+DISEASES OF JOINTS—THE SEROUS AND SYNOVIAL MEMBRANES+
The moist glistening membrane lining the abdomen (_peritoneum_) and
that lining the chest (_pleura_) are similar to the synovial sac
between the bone ends at joints or the synovial sheaths of tendons.
+Bursae.+ A bursa, which is a sac lined with serous membrane, placed
over a joint or other prominent part for protection, is also quite
similar. All of these membranes are smooth and moist, giving
lubrication to movable parts, thus: the peritoneum covering the
intestines, permits of their easy worm-like action within the abdomen;
the pleura makes for the free rise and fall of the lungs; the
_synovial sacs_ of joints allow the bones to ride smoothly one upon
the other; the _synovial sheath_ of a tendon acts like a silken sleeve
in which the tendon slides up and down and, lastly, pressure over a
bony point causes the member to move aside because of the slipping of
the walls of the bursa, one upon the other, when compressed.
+INJURIES AND DISEASES OF BURSAE.+
_Synovial bursae_ exist normally in connection with tendons or with
certain joints, and may be developed by continued friction or pressure
at certain parts of the body. Deep bursae are sometimes connected with
the joints, or are in very close relation with them.
+Injuries of Bursae.+ Wounds of bursae may be either contused, incised,
lacerated, or punctured, and, if they become infected, may prove most
serious injuries. Wounds of bursae should be thoroughly disinfected
and drained; they usually heal with obliteration of the sac.
+Acute Bursitis.+ This affection usually results from an injury or from
continuous irritation of a bursa, and is characterized by tenderness,
pain, redness of the skin, and swelling or distension of the bursa. If
suppuration occurs, the inflammation is apt to extend to the
surrounding cellular tissue, or, if in close proximity to a joint, the
latter may be involved. Bursitis can usually be diagnosed from other
affections by the rapidity of development of the inflammatory
symptoms, the location of the swelling in relation to certain tendons
or joints, and its globular shape.
+Treatment.+ This consists in elevating the part and putting it at rest
on a splint, and in the application of cold or pressure. If, however,
the pain and swelling due to effusion continue, and there is evidence
of suppuration, the bursa should be freely opened and irrigated, and
subsequently packed with sterilized or iodoform gauze. Under this
treatment the cavity soon becomes obliterated as healing occurs. The
bursae most commonly involved are the _prepatellar_ and that over the
metatarsal joint of the great toe.
+Chronic Bursitis.+ This affection may result from acute bursitis which
does not terminate in suppuration, or may develop slowly from long
continued irritation or pressure, or from tubercular infection of the
bursae and is accompanied by little pain.
The most marked feature in chronic bursitis is the distension of the
sac with fluid, and in some cases the walls of the sac become so
thickened that the bursa is converted into a solid tumor. Chronic
bursitis of the prepatellar bursae is not infrequent, and is commonly
known us _Housemaid’s knee_, resulting from long continued pressure
upon the knee occurring in those whose occupation causes them to
constantly bear pressure upon this part.
Gumma of the prepatellar bursa is very common, and should be suspected
in every case of suppuration of this bursa without assignable cause.
It often results in extensive sloughing.
Hernial protrusion of a portion of a bursa is sometimes seen after
injuries of bursae.
+Treatment.+ The treatment of chronic bursitis, if the sac is distended
with fluid, consists in removal of the fluid by aspiration, or by
making an incision and introducing a drain. The greatest care should
be observed to keep the wound aseptic. The bursae may be removed by
dissection. This is the only treatment which is likely to be of use in
cases where the bursa is very thick or is converted into a solid
tumor. In removing these growths by dissection, great care should be
exercised to avoid opening the neighboring joints.
+Bunion.+ This is a bursal enlargement over the metatarsophalangeal
articulation of the great toe, which is very frequently observed with
hallux valgus, this being the most universal cause. The part is
swollen and tender upon pressure, and if suppuration occurs the pain
is severe, and cellulitis is apt to develop, involving the surrounding
parts, or the joint may be involved, caries of the bones of the
articulation resulting.
