Chapter 22

DISEASES OF JOINTS

Definition of terms--Ankylosis. DISEASES: Errors of development--Bacterial diseases: _Pyogenic_; _Gonorrhœal_; _Tuberculous_; _Syphilitic_; _Acute rheumatism_--Diseases associated with certain constitutional conditions: _Gout_; _Chronic articular rheumatism_; _Arthritis deformans_; _Hæmophilia_--Diseases associated with affections of the nervous system: _Neuro-arthropathies_; _Charcot's disease_--Hysterical or mimetic affections of joints--Tumours and cysts--Loose bodies.

#Definition of Terms.#--The term _synovitis_ is applied to any reaction which affects the synovial membrane of a joint. It is usually associated with effusion of fluid, and this may be serous, sero-fibrinous, or purulent. As the term synovitis merely refers to the tissue involved, it should always be used with an adjective--such as gouty, gonorrhœal, or tuberculous--which indicates its pathological nature.

The terms _hydrops_, _hydrarthrosis_, and _chronic serous synovitis_ are synonymous, and are employed when a serous effusion into the joint is the prominent clinical feature. Hydrops may occur apart from disease--for example, in the knee-joint from repeated sprains, or when there is a loose body in the joint--but is met with chiefly in the chronic forms of synovitis which result from gonorrhœa, tuberculosis, syphilis, arthritis deformans, or arthropathies of nerve origin.

_Arthritis_ is the term applied when not only the synovial membrane but the articular surfaces, and it may be also the ends of the bones, are involved, and it is necessary to prefix a qualifying adjective which indicates its nature. When effusion is present, it may be serous, as in arthritis deformans, or sero-fibrinous or purulent, as in certain forms of pyogenic and tuberculous arthritis. Wasting of the muscles, especially the extensors, in the vicinity of the joint is a constant accompaniment of arthritis. On account of the involvement of the articular surfaces, arthritis is apt to be followed by ankylosis.

The term _empyema_ is sometimes employed to indicate that the cavity of the joint contains pus. This is observed chiefly in chronic disease of pyogenic or tuberculous origin, and is usually attended with the formation of abscesses outside the joint.

_Ulceration of cartilage_ and _caries of the articular surfaces_ are common accompaniments of the more serious and progressive forms of joint disease, especially those of bacterial origin. The destruction of cartilage may be secondary to disease of the synovial membrane or of the subjacent bone. When the disease begins as a synovitis, the synovial membrane spreads over the articular surface, fuses with the cartilage and eats into it, causing defects or holes which are spoken of as ulcers. When the disease begins in the bone, the marrow is converted into granulation tissue, which eats into the cartilage and separates it from the bone. Following on the destruction of the cartilage, the articular surface of the bone undergoes disintegration, a condition spoken of as _caries of the articular surface_. The occurrence of ulceration of cartilage and of articular caries is attended with the clinical signs of fixation of the joint from involuntary muscular contraction, wasting of muscles, and starting pains. These _starting pains_ are the result of sudden involuntary movements of the joint. They occur most frequently as the patient is dropping off to sleep; the muscles becoming relaxed, the sensitive ulcerated surfaces jar on one another, which causes sudden reflex contraction of the muscles, and the resulting movement being attended with severe pain, wakens the patient with a start. Advanced articular caries is usually associated with some abnormal attitude and with shortening of the limb. It may be possible to feel the bony surfaces grate upon one another. When all its constituent elements are damaged or destroyed, a joint is said to be _disorganised_. Should recovery take place, repair is usually attended with union of the opposing articular surfaces either by fibrous tissue or by bone.

#Conditions of Impaired Mobility of Joints.#--There are four conditions of impaired mobility in joints: rigidity, contracture, ankylosis, and locking. _Rigidity_ is the fixation of a joint by involuntary contraction of muscles, and is of value as a sign of disease in deep-seated joints, such as the hip. It disappears under anæsthesia.

_Contracture_ is the term applied when the fixation is due to permanent shortening of the soft parts around a joint--muscles, tendons, ligaments, fasciæ, or skin. As the structures on the flexor aspect are more liable to undergo such shortening, contracture is nearly always associated with flexion. Contracture may result from disease of the joint, or from conditions outside it--for example, disease in one of the adjacent bones, or lesions of the nerves.

_Ankylosis_ is the term applied when impaired mobility results from changes involving the articular surfaces. It is frequently combined with contracture. Three anatomical varieties of ankylosis are recognised--(a) The _fibrous_, in which there are adhesions between the opposing surfaces, which may be in the form of loose isolated bands of fibrous tissue, or may bind the bones so closely together as to obliterate the cavity of the joint. The resulting stiffness, therefore, varies from a mere restriction of the normal range of movement, up to a close union of the bones which prevents movement. Fibrous ankylosis may follow upon injury, especially dislocation or fracture implicating a joint, or it may result from any form of arthritis. (b) _Cartilaginous ankylosis_ implies the fusion of two apposed cartilaginous surfaces. It is often found between the patella and the trochlear surface of the femur in tuberculous disease of the knee. The fusion of the cartilaginous surfaces is preceded by the spreading of a vascular connective tissue, derived from the synovial membrane, over the articular cartilage. Clinically, it is associated with absolute immobility, (c) _Bony ankylosis_ or _synostosis_ is an osseous union between articulating surfaces (Figs. 154 and 155). It may follow upon fibrous or cartilaginous ankylosis, or may result from the fusion of two articular surfaces which have lost their cartilage and become covered with granulations. In the majority of cases it is to be regarded as a reparative process, presenting analogies with the union of fracture.

The term _arthritis ossificans_ has been applied by Joseph Griffiths to a condition in which the articular surfaces become fused without evident cause.

The occurrence of ankylosis in a joint before the skeleton has attained maturity does not appear to impair the growth in length of the bones affected; ankylosis of the temporo-maxillary joints, however, greatly impairs the growth of the mandible. When there is arrest of growth accompanying ankylosis, it usually depends on changes in the ossifying junctions caused by the original disease.

To differentiate by manipulation between muscular fixation and ankylosis, it may be necessary to anæsthetise the patient. The nature and extent of ankylosis may be learned by skiagraphy; in osseous ankylosis the shadow of the two bones is a continuous one. In fibrous as contrasted with osseous ankylosis mobility may be elicited, although only to a limited extent; while in osseous ankylosis the joint is rigidly fixed, and attempts to move it are painless.

The _treatment_ is influenced by the nature of the original lesion, the variety of the ankylosis, and the attitude of the joint. When there is restriction of movement due to fibrous adhesions, these may be elongated or ruptured. Elongation of the adhesions may be effected by manipulations, exercises, and the use of special forms of apparatus--such as the application of weights to the limb. It may be necessary to administer an anæsthetic before rupturing strong fibrous adhesions, and this procedure must be carried out with caution, in view of such risks as fracture of the bone--which is often rarefied--or separation of an epiphysis. There is also the risk of fat embolism, and of re-starting the original disease. The giving way of adhesions may be attended with an audible crack; and the procedure is often followed by considerable pain and effusion into the joint, which necessitate rest for some days before exercises and manipulations can be resumed.

_Operative treatment_ may be called for in cases in which the bones are closely bound to one another by fibrous or by osseous tissue.

_Arthrolysis_, which consists in opening the joint and dividing the fibrous adhesions, is almost inevitably followed by their reunion.

_Arthroplasty._--Murphy of Chicago devised this operation for restoring movement to an ankylosed joint. It consists in transplanting between the bones a flap of fat-bearing tissue, from which a bursal cavity lined with endothelium and containing a fluid rich in mucin is ultimately formed.

Arthroplasty is most successful in ankylosis following upon injury; when the ankylosis results from some infective condition such as tuberculosis or gonorrhœa, it is liable to result in failure either because of a fresh outbreak of the infection or because the ankylosis recurs.

When arthroplasty is impracticable, and a movable joint is desired--for example at the elbow--a considerable amount of bone, and it may be also of periosteum and capsular ligament, is resected to allow of the formation of a false joint.

When bony ankylosis has occurred with the joint in an undesirable attitude--for example flexion at the hip or knee--it can sometimes be remedied by osteotomy or by a wedge-shaped resection of the bone, with or without such additional division of the contracted soft parts as will permit of the limb being placed in the attitude desired.

Bony ankylosis of the joints of a finger, whether the result of injury or disease, is difficult to remedy by any operative procedure, for while it is possible to restore mobility, the new joint is apt to be flail-like.

_Locking._--A joint is said to lock when its movements are abruptly arrested by the coming together of bony outgrowths around the joint. It is best illustrated in arthritis deformans of the hip in which new bone formed round the rim of the acetabulum mechanically arrests the excursions of the head of the femur. The new bone, which limits the movements, is readily demonstrated in skiagrams; it may be removed by operative means. Locking of joints is more often met with as a result of injuries, especially in fractures occurring in the region of the elbow. In certain injuries of the semilunar menisci of the knee, also, the joint is liable to a variety of locking, which differs, however, in many respects from that described above.

