and the deranged gastric one, will give rise to the undue development of the lactic acid in the secondary destructive assimilative processes, thus infecting the blood from every source, and tending to perpetuate the diathesis." When these processes take place quickly, the system becomes deluged with the acid, and rheumatic fever is the result, with its The experiments of Dr. Garrod, reported in the Med. Chir. Trans., vol. 36, 1854, are intended to prove that lithic acid is not the poison of rheu matism. + Todd, on Gout and Rheumatism, p. 143. London, 1843. F |