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and progress, the patient usually being able to go about.

In the tertiary stage the joint lesions are persistent and destructive, and result from the formation of gummata, either in the deeper layers of the synovial membrane or in the adjacent bone or periosteum.

Peri-synovial and peri-bursal gummata are met with in relation to the knee-joint of middle-aged adults, especially women. They are usually multiple, develop slowly, and are rarely sensitive or painful. One or more of the gummata may break down and give rise to tertiary ulcers. The co-existence of indolent swellings, ulcers, and depressed scars in the vicinity of the knee is characteristic of tertiary syphilis.

The disease spreads throughout the capsule and synovial membrane, which becomes diffusely thickened and infiltrated with granulation tissue which eats into and replaces the articular cartilage. Clinically, the condition resembles tuberculous disease of the synovial membrane, for which it is probably frequently mistaken, but in the syphilitic affection the swelling is nodular and uneven, and the subjective symptoms are slight, mobility is little impaired, and yet the deformity is considerable.

Syphilitic osteo-arthritis results from a gumma in the periosteum or marrow of one of the adjacent bones. There is gradual enlargement of one of the bones, the patient complains of pains, which are worst at night. The disease may extend to the synovial membrane and be attended with effusion into the joint, or it may erupt on the periosteal surface and invade the skin, forming one or more sinuses. The further progress is complicated by the occurrence of pyogenic infection leading to necrosis of bone, in the knee-joint, for example, the patella or one of the condyles of the femur or tibia, may furnish a sequestrum. In such cases, anti-syphilitic treatment must be supplemented by operation for the removal of the diseased tissues. In the knee, excision is rarely necessary; but in the elbow it may be called for to obtain a movable joint.

In inherited syphilis the earliest joint affections are those in which there is an effusion into the joint, especially the knee or elbow; and in exceptional cases pyogenic infection may be superadded, and pus form in the joint.

In older children, a gummatous synovitis is met with of which the most striking features are: its insidious development, its chronic course, symmetrical distribution, freedom from pain, the free mobility of the joint, its tendency to relapse, and its association with other syphilitic stigmata, especially in the eyes. The knees are the joints most frequently affected, and the condition usually yields readily to anti-syphilitic treatment without impairment of function.

Joint Diseases accompanying certain Constitutional Conditions

Gout.Arthritis Urica.—One of the manifestations of gout is that certain joints are liable to attacks of inflammation associated with the deposit of a chalk-like material composed of sodium biurate, chiefly in the matrix of the articular cartilage, it may be in streaks or patches towards the central area of the joint, or throughout the entire extent of the cartilage, which appears as if it had been painted over with plaster of Paris. As a result of this uratic infiltration, the cartilage loses its vitality and crumbles away, leading to the formation of what are known as gouty ulcers, and these may extend through the cartilage and invade the bone. The deposit of urates in the synovial membrane is attended with effusion into the joint and the formation of adhesions, while in the ligaments and peri-articular structures it leads to the formation of scar tissue. The metatarso-phalangeal joint of the great toe, on one or on both sides, is that most frequently affected. The disease is met with in men after middle life, and while common enough in England and Ireland, is almost unknown in hospital practice in Scotland.

The clinical features are characteristic. There is a sudden onset of excruciating pain, usually during the early hours of the morning, the joint becomes swollen, red, and glistening, with engorgement of the veins and some fever and disturbance of health and temper. In the course of a week or ten days there is a gradual return to the normal. Such attacks may recur only once a year or they may be more frequent; the successive attacks tend to become less acute but last longer, and the local phenomena persist, the joint remaining permanently swollen and stiff. Masses of chalk form in and around the joint, and those in the subcutaneous tissue may break through the skin, forming indolent ulcers with exposure of the chalky masses (tophi). The hands may become seriously crippled, especially when the tendon sheaths and bursæ also are affected; the crippling resembles that resulting from arthritis deformans but it differs in not being symmetrical.

The local treatment consists in employing soothing applications and a Bier's bandage for two or three hours twice daily while the symptoms are acute; later, hot-air baths, massage, and exercises are indicated. It is remarkable how completely even the most deformed joints may recover their function. Dietetic and medicinal treatment must also be employed.

Chronic Rheumatism.—This term is applied to a condition which sometimes follows upon acute articular rheumatism in persons presenting a family tendency to acute rheumatism or to inflammations of serous membranes, and manifesting other evidence of the rheumatic taint, such as chorea or rheumatic nodules.

The changes in the joints involve almost exclusively the synovial membrane and the ligaments; they consist in cellular infiltration and exudation, resulting in the formation of new connective tissue which encroaches on the cavity of the joint and gives rise to adhesions, and by contracting causes stiffness and deformity. The articular cartilages may subsequently be transformed into connective tissue, with consequent fibrous ankylosis and obliteration of the joint. The bones are affected only in so far as they undergo fatty atrophy from disuse of the limb, or alteration in their configuration as a result of partial dislocation. Osseous ankylosis may occur, especially in the small joints of the hand and foot.