+Treatment.+ If suppuration has not occurred, the part should be
protected from pressure by a circular shield of felt or plaster; if
suppuration has taken place, the part should be incised and drained,
and if the joint is found diseased it should be curreted and dressed
with an antiseptic dressing; if malposition of the toe exists, its
position should be corrected by amputation of the head of the
metatarsal.
+Inflammation of Synovial and Serous Membranes.+ When the serous and
synovial membranes are attacked by inflammation, the stage of
congestion is accompanied by exudation of serum and fibrin from the
surface, and the endothelial cells become swollen and detached in
large numbers. The serous exudation may be sufficient to fill the
entire cavity involved. There is a form of dry or fibrinous
inflammation, without fluid exudate, in which the surface of the
membrane loses its polish, becoming dry and red, and adhesions readily
form wherever the surfaces are in contact.
In suppurative inflammation, pus is produced by emigration, and also
by the detached endothelial cells. If fibrin is present, false
membranes form on the surface and the membrane itself appears to be
greatly thickened. At a later stage the proliferating cells invade
these layers of fibrin and they become organized into connective
tissue, and new vessels develop on them. Their tendency, however, is
to disappear after a time, and the membrane returns to its original
condition, unless the inflammation has been very intense, in which
case the new connective tissue becomes permanent. Chronic inflammation
of these membranes is marked by general thickening of all the layers,
the formation of dense connective tissue in the fibrinous membranes,
strong adhesions, and sometimes complete obliteration of the cavities,
their endothelial lining disappearing entirely.
+SYNOVITIS+
Like other structures of the body the joints are subject to injury and
disease and because of the nature and course of pathologic processes
in them, one should bear in mind their anatomic construction.
The expanded ends of the bones in the joints are covered with a thin
layer of cartilage and are bound to each other by a dense capsule
which is firmly attached to the bones at their necks, where it is
closely connected with the periosteum. The joint cavity is lined
(excepting where additional fibrocartilages are present) with a
synovial sac which sometimes communicates with a bursa.
Inflammations of varying intensity are of frequent occurrence; they
maybe due to rheumatism or gout, to traumatism, to the action of
microorganisms, or, to disturbances of innervation. They may be slight
or severe, acute or chronic. They may terminate in resolution, in
permanent new formations, more or less deforming and disabling, or in
the destruction of the articulation.
Inflammations may arise in the joint structures proper or may extend
to it from contiguous structures, such as the cancellous bone ends,
the overlying tendons or the periarticular connective tissue. They may
be largely confined to a single structure, the synovial membrane being
ordinarily affected, or they may involve the whole joint.
+Acute synovitis.+ Synovitis may occur as a result of a simple injury,
such as a subcutaneous wound, a contusion, or a sprain. Exposure to
cold and the presence of a movable cartilage are also common causes.
Aseptic conditions in the synovial membrane seldom extend to the other
joint structures (see “Arthritis”) and heal with or without impairment
of the joint, depending on the degree of inflammation.
+Symptoms.+ The joint is painful, especially upon motion, and
particularly so at night. It is swollen and tense and may be
fluctuating. At the knee, the patella is floated up from the condyles
and can be depressed upon slight pressure. The joint is held in a
position of partial flexion which permits of the greatest ease,
because of the diminished tension in this position.
Local heat and tenderness are not necessarily great, and
constitutional symptoms, if present, are moderate in degree.
In the suppurative affections of joints, all of the above symptoms are
intense and there is a general arthritis.
After a few hours or days the intensity of the symptoms subsides, the
pain lessens, the swelling diminishes, as the effusion and
extravasated blood are absorbed, the limb takes its natural position,
and recovery promptly takes place. If there has been much hemorrhage
into the joint, adhesions due to the organization of the clot may
cause some restriction of motion.