#Errors of Development.#--These include congenital dislocations and other deformities of intra-uterine origin, such as abnormal laxity of joints, absence, displacement, or defective growth of one or other of the essential constituents of a joint. The more important of these are described along with the surgery of the Extremities.

DISEASES OF JOINTS

#Bacterial Diseases.#--In most bacterial diseases the organisms are carried to the joint in the blood-stream, and they lodge either in the synovial membrane or in one of the bones, whence the disease subsequently spreads to the other structures of the joint. Organisms may also be introduced through accidental wounds. It has been shown experimentally that joints are among the most susceptible parts of the body to infection, and this would appear to be due to the viscid character of the synovial fluid, which protects organisms from bactericidal agents in the tissues and fluids.

PYOGENIC DISEASES

The commoner pyogenic diseases are the result of infection of one or other of the joint structures with _staphylococci_ or _streptococci_, which may be demonstrated in the exudate in the joint and in the substance of the synovial membrane. The mode of infection is the same as in the pyogenic diseases of bone, the metastasis occurring most frequently from the mucous membrane of the pharynx (J. B. Murphy). The localisation of the infection in a particular joint is determined by injury, exposure to cold, antecedent disease of the joint, or other factors, the nature of which is not always apparent.

The effects on the joint vary in severity. In the milder forms, there is engorgement and infiltration of the synovial membrane, and an effusion into the cavity of the joint of serous fluid mixed with flakes of fibrin--_serous synovitis_. In more severe infections the exudate consists of pus mixed with fibrin, and, it may be, red blood corpuscles--_purulent_ or _suppurative synovitis_; the synovial membrane and the ligaments are softened, and the surface of the membrane presents granulations resembling those on an ulcer; foci of suppuration may develop in the peri-articular cellular tissue and result in abscesses. In _acute arthritis_, all the structures of the joint are involved; the articular cartilage is invaded by granulation tissue derived from the synovial membrane, and from the marrow of the subjacent bone; it presents a worm-eaten or ulcerated appearance, or it may undergo necrosis and separate, exposing the subjacent bone and leading to disintegration of the osseous trabeculæ--_caries_. With the destruction of the ligaments, the stability of the joint is lost, and it becomes disorganised.

The _clinical features_ vary with the extent of the infection. When this is confined to the synovial and peri-synovial tissues--_acute serous_ and _purulent synovitis_--there is the usual general reaction, associated with pyrexia and great pain in the joint. The part is hot and swollen, the swelling assuming the shape of the distended synovial sac, fluctuation can usually be elicited, and the joint is held in the flexed position.

When the joint is infected by extension from the surrounding cellular tissue, the joint lesion may not be recognised at an early stage because of the swollen condition of the limb, and because there are already symptoms of toxæmia. We have observed a case in which both the hip and knee joints were infected from the cellular tissue.

If the infection involves all the joint structures--_acute arthritis_--the general and local phenomena are intensified, the temperature rises quickly, often with a rigor, and remains high; the patient looks ill, and is either unable to sleep or the sleep is disturbed by starting pains. The joint is held rigid in the flexed position, and the least attempt at movement causes severe pain; the slightest jar--even the shaking of the bed--may cause agony. The joint is hot, tensely distended, and there may be œdema of the peri-articular tissues or of the limb as a whole. If the pus perforates the joint capsule, there are signs of abscess or of diffuse suppuration in the cellular tissue. The final disorganisation of the joint is indicated by abnormal mobility and grating of the articular surfaces, or by spontaneous displacement of the bones, and this may amount to dislocation. In the acute arthritis of infants, the epiphysis concerned may be separated and displaced.

When the _joint is infected through an external wound_, the anatomical features are similar to those observed when the infection has reached the joint by the blood-stream, but the destructive changes tend to be more severe and are more likely to result in disorganisation.

The _terminations_ vary with the gravity of the infection and with the stage at which treatment is instituted. In the milder forms recovery is the rule, with more or less complete restoration of function. In more severe forms the joint may be permanently damaged as a result of fibrous or bony ankylosis, or from displacement or dislocation. From changes in the peri-articular structures there may be contracture in an undesirable position, and in young subjects the growth of the limb may be interfered with. The persistence of sinuses is usually due to disease in one or other of the adjacent bones. In the most severe forms, and especially when several joints are involved, death may result from toxæmia.

The _treatment_ is carried out on the same principles as in other pyogenic infections. The limb is immobilised in such an attitude that should stiffness occur there will be the least interference with function. Extension by weight and pulley is the most valuable means of allaying muscular spasm and relieving intra-articular tension and of counteracting the tendency to flexion; as much as 15 or 20 pounds may be required to relieve the pain.

The induction of hyperæmia is sometimes remarkably efficacious in relieving pain and in arresting the progress of the infection. If the fluid in the joint is in sufficient quantity to cause tension, if it persists, or if there is reason to suspect that it is purulent, it should be withdrawn without delay; an exploring syringe usually suffices, the skin being punctured with a tenotomy knife, and, as practised by Murphy, 5 to 15 c.c. of a 2 per cent. solution of formalin in glycerin are injected and the wound is closed. In virulent infections the injection may be repeated in twenty-four hours. Drainage by tube or otherwise is to be condemned (Murphy). A vaccine may be prepared from the fluid in the joint and injected into the subcutaneous cellular tissue.

Suppuration in the peri-articular soft parts or in one of the adjacent bones must be looked for and dealt with.

When convalescence is established, attention is directed to the restoration of the functions of the limb, and to the prevention of stiffness and deformity by movements and massage, and the use of hot-air and other baths.

At a later stage, and especially in neglected cases, operative and other measures may be required for deformity or ankylosis.

#Metastatic Forms of Pyogenic Infection#

In #pyæmia#, one or more joints may fill with pus without marked symptoms or signs, and if the pus is aspirated without delay the joint often recovers without impairment of function.

In #typhoid fever#, joint lesions result from infection with the typhoid bacillus alone or along with pyogenic organisms, and run their course with or without suppuration; there is again a remarkable absence of symptoms, and attention may only be called to the condition by the occurrence of dislocation.

Joint lesions are comparatively common in #scarlet fever#, and were formerly described as scarlatinal rheumatism. The most frequent clinical type is that of a serous synovitis, occurring within a week or ten days from the onset of the fever. Its favourite seat is in the hand and wrist, the sheaths of the extensor tendons as well as the synovial membrane of the joints being involved. It does not tend to migrate to other joints, and rarely lasts longer than a few days. It is probably due to the specific virus of scarlet fever.

At a later stage, especially in children and in cases in which the throat lesion is severe, an arthritis is sometimes observed that is believed to be a metastasis from the throat; it may be acute and suppurative, affect several joints, and exhibit a septicæmic or pyæmic character.

The joints of the lower extremity are especially apt to suffer; the child is seriously ill, is delirious at night, develops bed-sores over the sacrum and, it may happen that, not being expected to recover, the legs are allowed to assume contracture deformities with ankylosis or dislocation at the hip and flexion ankylosis at the knees; should the child survive, the degree of crippling may be pitiable in the extreme; prolonged orthopædic treatment and a series of operations--arthroplasty, osteotomies, and resections--may be required to restore even a limited capacity of locomotion.

#Pneumococcal affections of joints#, the result of infection with the pneumococcus of Fraenkel, are being met with in increasing numbers. The local lesion varies from a _synovitis_ with infiltration of the synovial membrane and effusion of serum or pus, to an _acute arthritis_ with erosion of cartilage, caries of the articular surfaces, and disorganisation of the joint. The knee is most frequently affected, but several joints may suffer at the same time. In most cases the joint affection makes its appearance a few days after the commencement of a pneumonia, but in a number of instances, especially among children, the lung is not specially involved, and the condition is an indication of a generalised pneumococcal infection, which may manifest itself by endocarditis, empyema, meningitis, or peritonitis, and frequently has a fatal termination. The differential diagnosis from other forms of pyogenic infection is established by bacteriological examination of the fluid withdrawn from the joint. The treatment is carried out on the same lines as in other pyogenic infections, considerable reliance being placed on the use of autogenous vaccines.

In #measles#, #diphtheria#, #smallpox#, #influenza#, and #dysentery#, similar joint lesions may occur.

The joint lesions which accompany #acute rheumatism# or "rheumatic fever" are believed to be due to a diplococcus. In the course of a general illness in which there is moderate pyrexia and profuse sweating, some of the larger joints, and not infrequently the smaller ones also, become swollen and extremely sensitive, so that the sufferer lies in bed helpless, dreading the slightest movement. From day to day fresh joints are attacked, while those first affected subside, often with great rapidity. Affections of the heart-valves and of the pericardium are commonly present. On recovery from the acute illness, it may be found that the joints have entirely recovered, but in a small proportion of cases certain of them remain stiff and pass into the crippled condition described under chronic rheumatism. There is no call for operative interference.