The disease is generally poly-articular and may be met with in childhood and youth as well as in adult life. In some cases pain is so severe that the patient resists the least attempt at movement. In others, the joints, although stiff, can be moved but exhibit pronounced crackings. When there is much connective tissue formed in relation to the synovial membrane, the joint is swollen, and as the muscles waste above and below, the swelling is spindle-shaped. Subacute exacerbations occur from time to time, with fever and aggravation of the local symptoms and implication of other joints. After repeated recurrences, there is ankylosis with deformity, the patient becoming a helpless cripple. On account of the tendency to visceral complications, the tenure of life is uncertain.

From the nature of the disease, treatment is for the most part palliative. Salicylates are only of service during the exacerbations attended with pyrexia. The application of soda fomentations, turpentine cloths, or electric or hot-air baths may be useful. Improvement may result from the general and local therapeutics available at such places as Bath, Buxton, Harrogate, Strathpeffer, Wiesbaden, or Aix. In selected cases, a certain measure of success has followed operative interference, which consists in a modified excision. The deformities resulting from chronic rheumatism are but little amenable to surgical treatment, and forcible attempts to remedy stiffness or deformity are to be avoided.

Arthritis Deformans (Osteo-arthritis, Rheumatoid Arthritis, Rheumatic Gout, Malum Senile, Traumatic or Mechanical Arthritis).—Under the term arthritis deformans, which was first employed by Virchow, it is convenient to include a number of joint affections which have many anatomical and clinical features in common.

Fig. 157.—Arthritis Deformans of Elbow, showing destruction of articular surfaces and masses of new bone around the articular margins. (Anatomical Museum, University of Edinburgh.)

Fig. 157.—Arthritis Deformans of Elbow, showing destruction of articular surfaces and masses of new bone around the articular margins.

(Anatomical Museum, University of Edinburgh.)

The disease is widely distributed in the animal kingdom, both in domestic species and in wild animals in the natural state such as the larger carnivora and the gorilla; evidence of it has also been found in the bones of animals buried with prehistoric man.

The morbid changes in the joints present a remarkable combination of atrophy and degeneration on the one hand and overgrowth on the other, indicating a profound disturbance of nutrition in the joint structures. The nature of this disturbance and its etiology are imperfectly known. By many writers it is believed to depend upon some form of auto-intoxication, the toxins being absorbed from the gastro-intestinal tract, and those who suffer are supposed to possess what has been called an “arthritic diathesis.”

The localisation of the disease in a particular joint may be determined by several factors, of which trauma appears to be the most important. The condition is frequently observed to follow, either directly or after an interval, upon a lesion which involves gross injury of the joint or of one of the neighbouring bones. It occurs with greater frequency after repeated minor injuries affecting the joint and its vicinity, such as sprains and contusions, and particularly those sustained in laborious occupations. This connection between trauma and arthritis deformans led Arbuthnot Lane to apply to it the term traumatic or trade arthritis.

The traumatic or strain factor in the production of the disease may be manifested in a less obvious fashion. In the lower extremity, for example, any condition which disturbs the static equilibrium of the limb as a whole would appear to predispose to the disease in one or other of the joints. The static equilibrium may be disturbed by such deformities as flat-foot or knock-knee, and badly united fractures of the lower extremity. In hallux valgus, the metatarso-phalangeal joint of the great toe undergoes changes characteristic of arthritis deformans.

A number of cases have been recorded in which arthritis deformans has followed upon antecedent disease of the joint, such as pyogenic or gonorrhœal synovitis, upon repeated hæmorrhages into the knee-joint in bleeders, and in unreduced dislocations in which a new joint has been established.

Lastly, Poncet and other members of the Lyons school regard arthritis deformans as due to an attenuated form of tuberculous infection, and draw attention to the fact that a tuberculous family history is often met with in the subjects of the disease.

Fig. 158.—Arthritis Deformans of Knee, showing eburnation and grooving of articular surfaces. (Anatomical Museum, University of Edinburgh.)

Fig. 158.—Arthritis Deformans of Knee, showing eburnation and grooving of articular surfaces.

(Anatomical Museum, University of Edinburgh.)

Morbid Anatomy.—The commonest type is that in which the articular surfaces undergo degenerative changes. The primary change involves the articular cartilage, which becomes softened and fibrillated and is worn away until the subjacent bone is exposed. If the bone is rarefied, the enlarged cancellous spaces are opened into and an eroded and worm-eaten appearance is brought about; with further use of the joint, the bone is worn away, so that in a ball-and-socket joint like the hip, the head of the femur and the acetabulum are markedly altered in size and shape. More commonly, the bone exposed as a result of disappearance of the cartilage is denser than normal, and under the influence of the movements of the joint, becomes smooth and polished—a change described as eburnation of the articular surfaces (Fig. 158). In hinge-joints such as the knee and elbow, the influence of movement is shown by a series of parallel grooves corresponding to the lines of friction (Fig. 158).

Fig. 159.—Hypertrophied Fringes of Synovial Membrane in Arthritis Deformans of Knee. (Museum of Royal College of Surgeons, Edinburgh.)

Fig. 159.—Hypertrophied Fringes of Synovial Membrane in Arthritis Deformans of Knee.

(Museum of Royal College of Surgeons, Edinburgh.)

While these degenerative changes are gradually causing destruction of the articular surfaces, reparative and hypertrophic changes are taking place at the periphery. Along the line of the junction between the cartilage and synovial membrane, the proliferation of tissue leads to the formation of nodules or masses of cartilage—ecchondroses—which are

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