+Treatment.+ The joint must be placed at rest and an ice bag kept in
constant contact. Even pressure with cotton and broad bandages often
hastens absorption, but cannot at first be borne with comfort.
In rare instances aspiration of the effusion must be resorted to, but
the certainty should exist that absorption is impossible, before a
joint is punctured. The greatest care must be exercised in introducing
a needle into a joint to avoid infection.
+Chronic Synovitis.+ While it is true that an inflammation of a synovial
membrane cannot long remain without extending to the other joint
structures, the fact remains that symptoms peculiar to synovitis often
persist for months. These are properly viewed as constituting a
condition of chronicity. The active swelling and abundant effusion,
belonging to the acute stage, subside, but an undue amount of fluid
remains, with some pain and weakness.
If, with proper treatment and rest, these symptoms persist, there is
an extension of the process to the bone ends and an exacerbation of
symptoms.
The subsidence of a chronic synovitis generally leaves a weak and
impaired joint, though pain may be absent. Movements, especially in
extension, are restricted, and grating or cracking remain as evidences
of the roughened membrane.
+Treatment.+ The mere presence of a superabundance of fluid in a joint
does not in itself constitute a diseased state, but may be the
evidence of impaired circulation of the part. Absorption may occur
with rest and tight bandaging, or with massage, friction, and baking,
results may often be obtained. Certain cases resisting such procedures
are best treated with a plaster of Paris cast to immobilize the part
for several months. When the affection is of long standing and the
joint is much distended it may be termed _hydrops articuli_ or
_hydrarthrosis_.
When, in spite of all the methods of treatment here described, the
condition does not yield, very good results may be obtained by the
aspiration of the fluid, and the injection of a few drams of a three
per cent. or five per cent. solution of carbolic acid. This operation,
though simple, requires every aseptic precaution, and should never be
performed in the presence of any acute symptoms.
For other phases of Synovitis see Arthritis.
+ARTHRITIS+
The structures of a joint are: bone, cartilage, ligaments, synovial
membrane and, in some cases, fibrocartilage. Hence, a joint
inflammation is an inflammation of all of these structures, and is
designated, _arthritis_.
The inflammation may begin in any one of these structures, but sooner
or later, all are involved. The synovial membrane, however, when
inflamed, seems to prove an exception to the rule in that inflammation
may or may not extend from it to the rest of the joint. If such an
extension does take place we have an arthritis.
We may therefore have two distinct classes of joint inflammation: (1)
the varieties of synovitis, and (2) the varieties of arthritis. These
inflammations may be acute or chronic.
In synovitis there is only the inflammation of the synovial membrane,
while in arthritis there is inflammation of the synovial membrane plus
inflammation of the bone covering (_periostitis_); of the bone
(_osteitis_); of cartilage (_chondritis_); of bone marrow
(_osteomyelitis_); and also a cellulitis of the ligaments attached to
the joint involved.
+Symptoms.+ The symptoms of arthritis are obviously more severe than
those of a simple articular synovitis and are both local and general.
The general symptoms arise from the absorption into the circulation of
either bacteria or their toxins, and vary greatly in severity. There
is either a toxemia or a septicemia, with the usual symptoms of a
general sepsis.
The local symptoms are those common to synovitis and arthritis: pain,
tenderness, swelling, heat, redness and loss of function. From these
alone a differential diagnosis between synovitis and arthritis cannot
be made. If, however, there is a sensation of crepitus conveyed to the
examiner’s hand upon passive motion, there is an arthritis present
beyond doubt. This symptom is due to the destruction of the synovial
covering of the bone ends involved, permitting contact of bone with
bone. It is more common to chronic joint disease, but may also
accompany acute conditions, especially if they are severe.
Symptoms peculiar to the variety of infection and the history as to
duration, causation, course and number of joints involved, must be
considered in making a diagnosis or prognosis.
+Varieties.+ Besides simple traumatic arthritis, there are many
constitutional disorders which affect the joints conspicuously; these
are: tuberculosis, syphilis, gonorrhea, gout and rheumatism.