#Gonococcal Affections of Joints.#--These include all forms of joint lesion occurring in association with gonorrhœal urethritis, vulvo-vaginitis, or gonorrhœal ophthalmia. They may develop at any stage of the urethritis, but are most frequently met with from the eighteenth to the twenty-second day after the primary infection, when the organisms have reached the posterior urethra; they have been observed, however, after the discharge has ceased. There is no connection between the severity of the gonorrhœa and the incidence of joint disease. In women, the gonorrhœal nature of the discharge must be established by bacteriological examination.

As a complication of ophthalmia, the joint lesions are met with in infants, and occur more commonly towards the end of the second or during the third week.

The gonococcus is carried to the joint in the blood-stream and is first deposited in the synovial membrane, in the tissues of which it can usually be found; it may be impossible to find it in the exudate within the joint. The joint lesions may be the only evidence of metastasis, or they may be part of a general infection involving the endocardium, pleura, and tendon sheaths.

The joints most frequently affected are the knee, elbow, ankle, wrist, and fingers. Usually two or more joints are affected.

Several clinical types are differentiated. (1) A _dry poly-arthritis_ met with in the joints and tendon sheaths of the wrist and hand, formerly described as gonorrhœal rheumatism, which in some cases is trifling and evanescent, and in others is persistent and progressive, and results in stiffness of the affected joints and permanent crippling of the hand and fingers.

(2) The commonest type is a _chronic synovitis_ or _hydrops_, in which the joint--very often the knee--becomes filled with a serous or sero-fibrinous exudate. There are no reactive changes in the synovial membrane, cellular tissue, or skin, nor is there any fever or disturbance of health. The movements are free except in so far as they are restricted by the amount of fluid in the joint. It usually subsides in two or three weeks under rest, but tends to relapse.

(3) An _acute synovitis_ with peri-articular phlegmon is most often met with in the elbow, but it occurs also in the knee and ankle. There is a sudden onset of severe pain and swelling in and around the joint, with considerable fever and disturbance of health. The slightest movement causes pain, and the part is sensitive to touch. The skin is hot and tense, and in the case of the elbow may be red and fiery as in erysipelas.

The deposit of fibrin on the synovial membrane and on the articular surfaces may lead to the formation of adhesions, sometimes in the form of isolated bands, sometimes in the form of a close fibrous union between the bones.

(4) A _suppurative arthritis_, like that caused by ordinary pus microbes, may be the result of gonococcal infection alone or of a mixed infection. Usually only one joint is affected, but the condition may be multiple. The articular cartilages are destroyed, the ends of the bones are covered with granulations, extra-articular abscesses form, and complete osseous ankylosis results.

The _diagnosis_ is often missed because the possibility of gonorrhœa is not suspected.

The denial of the disease by the patient is not always to be relied upon, especially in the case of women, as they may be ignorant of its presence. The chief points in the differential diagnosis from acute articular rheumatism are, that the gonorrhœal affection is more often confined to one or two joints, has little tendency to wander from joint to joint, and its progress is not appreciably influenced by salicylates, although these drugs may relieve pain. The conclusive point is the recognition of a gonorrhœal discharge or of threads in the urine.

The disease may persist or may relapse, and the patient may be laid up for weeks or months, and may finally be crippled in one or in several joints.

The _treatment_--besides that of the urethral disease or of the ophthalmia--consists in rest until all pain and sensitiveness have disappeared. The pain is relieved by salicylates, but most benefit follows weight extension, the induction of hyperæmia by the rubber bandage and hot-air baths; if the joint is greatly distended, the fluid may be withdrawn by a needle and syringe. Detoxicated vaccines should be given from the first, and in afebrile cases the injection of a foreign protein, such as anti-typhoid vaccine, is beneficial (Harrison).

Murphy has found benefit from the introduction into the joint, in the early stages, of from 5 to 15 c.c. of a 2 per cent. solution of formalin in glycerin. This may be repeated within a week, the patient being kept in bed with light weight extension. In the chronic hydrops the fluid is withdrawn, and about an ounce of a 1 per cent. solution of protargol injected; the patient should be warned of the marked reaction which follows.

After all symptoms have settled down, but not till then, for fear of exciting relapse or metastasis, the joint is massaged and exercised. Stiffness from adhesions is most intractable, and may, in spite of every attention, terminate in ankylosis even in cases where there has been no suppuration. Forcible breaking down of adhesions under anæsthesia is not recommended, as it is followed by great suffering and the adhesions re-form. Operation for ankylosis--arthroplasty--should not be undertaken, as the ankylosis recurs.

TUBERCULOUS DISEASE

Tuberculous disease of joints results from bacillary infection through the arteries. The disease may commence in the synovial membrane or in the marrow of one of the adjacent bones, and the relative frequency of these two seats of infection has been the subject of considerable difference of opinion. The traditional view of König is that in the knee and most of the larger joints the disease arises in the bone and in the synovial membrane in about equal proportion, and that in the hip the number of cases beginning in the bones is about five times greater than that originating in the membrane. This estimate, so far as the actual frequency of bone lesions is concerned, has been generally accepted, but recent observers, notably John Fraser, do not accept the presence of bone lesions as necessarily proving that the disease commenced in the bones; he maintains, and we think with good grounds, that in many cases the disease having commenced in the synovial membrane, slowly spreads to the bone by way of the blood vessels and lymphatics, and gives rise to lesions in the marrow.

#Morbid Anatomy.#--Tuberculous disease in the articular end of a long bone may give rise to _reactive changes_ in the adjacent joint, characterised by effusion and by the extension of the synovial membrane over the articular surfaces. This may result in the formation of adhesions which obliterate the cavity of the joint or divide it into compartments. These lesions are comparatively common, and are not necessarily due to actual tuberculous infection of the joint.

The _infection of the joint_ by tubercle originating in the adjacent bone may take place at the periphery, the osseous focus reaching the surface of the bone at the site of reflection of the synovial membrane, and the infection which begins at this point then spreads to the rest of the membrane. Or it may take place in the central area, by the projection of tuberculous granulation tissue into the joint following upon erosion of the cartilage (Fig. 156).

_Changes in the Synovial Membrane._--In the majority of cases there is a _diffuse thickening of the synovial membrane_, due to the formation of granulation tissue, or of young connective tissue, in its substance. This new tissue is arranged in two layers--the outer composed of fully formed connective or fibrous tissue, the inner of embryonic tissue, usually permeated with miliary tubercles. On opening the joint, these tubercles may be seen on the surface of the membrane, or the surface may be covered with a layer of fibrinous or caseating tissue. Where there is greater resistance on the part of the tissues, there is active formation of young connective tissue which circumscribes or encapsulates the tubercles, so that they remain embedded in the substance of the membrane, and are only seen on cutting into it.

The thickened synovial membrane is projected into the cavity of the joint, filling up its pouches and recesses, and spreading over the surface of the articular cartilage "like ivy growing on a wall." Wherever the synovial tissue covers the cartilage it becomes adherent to and fused with it. The morbid process may be arrested at this stage, and fibrous adhesions form between the opposing articular surfaces, or it may progress, in which case further changes occur, resulting in destruction of the articular cartilage and exposure of the subjacent bone.

In rare instances the synovial membrane presents nodular masses or lumps, resembling the tuberculous tumours met with in the brain; they project into the cavity of the joint, are often pedunculated, and may give rise to the symptoms of loose body. The fringes of synovial membrane may also undergo a remarkable development, like that observed in arthritis deformans, and described as arborescent lipoma. Both these types are almost exclusively met with in the knee.

_The Contents of Tuberculous Joints._--In a large proportion of cases of synovial tuberculosis the joint is entirely filled up by the diffuse thickening of the synovial membrane. In a small number there is an abundant serous exudate, and with this there may be a considerable formation of fibrin, covering the surface of the membrane and floating in the fluid as flakes or masses; under the influence of movement it may assume the shape of melon-seed bodies. More rarely the joint contains pus, and the surface of the synovial membrane resembles the wall of a cold abscess.

_Ulceration and Necrosis of Cartilage._--The synovial tissue covering the cartilage causes pitting and perforation of the cartilage and makes its way through it, and often spreads widely between it and the subjacent bone; the cartilage may be detached in portions of considerable size. It may be similarly ulcerated or detached as a result of disease in the bone.

_Caries of Articular Surfaces._--Tuberculous infiltration of the marrow in the surface cancelli breaks up the spongy framework of the bone into minute irregular fragments, so that it disintegrates or crumbles away--caries. When there is an absence of caseation and suppuration, the condition is called _caries sicca_.

The pressure of the articular surfaces against one another favours the progress of ulceration of cartilage and of articular caries. These processes are usually more advanced in the areas most exposed to pressure--for example, in the hip-joint, on the superior aspect of the head of the femur, and on the posterior and upper segment of the acetabulum.