A prominent cause of many instances of arthritis heretofore regarded
as rheumatic in origin, is now known to exist in any area of
infection. Such “foci of infection” discharge a certain amount of
infective material into the circulation, which may find lodgment in a
joint and set up an acute process.
It has been proven in numerous cases that a so-called rheumatism will
yield promptly to drainage of a chronic abscess, no matter how remote
the location. Oral conditions especially have been found responsible
for this form of arthritis. Abscesses at the apexes of teeth and
pyorrhœa alveolaris, when properly operated, yield nothing short of
miracles, in the way of relieved symptoms.
In addition to the varieties of arthritis already mentioned, those due
to certain infectious diseases, such as measles, scarlet fever,
typhoid fever, smallpox or erysipelas, should be included, as well as
cases of neuropathic origin.
+TRAUMATIC ARTHRITIS+
+Nonpenetrating and Penetrating+
+Nonpenetrating.+ Ordinary contusions or twisting at a joint, may result
in the establishment of an inflammatory process within the joint,
evidenced by much swelling and giving the sensation of fluctuation to
the examining hands, indicating the presence of fluid within the
synovial membrane. This occurs also when there is a detached
fibrocartilage in the joint. The synovial membrane is thickened and
there is an exudation of serum.
Sprains belong in this classification. These are simple, clean,
inflammatory conditions.
+Symptoms.+ These are generally limited to those enumerated as belonging
to synovitis, except that the disability is more pronounced.
+Treatment.+ Rest and wet dressings generally suffice to effect
restitution in a few weeks.
+Penetrating.+ Should the joint be injured by violence so that there is
a loss of continuity of the tissues leading into the joint proper,
there is every probability of infective material gaining entrance.
These are serious accidents, though restoration of an efficient joint
is possible, but when improperly treated or neglected, local
destruction, or even loss of life may occur.
Penetrating wounds of joints usually occur in consequence of accidents
with firearms, sharp tools, or falling upon sharp objects. Frequently,
penetration of a joint follows suppuration in the immediate
neighborhood.
+Symptoms.+ The extent of the injury, the particular joint involved, and
the nature of the vulnerating body will affect the train of symptoms.
An escape of synovial fluid, pain and some swelling will occur even
with a very small penetration. Should the joint escape infection, the
synovitis quickly subsides and recovery takes place with little or no
impairment of the functional value of the part. The opening in the
capsule closes, the extravasated blood is absorbed and the synovial
surface is again smooth. If, however, the wound has been inflicted
with an unclean instrument, or if at any time before healing it
becomes septic, a very different and graver condition obtains.
+Septic Arthritis.+ Infection with bacteria of suppuration, chiefly the
staphylococcus albus or the streptococcus pyogenes, produces an acute
arthritis which frequently, despite the most careful treatment, will
result in the destruction of the joint, and not seldom in the loss of
life.
The infection may occur in one of several ways: (1) directly through a
dirty instrument, or the lodgment of infective material in the tract
leading to the joint cavity; (2) by the extension of a suppurative
process, either of the bones or soft tissue adjacent; or, by (3) the
deposition into the joint of infective organisms circulating in the
blood stream.
+Symptoms.+ However produced, large numbers of organisms are present and
a high grade of inflammation ensues. An abundant amount of pus is soon
formed; the synovial membrane, the bone ends and the joint capsule are
actively inflamed, and soon become disorganized. Perforation of the
capsule is followed by infection and suppuration of the tendons and
other structures about the joint, which soon affects the superficial
structures and forms an opening through the skin. The pain is intense,
generally worse at night; the swelling is great and fluctuation is
distinct; the skin is red and hot, and the parts above and below are
edematous. Any attempt at motion increases the suffering.