The occurrence of _pathological dislocation_ is due to softening and stretching of the ligaments which normally retain the bones in position, and to some factor causing displacement, which may be the accumulation of fluid or of granulations in the joint, the involuntary contraction of muscles, or some movement or twist of the limb. The occurrence of dislocation is also favoured by destructive changes in the bones.

_Peri-articular tubercle and abscess_ may result from the spread of disease from the bone or joint into the surrounding tissues, either directly or by way of the lymphatics. A peri-articular abscess may spread in several directions, sometimes invading tendon sheaths or bursæ, and finally reaching the skin surface by tortuous sinuses.

Reactive changes in the vicinity of tuberculous joints are of common occurrence, and play a considerable part in the production of what is clinically known as _white swelling_. New connective tissue forms in the peri-articular fat and between muscles and tendons. It may be tough and fibrous, or soft, vascular, and œdematous, and the peri-articular fat becomes swollen and gelatinous, constituting a layer of considerable thickness. The fat disappears and is replaced by a mucoid effusion between the fibrous bundles of connective tissue. This is what was formerly known as _gelatinous degeneration_ of the synovial membrane. In the case of the wrist the newly formed connective tissue may fix the tendons in their sheaths, interfering with the movements of the fingers. In relation to the bones also there may be reactive changes, resulting in the formation of spicules of new bone on the periosteal surfaces and at the attachment of the capsular and other ligaments; these are only met with where pyogenic infection has been superadded.

_Terminations and Sequelæ._--A natural process of cure may occur at any stage, the tuberculous tissue being replaced by scar tissue. Recovery is apt to be attended with impairment of movement due to adhesions, ankylosis, or contracture of the peri-articular structures. Caseous foci in the interior of the bones may become encapsulated, and a cure be thus effected, or they may be the cause of a relapse of the disease at a later date. Interference with growth is comparatively common, and may involve only the epiphysial junctions in the immediate vicinity of the joint affected, or those of all the bones of the limb. This is well seen in adults who have suffered from severe disease of the hip in childhood--the entire limb, including the foot, being shorter and smaller than the corresponding parts of the opposite side.

Atrophic conditions are also met with, the bones undergoing fatty atrophy, so that in extreme cases they may be cut with a knife or be easily fractured. These atrophic conditions are most marked in bedridden patients, and are largely due to disuse of the limb; they are recovered from if it is able to resume its functions.

#Clinical Features.#--These vary with the different anatomical forms of the disease, and with the joint affected.

Sometimes the disease is ushered in by a febrile attack attended with pains in several joints--described by John Duncan as _tuberculous arthritic fever_. This is liable to be mistaken for rheumatic fever, from which, however, it differs in that there is no real migration from joint to joint; there is an absence of sweating and of cardiac complications; and no benefit follows the administration of salicylates.

In exceptional cases, tuberculous joint disease follows an acute course resembling that of the pyogenic arthritis of infants. This has been observed in children, especially in the knee, the lesion being in the synovial membrane, and attended with an accumulation of pus in the joint. If promptly treated by incision and drainage, recovery is rapid, and free movement of the joint, may be preserved.

The onset and early stages of tuberculous disease, however, are more often insidious, and are attended with so few symptoms that the disease may have obtained a considerable hold before it attracts notice. It is not uncommon for patients or their friends to attribute the condition to injury, as it often first attracts attention after some slight trauma or excessive use of the limb. The symptoms usually subside under rest, only to relapse again with use of the limb.

The initial local symptoms may be due to the presence of a focus in the neighbouring bone, perhaps causing neuralgic pains in the joint, or weakness, tiredness, stiffness, and inability to use the limb, these symptoms improving with rest and being aggravated by exertion.

It is rarely possible by external examination to recognise deep-seated osseous foci in the vicinity of joints; but if they are near the surface in a superficial bone--such as the head of the tibia--there may be local thickening of the periosteum, œdema, pain, and tenderness on pressure and on percussion.

_X-ray Appearances of Tuberculous Joints._--Gross lesions such as caseous foci in the marrow of the adjacent bone show as clear areas with an ill-defined margin; a sclerosed focus gives a denser shadow than the surrounding bone, and a sequestrum presents a dark shadow of irregular contour, and a clear interval between it and the surrounding bone.

Caries of the articular surface imparts a woolly appearance or irregular contour in place of the well-defined outline of the articular end of the bone. In bony ankylosis the shadow of the two bones is a continuous one, the joint interval having been filled up. The minor changes are best appreciated on comparison with the normal joint of the other limb.

_Wasting of muscles_ is a constant accompaniment of tuberculous joint disease. It is to be attributed partly to want of use, but chiefly to reflex interference with the trophic innervation of the muscles. It is specially well seen in the extensor and adductor muscles of the thigh in disease of the knee, and in the deltoid in disease of the shoulder. The muscles become soft and flaccid, they exhibit tremors on attempted movement, and their excitability to the faradic current is diminished. The muscular tissue may be largely replaced by fat.

_Impairment of the normal movements_ is one of the most valuable diagnostic signs, particularly in deeply seated joints such as the shoulder, hip, and spine. It is due to a protective contraction of the muscles around the joint, designed to prevent movement. This muscular fixation disappears under anæsthesia.

_Abnormal attitudes of the limb_ occur earlier, and are more pronounced in cases in which pain and other irritative symptoms of articular disease are well marked, and are best illustrated by the attitudes assumed in disease of the hip. They are due to reflex or involuntary contraction of the muscles acting on the joint, with the object of placing it in the attitude of greatest ease; they also disappear under anæsthesia. With the lapse of time they not only become exaggerated, but may become permanent from ankylosis or from contracture of the soft parts round the joint.

_Startings at night_ are to be regarded as an indication that there is progressive disease involving the articular surfaces.

_The formation of extra-articular abscess_ may take place early, or it may not occur till long after the disease has subsided. The abscess may develop so insidiously that it does not attract attention until it has attained considerable size, especially when associated with disease of the spine, pelvis, or hip. The position of the abscess in relation to different joints is fairly constant and is determined by the anatomical relationships of the capsule and synovial membrane to the surrounding tissues. The bursæ and tendon sheaths in the vicinity may influence the direction of spread of the abscess and the situation of resulting sinuses. When the abscess is allowed to burst, or is opened and becomes infected with pyogenic bacteria, there is not only the risk of aggravation of the disease and persistent suppuration, but there is a greater liability to general tuberculosis.

The sinuses may be so tortuous that a probe cannot be passed to the primary focus of disease, and their course and disposition can only be demonstrated by injecting the sinuses with an emulsion of bismuth and taking X-ray photographs.

Tuberculous infection of the lymph glands of the limb is exceptional, but may follow upon infection of the skin around the orifice of a sinus.

A slight rise of temperature in the evening may be induced in quiescent joint lesions by injury or by movement of the joint under anæsthesia, or by the fatigue of a railway journey. When sinuses have formed and become infected with pyogenic bacteria, there may be a diurnal variation in the temperature of the type known as hectic fever (Fig. 11).

_Relative Frequency of Tuberculous Disease in Different Joints._--Hospital statistics show that joints are affected in the following order of frequency: Spine, knee, hip, ankle and tarsus, elbow, wrist, shoulder. The hip and spine are most often affected in childhood and youth, the shoulder and wrist in adults; the knee, ankle, and elbow show little age preference.

_Clinical Variations of Tuberculous Joint Disease._--The above description applies to tuberculous joint disease in general; it must be modified to include special manifestations or varieties.

When the main incidence of the infection affects the synovial membrane, the clinical picture may assume the form of a _hydrops_, or of an _empyema_ in which the joint is filled with pus. More common than either of these is the well-known _white swelling_ or _tumor albus_ (Wiseman, 1676) which is the clinical manifestation of diffuse thickening of the synovial membrane along with mucoid degeneration of the peri-synovial cellular tissue. It is well seen in joints which are superficial--such as the knee, ankle, elbow, and wrist. The swelling, which is the first and most prominent clinical feature, develops gradually and painlessly, obliterating the bony prominences by filling up the natural hollows. It appears greater to the eye than is borne out by measurement, being thrown into relief by the wasting of the muscles above and below the joint. In the early stage the swelling is elastic, doughy, and non-sensitive, and corresponds to the superficial area of the synovial membrane involved, and there is comparatively little complaint on the part of the patient, because the articular surfaces and ligaments are still intact. There may be a feeling of weight in the limb, and in the case of the knee and ankle the patient tires on walking and drags the leg with more or less of a limp. Movements of the joint are permitted, but are limited in range. The disability is increased by use and exertion, but, for a time at least, it improves under rest.

If the disease is not arrested, there follow the symptoms and signs of involvement of the articular surfaces.