With these local symptoms there is an accompanying train of
constitutional symptoms which may eventuate fatally. At first there is
a chill, or a sensation of chilliness after which the temperature
quickly runs up several degrees, and either remains so, or goes down
and up several times in twenty-four hours, as in other septic
conditions. The pulse may be strong and full at first, but soon
becomes rapid and weak. In very acute cases, death from septicemia may
occur in a few days.
In ordinary cases, drainage of the pus, either naturally or
artificially, will result in a remission of the symptoms both locally
and generally.
+Treatment.+ In this, as in other suppurative processes, safety lies in
the prompt opening of the abscesses and the evacuation of the pus,
thus accomplishing free drainage, with subsequent disinfection by
means of applications or irrigations. Immobilization of the parts and
rigid antisepsis will generally yield good results as to life, though
recovery with ankylosis is the rule. In the most severe cases,
constitutional symptoms are so grave as to warrant immediate
amputation above the infected joint.
+Tubercular Arthritis.+ The great majority of chronic joint diseases are
tubercular in origin, the tubercle bacilli being deposited in any of
the joint structures, or in structures contiguous to a joint; with
children, very frequently in the bone substance.
Whether the tubercular process originates in the joint cavity itself
or outside of it in the surrounding tissues, destruction of the
articular ends of the bones is usual.
The parts become thickened and edematous; there is a gelatinous or
cheesy appearance, in which the membrane, cartilaginous bone ends,
capsule, and ligamentous structures all share. Frequently the synovial
membrane is studded with miliary tubercles and its cavity is filled
with an abundant serous secretion. The contour of the joint becomes
globular or spindle shaped, because of the atrophy of the parts above
and below it and the swelling of the periarticular structures. The
skin becomes white and thick because of the obliteration of the
superficial vessels and because of its edematous infiltration.
+Symptoms.+ Pain is, as a rule, but slight in the strictly synovial
stage of tubercular arthritis, but when the bones are involved, it is
severe, though acute symptoms, such as heat and redness, are lacking.
Deformity is a constant accompaniment of the disease; its degree is
greater or less according to the joint affected, the extent of the
disease, and the treatment pursued. It is due to the natural tendency
to assume the position of greatest ease; to the softening and
destruction of the ligaments, and to the effort on the part of nature
to immobilize an injured member by means of tonic contraction of the
muscles. These causes often result in the creation and persistence of
a malformation and malposition of the part.
Cheesy degeneration and liquefaction take place in more or less
degree, and though their occurrence is often not evidenced by any
aggravation of the symptoms, sinus formation with persisting discharge
occurs.
When these sinuses occur, they generally become infected with other
pus producing organisms, and aggravate the condition considerably. In
the course of months or years, many such openings may occur through
which masses of soft tissue or bone, either carious or necrosed
(_sequestra_), may be discharged.
+Diagnosis.+ This may be easy, difficult, or impossible, depending on
the duration, the joint involved, and the character of the disease in
any individual case.
At times it is impossible to differentiate from syphilis, which,
however, is quite uncommon, but with which tuberculosis has many
symptoms in common. The history of the individual, and a blood
examination will generally suffice. If the disease is advanced to the
stage of abscess and sinus formation, there can be no doubt as the
nature of the trouble.
Very often the disease in the articular ends of the bones advances
slowly, giving very little pain and no appreciable swelling or
atrophy. There may be only an unwillingness to use the part very much,
and the disease may very well be overlooked. In such insidious cases a
diagnosis can be reached by aspiration and subsequent examination of
the serous fluid for tubercle bacilli. An X-ray will show the
rarifaction of the bony structures and the thickened periosteum.
The course of tubercular joint disease is entirely dependent upon its
extent at the time it is recognized, and the treatment pursued. It is
of paramount importance that attention be given any persisting pain or
discomfort in or near a joint, and that rest and every diagnostic aid
be employed before pronouncing a case hysteria, neuralgia or “growing
pains.” In a few cases the process can be arrested and little or no
diminution of function remains. This, however, is the exception; there
is usually destruction of the intra-articular cartilages, and of the
synovial membrane, and the formation of bands of great density, which
impair the motion of the part even to rigidity (_fibrous ankylosis_).
The restriction of motion may be absolute if ossification of the
granulation tissue lying between the epiphyses unites their eroded
ends (_bony ankylosis_).
At times, though recovery seems to have been secured, a sinus may
persist because of some slight area of remaining caries, or because
the tract itself is tubercular. In other instances a recurrence may
follow after months or years of quiescence. This may be due to the
setting free of encapsulated organisms, or because of a new infection
at a point of least resistance.
+Treatment+ is that of tubercular disease in general. The most essential
features in the conduct of these cases are rest and the establishment
of ideal hygienic conditions. Forced feeding, sunlight and air, play
as important a part here as in pulmonary tuberculosis. Absolute rest
of the part can be secured only with the aid of plaster of Paris
braces, or splints of other materials. Such immobilization should
include the joints immediately above and below the one affected.
Hyperemia, by the use of a rubber bandage above the joint, or by
baking of the joint, is of great value.
In the majority of instances these methods will yield good results in
from six months to a year. Operative interference will be necessary in
addition to the above, where caseation and secondary infection have
occurred. Thorough drainage of the infected joint, either by widening
already existing sinuses, or by free incision followed by irrigation,
will frequently be necessary.
+Joints Generally Involved+ are the larger ones of the extremities, but
this does not preclude the possibility of any joint being the seat of
a tubercular inflammation. The vertebral articulations and the digital
articulations of the feet and hands are commonly affected. In
children, the hip joint is the one most attacked; frequently the knee,
ankle and elbow are affected in the order given.
In nearly all cases of arthritis of tubercular origin the original
focus of infection is located in the bone, though the synovial
membrane, or an adjacent osteomyelitis, may be the first point
attacked.
+Syphilitic Arthritis.+ This is rather a rare condition, but must be
differentiated from tuberculosis, because of its slow onset and
progress, and because of the mildness of the symptoms and the
spindlelike shape of the joint. There is usually but one joint
involved and eventually a dark fluid will escape should sinus
formation occur.
+Diagnosis+ will generally be known in advance from the history, through
a Wassermann test of the blood, or an X-ray picture will often be of
value.
In syphilis, the original focus of infection in a joint will be found
in the soft tissues, while in tuberculosis, the articular ends of the
bone are first involved. An examination of the discharged fragments of
tissue in syphilis will show a round cell infiltration; in
tuberculosis, possibly typical tubercle tissue.
+Treatment+ by anti-syphilitic remedies, if successful, will also
indicate the nature of an obscure case, a pronounced response to such
treatment being a positive diagnostic aid.
+Gonorrhoeal Arthritis.+ This affection is nearly always very acute,
beginning as an acute synovitis and extending to the articular
fibrocartilages at an early date.
Constitutional symptoms nearly always accompany this variety of
arthritis, a chill and high temperature being the rule.
This condition is often called gonorrhoeal rheumatism. It is due to
the lodgment of the gonococcus of Neisser in the joint, from the blood
stream.
Gonorrhoeal arthritis is a form of septic arthritis, its pathology and
symptomatology being in many respects the same. It may, in favorable
cases, limit itself to the synovial membrane, in which event the
symptoms will yield more readily to treatment, though the affection in
any event is an acute one, and a diagnosis as to extent is difficult
to make owing to the extreme pain of even slight motion.
+Symptoms.+ These are similar to those of septic arthritis, except that
usually only one joint is affected and the existence of a gonorrhoeal
infection can always be determined. Both knees, or both ankles, but
more commonly, only one joint, are affected, accompanied by severe
constitutional symptoms. There rarely occurs any indication of sinus
formation or of spontaneous drainage in this variety of arthritis, and
it is held by many, that in cases where this tendency exists, there is
a mixed infection, other pus producing organisms being present.