_Influence of Tuberculous Joint Disease on the General Health._--Experience shows that the early stages of tuberculous joint disease are compatible with the appearance of good health. As a rule, however, and especially if there is mixed infection, the health suffers, the appetite is impaired, the patient is easily tired, and there may be some loss of weight.

#Treatment.#--In addition to the general treatment of tuberculosis, local measures are employed. These may be described under two heads--the conservative and the operative.

_Conservative treatment_ is almost always to be employed in the first instance, as by it a larger proportion of cures is obtained with a smaller mortality and with better functional results than by operation.

_Treatment by rest_ implies the immobilisation of the diseased limb until pain and tenderness have disappeared. The attitude in which the limb is immobilised should be that in which, in the event of subsequent stiffness, it will be most serviceable to the patient. Immobilisation may be secured by bandages, splints, extension, or other apparatus. _Extension_ with weight and pulley is of value in securing rest, especially in disease of the hip or knee; it eliminates muscular spasm, relieves pain and startings at night, and prevents abnormal attitudes of the limb. If, when the patient first comes under observation, the limb is in a deformed attitude which does not readily yield to extension, the deformity should be corrected under an anæsthetic.

_The induction of hyperæmia_ is often helpful, the rubber bandage or the hot-air chamber being employed for an hour or so morning and evening.

_Injection of Iodoform._--This is carried out on the same lines as have been described for tuberculous abscess. After the fluid contents of the joint are withdrawn, the iodoform is injected; and this may require to be repeated in a month or six weeks.

After the injection of iodoform there is usually considerable reaction, attended with fever (101° F.), headache, and malaise, and considerable pain and swelling of the joint. In some cases there is sickness, and there may be blood pigment in the urine. The severity of these phenomena diminishes with each subsequent injection.

The use of Scott's dressing and of blisters and of the actual cautery has largely gone out of fashion, but the cautery may still be employed with benefit for the relief of pain in cases in which ulceration of cartilage is a prominent feature.

The application of the X-rays has proved beneficial in synovial lesions in superficial joints such as the wrist or elbow; prolonged exposures are made at fortnightly intervals, and on account of the cicatricial contraction which attends upon recovery, the joint must be kept in good position.

Conservative treatment is only abandoned if improvement does not show itself after a thorough trial, or if the disease relapses after apparent cure.

_Operative Treatment._--Other things being equal, operation is more often indicated in adults than in children, because after the age of twenty there is less prospect of recovery under conservative treatment, there is more tendency for the disease to relapse and to invade the internal organs, and there is no fear of interfering with the growth of the bones. The state of the general health may necessitate operation as the most rapid method of removing the disease. The social status of the patient must also be taken into account; the bread-winner, under existing social conditions, may be unable to give up his work for a sufficient time to give conservative measures a fair trial.

The _local conditions_ which decide for or against operation are differently regarded by different surgeons, but it may be said in general terms that operative interference is indicated in cases in which the disease continues to progress in spite of a fair trial of conservative measures; in cases unsuited for conservative treatment--that is to say, where there are severe bone lesions. Operative interference is indicated also when the functional result will be better than that likely to be obtained by conservative measures, as is often the case in the knee and elbow. Cold abscesses should, if possible, be dealt with before operating on the joint.

In many cases the extent of the operation can only be decided after exploration. The aim is to remove all the disease with the least impairment of function and the minimum sacrifice of healthy tissue. The more open the method of operating the better, so that all parts of the joint may be available for inspection. The methods of Kocher, which permit of dislocating the joint, are specially to be recommended, as this procedure affords the freest possible access. Diseased synovial membrane is removed with the scissors or knife. If the cartilages are sound, and if a movable joint is aimed at, they may be left; but if ankylosis is desired, they must be removed. Localised disease of the cartilage should be removed with the spoon or gouge, and the bone beneath investigated. If the articular surface is extensively diseased, a thin slice of bone should be removed, and if foci in the marrow are then revealed, it is better to gouge them out than to remove further slices of bone, as this involves sacrifice of the cortex and periosteum.

Operative treatment of deformities resulting from tuberculous joint disease has almost entirely replaced reduction by force; the contracted soft parts are divided, and the bone is resected.

_Amputation_ for tuberculous joint disease has become one of the rare operations of surgery, and is only justified when less radical measures have failed and the condition of the limb is affecting the general health. Amputation is more frequently called for in persons past middle life who are the subjects of pulmonary tuberculosis.

SYPHILITIC DISEASE

Syphilitic affections of joints are comparatively rare. As in tuberculosis, the disease may be first located in the synovial membrane, or it may spread to the joint from one of the bones.

In #acquired syphilis#, at an early stage and before the skin eruptions appear, one of the large joints, such as the shoulder or knee, may be the seat of pain--_arthralgia_--which is worse at night. In the secondary stage, a _synovitis_ with serous effusion is not uncommon, and may affect several joints. Syphilitic _hydrops_ is met with almost exclusively in the knee; it is frequently bilateral, and is insidious in its onset 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.

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.

_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).

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 subsequently converted into bone (Fig. 157). Gross alterations in the ends of the bone are thus brought about which can be recognised clinically and in skiagrams, and which tend to restrict the normal range of movement. The extension of the ossification into the synovial reflection and capsular ligament adds a collar or "lip" of new bone, known as "lipping" of the articular margins, and also into other ligaments, insertions of tendons and intermuscular septa giving rise to bony outgrowths or osteophytes not unlike those met with in the neuro-arthropathies.

Proliferative changes in the synovial membrane are attended with increased vascularity and thickening of the membrane and an enlargement of its villi and fringes. When the fatty fringes are developed to an exaggerated degree, the condition is described as an _arborescent lipoma_ (Fig. 159). Individual fringes may attain the size of a hazel nut, and the fibro-fatty tissue of which they are composed may be converted into cartilage and bone; such a body may remain attached by a narrow pedicle or stalk, or this may be torn across and the body becomes loose and, unless confined in a recess of the joint, it wanders about and may become impacted between the articular surfaces. These changes in the synovial membrane are often associated with an abundant exudate or hydrops. These degenerative and hypertrophic changes, while usually attended with marked restriction of movement and sometimes by "locking" of the joint, practically never result in ankylosis.

The _ankylosing type_ of chronic arthritis is fortunately much rarer than those described above, and is chiefly met with in the joints of the fingers and toes and in those of the vertebral column. The synovial membrane proliferates, grows over the cartilage, and replaces it, and when two such articular surfaces are in contact they tend to adhere, thus obliterating the joint, cavity, and resulting in fibrous or bony ankylosis. The changes progress slowly and, before they result in ankylosis, various sub-luxations and dislocations may occur with distortion and deformity which, in the case of the fingers, is extremely disabling and unsightly (Fig. 160).

_Clinical Features._--It is usually observed that in patients who are still young the tendency is for the disease to advance with considerable rapidity, so that in the course of months it may cause crippling of several joints. The course of the disease as met with in persons past middle life is more chronic; it begins insidiously, and many years may pass before there is pronounced disability. The earliest symptom is stiffness, especially in the morning after rest, which passes off temporarily with use of the limb. As time goes on, the range of movement becomes restricted, and crackings occur. This stage of the disease may be prolonged indefinitely; if it progresses, stiffness becomes more pronounced, certain movements are lost, others develop in abnormal directions, and deformed attitudes add to the disablement. The disease is compatible with long life, but not with any active occupation, hence those of the hospital class who suffer from it tend to accumulate in workhouse infirmaries.

_Hydrops_ is most marked in the knee, and may affect also the adjacent bursæ. As the joint becomes distended with fluid, the ligaments are stretched, the limb becomes weak and unstable, and the patient complains of a feeling of weight, of insecurity, and of tiredness. Pain is occasional and evanescent, and is usually the result of some extra exertion, or exposure to cold and wet. This form of the disease is extremely chronic, and may last for an indefinite number of years. It is to be diagnosed from the other forms of hydrops already considered--the purely traumatic, the pyogenic, gonorrhœal, tuberculous, and syphilitic--and from that associated with Charcot's disease.

_Hypertrophied fringes and pedunculated or loose bodies_ often co-exist with hydrops, and give rise to characteristic clinical features, particularly in the knee. The fringes, especially when they assume the type of the arborescent lipoma, project into the cavity of the joint, filling up its recesses and distending its capsule so that the joint is swollen and slightly flexed. Pain is not a prominent feature, and the patient may walk fairly well. On grasping the joint while it is being actively flexed and extended, the fringes may be felt moving under the fingers. Symptoms from impaction of a loose body are exceptional.

_The dry form of arthritis deformans_, although specially common in the knee, is met with in other joints, either as a mon-articular or poly-articular disease; and it is also met with in the joints of the spine and of the fingers as well as in the temporo-mandibular joint. In the joints of the fingers the disease is remarkably symmetrical, and tends to assume a nodular type (Heberden's nodes) (Fig. 160); in younger subjects it assumes a more painful and progressive fusiform type (Fig. 161). In the larger joints the subjective symptoms usually precede any palpable evidence of disease, the patient complaining of stiffness, crackings, and aching, aggravated by changes in the weather. The roughness due to fibrillation of the articular cartilages causes coarse friction on moving the joint, or, in the knee, on moving the patella on the condyles of the femur. It may be months or even years before the lipping and other hypertrophic changes in the ends of the bones are recognisable, and before the joint assumes the deformed features which the name of the disease suggests.

The capsular ligament, except in hydrops, is the seat of connective-tissue overgrowth, and tends to become contracted and rigid. Intra-articular ligaments, such as the ligamentum teres in the hip, are usually worn away and disappear. The surrounding muscles undergo atrophy, tendons become adherent to their sheaths and may be ossified, and the sheaths of nerves may be involved by the cicatricial changes in the surrounding tissues.

_The X-ray appearances of arthritis deformans_ necessarily vary with the type of the disease and the joint affected; in the joints of the fingers there is a narrowing of the spaces between the articular ends of the bones as a result of absorption of the articular cartilage, and rarefaction of the cancellous tissue in the vicinity of the joints; in the larger joints there is "lipping" of the articular margins, osteophytes, and other evidence of abnormal ossification in and around the joint. Eburnation of the articular surfaces is shown by increase in the density of the shadow of the bone in the areas affected.

_Treatment._--Treatment is for the most part limited to the relief of symptoms. On no account should the affected joints be kept at rest by means of splints or other apparatus. Active movements and exercises of all kinds are to be persevered with. When pain is a prominent feature, it may be relieved either by douches of iodine and hot water (tincture of iodine 1 oz. to the quart), or by the application of lint saturated with a lotion made up of chloral hydrate, gr. v, glycerin Ʒj, water ℥j, and covered with oil-silk. Strain and over-use of the joint and sudden changes of temperature are to be avoided. The induction of hyperæmia by means of massage, the elastic bandage, and hot-air baths is often of service. Operative interference is indicated when the disease is of a severe type, when it is mon-articular, and when the general condition of the patient is otherwise favourable. Excision has been practised with success in the hip, knee, elbow, and temporo-mandibular joints. Limitation of movement and locking at the hip-joint when due to new bone round the edge of the acetabulum may be greatly relieved by removal of the bone--a procedure known as _cheilotomy_. Loose bodies and hypertrophied fringes if causing symptoms may also be removed by operation.

When stiffness and grating on movement are prominent features we have found the injection of from half to one ounce of sterilised white vaseline afford decided relief.

The patient should be nourished well, and there need be no restriction in the diet such as is required in gouty patients, so long as the digestion is not impaired. Benefit is also derived from the administration of cod-liver oil, and of tonics, such as strychnin, arsenic, and iron, and in some cases of iodide of potassium. Luff recommends the administration over long periods of guaiacol carbonate, in cachets beginning with doses of 5–10 grs. and increased to 15–20 grs. thrice daily. A course of treatment at one of the reputed spas--Aix, Bath, Buxton, Gastein, Harrogate, Strathpeffer, Wiesbaden, Wildbad--is often beneficial.

In some cases benefit has followed the prolonged internal administration of liquid paraffin.

On the assumption that the condition is the result of an auto-intoxication from the intestinal tract, saline purges and irrigation of the colon are indicated, and Arbuthnot Lane claims to have brought about improvement by short-circuiting or by resecting the colon.

Residence in a warm and dry climate, with an open-air life, has been known to arrest the disease when other measures have failed to give relief.

The application of radium and the ingestion of radio-active waters have also been recommended.

#Hæmophilic# or #Bleeder's Joint#.--This is a rare but characteristic affection met with chiefly in the knee-joint of boys who are the subjects of hæmophilia. After some trivial injury, or even without apparent cause, a hæmorrhage takes place into the joint. The joint is tensely swollen, cannot be completely extended, and is so painful that the patient is obliged to lie up. The temperature is often raised (101° to 102° F.), especially if there are also hæmorrhages elsewhere. The blood in the joint is slowly re-absorbed, and by the end of a fortnight or so, the symptoms completely disappear. As a rule these attacks are repeated; the pain attending them diminishes, but the joint becomes the seat of permanent changes: the synovial membrane is thickened, abnormally vascular, and coloured brown from the deposit of blood pigment; on its surface, and in parts of the articular cartilage, there is a deposit of rust-coloured fibrin; there may be extensive adhesions, and in some cases changes occur like those observed in arthritis deformans with erosion and ulceration of the cartilage and a form of dry caries of the articular surfaces, which may terminate in ankylosis.

As the swelling of the joint is associated with wasting of the muscles, with stiffness, and with flexion, the condition closely resembles tuberculous disease of the synovial membrane. From errors in diagnosis such joints have been operated upon, with disastrous results due to hæmorrhage.

The treatment of a recent hæmorrhage consists in securing absolute rest and applying elastic compression. The introduction of blood-serum (10–15 c.c.) into a vein may assist in arresting the hæmorrhage; anti-diphtheritic serum is that most readily obtainable.

After an interval, measures should be adopted to promote the absorption of blood and to prevent stiffness and flexion; these include massage, movements, and extension with weight and pulley.

JOINT DISEASES ASSOCIATED WITH LESIONS OF THE NERVOUS SYSTEM: NEURO-ARTHROPATHIES

_In Lesions of Peripheral Nerves._--In the hand, and more rarely in the foot, when one or other of the main nerve-trunks has been divided or compressed, the joints may become swollen and painful and afterwards become stiff and deformed. Bony ankylosis has been observed.

_In Affections of the Spinal Medulla._--In myelitis, progressive muscular atrophy, poliomyelitis, insular sclerosis, and in traumatic lesions, joint affections are occasionally met with.

The occurrence of joint lesions in _locomotor ataxia_ (tabes dorsalis) was first described by Charcot in 1868--hence the term "Charcot's disease" applied to them. Although they usually develop in the ataxic stage, one or more years after the initial spinal symptoms, they may appear before there is any evidence of tabes. The onset is frequently determined by some injury. The joints of the lower extremity are most commonly affected, and the disease is bilateral in a considerable proportion of cases--both knees or both hips, for instance, being implicated.

Among the theories suggested in explanation of these arthropathies the most recent is that by Babinski and Barré, which traces the condition to vascular lesions of a syphilitic type in the articular arteries.

The first symptom is usually a swelling of the joint and its vicinity. There is no redness or heat and no pain on movement. The peri-articular swelling, unlike ordinary œdema, scarcely pits even on firm pressure.

In mild cases this condition of affairs may persist for months; in severe cases destructive changes ensue with remarkable rapidity. The joint becomes enormously swollen, loses its normal contour, and the ends of the bones become irregularly deformed (Fig. 162). Sometimes, and especially in the knee, the clinical features are those of an enormous hydrops with fibrinous and other loose bodies and hypertrophied fringes--and great œdema of the peri-articular tissues (Fig. 163). The joint is wobbly or flail-like from stretching and destruction of the controlling ligaments, and is devoid of sensation. In other cases, wearing down and total disappearance of the ends of the bones is the prominent feature, attended with flail-like movements and with coarse grating. Dislocation is observed chiefly at the hip, and is rather a gross displacement with unnatural mobility than a typical dislocation, and it is usually possible to move the bones freely upon one another and to reduce the displacement. A striking feature is the extensive formation of new bone in the capsular ligament and surrounding muscles. The enormous swelling and its rapid development may suggest the growth of a malignant tumour. The most useful factor in diagnosis is the entire absence of pain, of tenderness, and of common sensibility. The freedom with which a tabetic patient will allow his disorganised joint to be handled requires to be seen to be appreciated.

The rapidity of the destructive changes in certain cases of tabes, and the entire absence of joint lesions in others, would favour the view that special parts of the spinal medulla must be implicated in the former group.

In _syringomyelia_, joint affections (gliomatous arthropathies) are more frequent than in tabes, and they usually involve the upper extremity in correspondence with the seat of the spinal lesion, which usually affects the lower cervical and upper thoracic segments. Except that the joint disease is seldom symmetrical, it closely resembles the arthropathy of tabes. The completeness of the analgesia of the articular structures and of the overlying soft parts is illustrated by the fact that in one case the patient himself was in the habit of letting out the fluid from his elbow with the aid of a pair of scissors, and that in another the joint was painlessly excised without an anæsthetic.

The disease may become arrested or may go on to complete disorganisation; suppuration may ensue from infection through a breach of the surface, and in rare cases the joint has become the seat of tuberculosis.

_Treatment_, in addition to that of the nerve lesion underlying the arthropathy, consists in supporting and protecting the joint by means of bandages, splints, and other apparatus. In the lower extremity, the use of crutches is helpful in taking the strain off the affected limb. When there is much distension of the joint, considerable relief follows upon withdrawal of fluid. The best possible result being rigid ankylosis in a good position, it may be advisable to bring this about artificially by arthrodesis or resection. Operation is indicated when only one joint is affected and when the cord lesion is such as will permit of the patient using the limb. The wounds heal well, but the victims of tabes are unfavourable subjects for operative interference, on account of their liability to intercurrent complications. When the limb is quite useless, amputation may be the best course.