+Treatment.+ The original infection of the urologic tract must receive
the utmost care, in order to eradicate the supply of germs to the
circulation. The injection of anti-gonococcic sera or vaccines finds
its best application in these cases. The local treatment consists of
rest and immobilization of the extremity affected.
The application of either extreme heat or cold to the joint is
agreeable and efficacious.
There are many reasons in justification of either of these treatments
over the other, but in general it may be said that, in the acute
stage, cold is better, while in the latter stages, heat will
accomplish more to establish easy motion of the part and to lessen the
danger of ankylosis.
Active or arterial hyperemia by baking, is especially valuable in the
subacute stage.
+Prognosis.+ In those cases in which the pain and swelling is severe and
the constitutional symptoms alarming, we may always expect a true
arthritis to exist. In these cases much exudate is formed in the
joint, which upon organization, leads to fibrous bands and limitation
of the joint function (_fibrous ankylosis_).
In the milder cases, ankylosis is the exception, if proper remedial
measures are carried out.
+Rheumatic Arthritis.+ Rheumatic articular affections are common, and
are both acute or chronic. In the light of recent investigations it is
believed that many of these cases are due to foci of infection in
various parts of the body which pollute the blood stream with
organisms which subsequently find lodgment in either the organs or
joints. Infections existing in the tonsils and teeth roots have been
shown to act in this way. There may, however, be cases directly
attributable to rheumatism, though these are not so well understood.
+Acute Rheumatism.+ One or several joints may be attacked
simultaneously. Subsidence of the inflammation may occur, while others
are becoming inflamed.
+Symptoms+ are those of acute synovitis; suppuration never occurs unless
there has been a mixed infection, and limitation of motion is a rare
sequela. The pain, swelling and tenderness is extreme, and the
constitutional symptoms, while being severe are not usually grave. In
the _chronic variety_, on the other hand, there may be limitation of
motion due to the formation of bands and adhesions after months or
years of inflammation. This variety may start as such or may begin as
an acute condition.
+Treatment.+ The treatment, besides local rest and heat, consists of the
administration of antirheumatic remedies and hygienic precautions.
+Diagnosis+ will rest largely on the blood examination for circulating
organisms, the general examination for foci of infection, and the
family history.
+Gouty Arthritis.+ Whatever may be the essential nature of gout, its
manifestations are common in the smaller joints, such as the fingers
and the metatarsophalanges of the great toe. Deposits of urates,
chiefly sodium urate, take place in the connective tissue of the joint
and also in the cartilage. Consequent upon the irritation of these
salts, there is an increase in the connective tissue followed by
contraction, impairment of motion, and alteration in the shape of the
joint. Repeated attacks of acute inflammation occur, of greater or
lesser intensity, and the uratic deposits attain a considerable size,
occasionally forming abscesses or ulcerations in the overlying skin.
Like rheumatism, gout is a manifestation of a constitutional state,
and requires medical care.
+Infective Arthritis.+ These are the arthritic manifestations of
diseases as smallpox, scarlet fever, typhoid fever, measles and
erysipelas. They are due to infective material deposited from the
circulation, and are in every way similar to septic arthritis, which
see. There are always suppurative synovitis and osteomyelitis, with a
consequent ankylosis of bony structure. The constitutional symptoms
are very intense, and free incision and drainage is indicated.
+Neuropathic Arthritis.+ (_Charcot’s Disease_). This is a peculiar
osteoarthritis observed in patients with locomotor ataxia. The disease
is an acute one, so far as objective conditions are concerned, there
being no pain or constitutional derangements of consequence. Without
any injury having been received, the joint, particularly the knee,
suddenly swells, the intra-articular effusion becoming abundant. This
may soon be absorbed and with it the articular ends of the bones wear
away and break down into small fragments. The limb becomes atrophied
and shrunken, and the joint itself becomes weak, often flail.
This disease seems to be due to nutritive changes in consequence of
changes in the spinal cord nerve centres. There is no satisfactory
treatment and the patients must be kept in bed.