_In cerebral lesions_ attended with hemiplegia, joint affections, characterised by evanescent pain, redness, and swelling, are occasionally met with. The secondary changes in joints which are the seat of paralytic contracture are considered with the surgery of the Extremities.

In cases of _hysteria_ and other _functional affections of the nervous system_, an intermittent neuropathic hydrops has been observed--especially in the knee. Without apparent cause, the joint fills with fluid and its movements become restricted, and after from two to eight days the swelling subsides and the joint returns to normal. A remarkable feature of the condition is that the effusion into the joint recurs at regular intervals, it may be over a period of years. Psychic conditions have been known to induce attacks, and sometimes to abort them or even to cause their disappearance. Hence it has been recommended that treatment by suggestion should be employed along with tonic doses of quinine and arsenic.

HYSTERICAL OR MIMETIC JOINT AFFECTIONS

Under this heading, Sir Benjamin Brodie, in 1822, described an affection of joints, characterised by the prominence of subjective symptoms and the absence of pathological changes. Although most frequently met with in young women with an impressionable nervous system, and especially among those in good social circumstances, it occurs occasionally in men. The onset may be referred to injury or exposure to cold, or may be associated with some disturbance of the emotions or of the generative organs; or the condition may be an involuntary imitation of the symptoms of organic joint disease presented by a relative or friend.

It is characteristic that the symptoms develop abruptly without satisfactory cause, that they are exaggerated and wanting in harmony with one another, and that they do not correspond with the features of any of the known forms of organic disease. In some cases the only complaint is of severe pain; more often this is associated with excessive tenderness and with impairment of the functions of the joint. On examination the joint presents a normal appearance, but the skin over it is remarkably sensitive. A light touch is more likely to excite pain than deep and firm pressure. Stiffness is a variable feature--in some cases amounting to absolute rigidity, so that no ordinary force will elicit movement. It is characteristic of this, as of other neuroses, that the symptoms come and go without sufficient cause. When the patient's attention is diverted, the pain and stiffness may disappear. There is no actual swelling of the joint, although there may be an appearance of this from wasting of the muscles above and below. If the joint is kept rigid for long periods, secondary contracture may occur--in the knee with flexion, in the hip with flexion and adduction.

The _diagnosis_ is often a matter of considerable difficulty, and the condition is liable to be mistaken for such organic lesions as a tuberculous or pyogenic focus in the bone close to the joint.

The greatest difficulty is met with in the knee and hip, where the condition may closely simulate tuberculous disease. The use of the Röntgen rays, or examination of the joint under anæsthesia, is helpful.

The _local treatment_ consists chiefly in improving the nutrition of the affected limb by means of massage, exercises, baths, and electricity. Splints are to be avoided. In refractory cases, benefit may follow the application of blisters or of Corrigan's button. The general condition of the patient must be treated on the same lines as in other neuroses. The Weir-Mitchell treatment may have to be employed in obstinate cases, the patient being secluded from her friends and placed in charge of a nurse. Complete recovery is the rule, but when the muscles are weak and wasted from prolonged disuse, a considerable time may elapse before the limb returns to normal.

TUMOURS AND CYSTS

New growths taking origin in the synovial membrane are rare, and are not usually diagnosed before operation. They are attended with exudation into the joint, and in the case of _sarcoma_ the fluid is usually blood-stained. If the tumour projects in a polypoidal manner into the joint, it may cause symptoms of loose body. One or two cases have been recorded in which a _cartilaginous tumour_ growing from the synovial membrane has erupted through the joint capsule and infiltrated the adjoining muscles. _Multiple cartilaginous tumours_ forming loose bodies are described on p. 544.

_Cysts of joints_ constitute an ill-defined group which includes ganglia formed in relation to the capsular ligament. Cystic distension of bursæ which communicate with the joint is most often met with in the region of the knee in cases of long-standing hydrops. It was suggested by Morrant Baker that cystic swellings may result from the hernial protrusion of the synovial membrane between the stretched fibres of the capsular ligament, and the name "Baker's cysts" has been applied to these.

In the majority of cases, cysts in relation to joints give rise to little inconvenience and may be left alone. If interfered with at all, they should be excised.

LOOSE BODIES

It is convenient to describe the varieties of loose bodies under two heads: those composed of fibrin, and those composed of organised connective tissue.

#Fibrinous Loose Bodies# (Corpora oryzoidea).--These are homogeneous or concentrically laminated masses of fibrin, sometimes resembling rice grains, melon seeds, or adhesive wafers, sometimes quite irregular in shape. Usually they are present in large numbers, but sometimes there is only one, and it may attain considerable dimensions. They are not peculiar to joints, for they are met with in tendon sheaths and bursæ, and their origin from synovial membrane may be accepted as proved. They occur in tuberculosis, arthritis deformans, and in Charcot's disease, and their presence is almost invariably associated with an effusion of fluid into the joint. While they may result from the coagulation of fibrin-forming elements in the exudate, their occurrence in tuberculous hydrops would appear to be the result of coagulation necrosis, or of fibrinous degeneration of the surface layer of the diseased synovial membrane. However formed, their shape is the result of mechanical influences, and especially of the movement of the joint.

_Clinically_, loose bodies composed of fibrin constitute an unimportant addition to the features of the disease with which they are associated. They never give rise to the classical symptoms associated with impaction of a loose body between the articular surfaces. Their presence may be recognised, especially in the knee, by the crepitating sensation imparted to the fingers of the hand grasping the joint while it is flexed and extended by the patient.

The _treatment_ is directed towards the disease underlying the hydrops. If it is desired to empty the joint, this is best done by open incision.

#Bodies composed of Organised Connective Tissue.#--These are comparatively common in joints that are already the seat of some chronic disease, such as arthritis deformans, Charcot's arthropathy, or synovial tuberculosis. They take origin almost exclusively from an erratic overgrowth of the fringes of the synovial membrane, and may consist entirely of fat, the arborescent lipoma (Fig. 159) being the most pronounced example of this variety. Fibrous tissue or cartilage may form in one or more of the fatty fringes and give rise to hard nodular masses, which may attain a considerable size, and in course of time may undergo ossification.

Like other hypertrophies on a free surface, they tend to become pedunculated, and so acquire a limited range of movement. The pedicle may give way and the body become free. In this condition it may wander about the joint, or lie snugly in one of its recesses until disturbed by some sudden movement. A loose body free in a joint is capable of growth, deriving the necessary nutriment from the surrounding fluid. The size and number of the bodies vary widely. Single specimens have been known to attain the size of the patella. The smaller varieties may number considerably over a hundred.

In arthritis deformans a rarer type of loose body is met with, a portion of the lipping of one of the articular margins being detached by injury. In Charcot's disease, bodies composed of bone are formed in relation to the capsular and other ligaments, and may be made to grate upon one another.

The _clinical features_ in this group are mainly those of the disease which has given rise to the loose bodies, and it is exceptional to meet with symptoms from impaction of the body between the articular surfaces. Treatment is to be directed towards the primary disease in the joint, as well as to the removal of the loose bodies.

_Loose Bodies in Joints which are otherwise healthy._--It is in joints otherwise healthy that loose bodies causing the classical symptoms and calling for operative treatment are most frequently met with. They occur chiefly in the knee and elbow of healthy males under the age of thirty. The complaint may be of vague pains, of occasional cracking on moving the joint, or of impairment of function--usually an inability to extend or flex the joint completely. In many cases a clear account is given of the symptoms which arise when the body is impacted between the articular surfaces, namely, sudden onset of intense sickening pain, loss of power in the limb and locking of the joint, followed by effusion and other accompaniments of a severe sprain. On some particular movement, the body is disengaged, the locking disappears, and recovery takes place. Attacks of this kind may recur at irregular intervals, during a period of many years. On examining the joint, it is usually found to contain fluid, and there may be points of special tenderness corresponding to the ligaments that have been overstretched. In cases in which there has been recurrent attacks of locking, the ligaments become slack, the joint is wobbly, and the quadriceps is wasted. The patient himself, or the surgeon, may discover the loose body and feel it roll beneath his fingers, especially if it is lodged in the supra-patellar pouch in the knee, or on one or other side of the olecranon in the elbow. In most instances the patient has carefully observed his own symptoms, and is aware not only of the existence of the loose body, but of its erratic appearance at different parts of the joint. This feature serves to differentiate the lesions from a torn medial meniscus in which the pain and tenderness are always in the same spot. As the body usually contains bone, it is recognisable in a skiagram.

There are two methods of _removing the body_; the first and simpler method is applicable when the body can be palpated, usually in the supra-patellar pouch; it is preferably transfixed by a needle and can then be removed through a small incision; otherwise, the joint must be freely opened and explored, firstly to find the body and further to remove it.

The characters of this type of loose body are remarkably constant. It is usually solitary, about the size of a bean or almond, concavo-convex in shape, the convex aspect being smooth like an articular surface, the concave aspect uneven and nodulated and showing reparative changes, healing over of the raw surface, and the new formation of fibrous tissue, hyaline cartilage and bone, the necessary nutriment being derived from the synovial fluid (Fig. 167). The body is sometimes found to be lodged in a defect or excavation in one of the articular surfaces, usually the medial condyle of the femur, from which it is readily shelled out by means of an elevator. It presents on section a layer of articular cartilage on the convex aspect and a variable thickness of spongy bone beneath this.

The origin of these bodies is one of the most debated questions in surgical pathology; they obviously consist of a portion of the articular surface of one of the bones, but how this is detached still remains a mystery; some maintain that it is purely traumatic; König regards them as portions of the articular surface which have been detached by a morbid process which he calls "osteochondritis dessicans."

_Multiple Chondromas and Osteomas of the Synovial Membrane._--In this rare type of loose body, the surface of the synovial membrane is studded with small sessile or pedunculated tumours composed of pure hyaline cartilage, or of bone, or of transition stages between cartilage and bone. They are pearly white in colour, pitted and nodular on the surface, rarely larger than a pea, although when compressed they may cake into masses of considerable size. With the movements of the joint many of the tumours become detached and lie in the serous exudate excited by their presence. They are found also in the diverticula of the synovial membrane, in the shoulder in the downward prolongation along the tendon of the biceps, in the hip in the bursal extension beneath the psoas.

The patient complains of increasing disability of the limb, movements of the joint becoming more and more restricted and painful. There is swelling corresponding to the distended capsule of the joint, and on palpation the bodies moving under the fingers yield a sensation as of grains of rice shifting in a bag. If the bodies are so numerous as to be tightly packed together, the impression is that of a plastic mass having the shape of the synovial sac. The stiffness and the cracking on movement may suggest arthritis deformans, but the X-ray appearances make the diagnosis an easy one. We have observed two cases of this affection in the knee-joint of adult women, one in the shoulder-joint of an adult male (Fig. 168), and Caird has observed one in the hip. The treatment consists in opening the joint by free incision and removing the bodies.

_Displacement of the menisci_ of the knee is referred to with injuries of that joint.

INDEX

Abdominal aneurysm, 313 aorta, compression of, 269 embolus of, 93

Abscess, 46 acute circumscribed, 46 of bone, 448 Brodie's, 448 chronic, 139 cold, 139 embolic, 66 formation of, 47 Hilton's method of opening, 50 pointing of, 48 pyæmic, 287 residual, 141 of skin, multiple, 382 stitch, 51 treatment of, 49 tuberculous, 139, 141 peri-articular, 514, 517

Achillo-bursitis, 432

Achillo-dynia, 422

Acidosis, 251

Acromion bursa, 429

Actinomycosis, 126

Active hyperæmia, 39

Acupuncture in aneurysm, 308

Acute arthritis of infants, 440 necrosis of bone, 439

Adductor longus muscle, rupture of, 408

Adenoma, 202 malignant, 209 sebaceous, 393 of skin, 393 varieties of, 202

Adiposus dolorosa, 186

Aërobes, 19

Air embolism, 265 hunger, 276

Albumosuria, 195, 474, 492

Aleppo boil, 129

Alexins, 22

Ambrine, 13, 238

Amputation neuroma, 344

Anaërobes, 19

Anæsthesia, after nerve injuries, 347

Analgesia, 347

Anaphylaxis, 23

Anatomical tubercle, 134

Anatomy. _See_ Surgical Anatomy

Anel's operation for aneurysm, 307

Aneurysm, 300. _See also_ Individual Arteries abdominal, 313 acupuncture in, 308 amputation in, 310 by anastomosis, 298 Anel's operation for, 307, 310 arterio-venous, 263 axillary, 318 of bone, 498 brachial, 318 Brasdor's operation for, 308 cirsoid, 299 Colt's method of wiring for, 309 compression for, 308 consolidated, 304, 305 differential diagnosis of, 305 diffused, 302 digital compression in, 308 excision of, 307 of forearm and hand, 318 fusiform, 301 gelatin injections in, 309 Hunter's operation for, 307 iliac, 318 of individual arteries, 312 inguinal, 318 innominate, 314 intracranial, 316 of leg and foot, 320 ligation of artery for, 307 Macewen's acupuncture for, 308 Matas' operation for, 307 Moore-Corradi method, 308 natural cure of, 305 old operation for, 307 of ophthalmic artery, 317 orbital, 317 pathological, 301 pulse in, 304 rupture of, 306 sacculated, 302 suppuration in, 306 thoracic, 312 traumatic, 263, 310 treatment of, 306 varicose, 311 Wardrop's operation for, 308 X-rays in diagnosis of, 304

Aneurysmal varix, 311, 316, 318, 319, 320

Angioma, 284 arterial, 299 capillary, 294 cavernous, 297 racemosum venosum, 287 venous, 294

Angio-neurotic œdema, 348 sarcoma, 199

Angler's elbow, 406

Ankle, cellulitis of, 58

Ankylosis of joints, 503. _See also_ Individual Joints

Anoci-association, 253

Anthracæmia, 121

Anthrax, 119

Anti-bacterial sera, 23 -diphtheritic serum, 111 -streptococcic serum, 23, 109 -tetanic serum, 117

Antibodies, 22

Antigens, 22

Antiseptics, 242

Antitoxic sera, 23

Antitoxins, 22

Antivenin, 132

Aorta, abdominal, compression of, 269 aneurysm of, 313 embolism of, 93 ligation of, 314 pulsating, 305, 314

Arborescent lipoma, 423

Arseno-billon, 163

Arteries, anatomy of, 258 compression of individual, 269 contusion of, 260 digital compression of, 269 gangrene following ligation of, 94 gunshot wounds of, 263

Arteries, ligation of, for aneurysm, 307 punctured wounds of, 262 repair of, 266, 268 rupture of, 260 wounds of, 261, 262

Arterio-sclerosis, 282

Arterio-venous aneurysm, 310

Arteritis, varieties of, 282

Arthritis, 501. _See also_ Individual Joints acute, 506 of infants, 440 deformans, 524 gonococcal, 510 neuropathic, 532 ossificans, 503 pneumococcal, 509 pyogenic, 506 rheumatic, 523 rheumatoid, 524 septic, 506 scarlatinal, 508 trade, 525 traumatic, 524 tuberculous, 512 urica, 522

Arthrolysis, 505

Arthropathies, 532 gliomatous, 534

Arthroplasty, 505

Articular caries, 502, 514

Artificial hyperæmia, 39

Ascites, chylous, 325

Asepsis, 18

Asphyxia, local, 97 traumatic, 254

Atheroma, 283

Avulsion of nerves, 375 of tendons, 411

Axilla, cellulitis of, 58 hygroma of, 328

Axillary aneurysm, 318 artery, embolus of, 93 lymph glands, 336 nerve, injuries of, 363

Bacilli, 19

Bacillus aërogenes capsulatus, 99 anthracis, 119 coli communis, 27 diphtheriæ 109 drum-stick, 112 of Ducrey, 154 of glanders, 123 Klebs-Löffler, 109 of malignant œdema, 101 mallei, 123 pyocyaneus, 29 of soft sore, 154 of tetanus, 112 tubercle, 133 typhosus, 29, 452

Bacteria, death of, 21 general characters of, 18 pathogenic properties of, 19 pyogenic, 24, 29

Bacterial intoxication, 21

Bacteriology, surgical, 17

Baker's cysts, 539

Bazin's disease, 74, 169

Beck's paste in sinuses, 145

Bed-sores, 73, 103

Bence-Jones on albumosuria, 195, 474, 492

Biceps, bursa under, 430 dislocation of long tendon of, 409 rupture of, 407

Bier's artificial hyperæmia, 38

B.I.P.P., 143

Birth palsies, 362

Biskra button, 129

Bismuth gauze, 247 injections in sinuses, 145

Bites of animals, 223

Black eye, 219

Bleeder's joint, 531

Bleeders, 277 bruises in, 218

Blisters, 376 purulent, 55

Blocking of nerves for shock, 252

Blood, count, 30 cysts, 214, 220 transfusion of, 11, 253

Blood vessels. _See_ Arteries and Veins

Bloodless state, treatment of, 276

Blood letting, general, 42

Boil, 379 Aleppo, 129 Delhi, 129

Bone. _See also_ Individual Bones abscess of, 448 aneurysm of, 498 angioma of, 491 atrophy of, 479 bacterial diseases of, 438 Brodie's abscess of, 448 cancer of, secondary, 499 caries of, 437, 438 changes in ulcers of leg, 79 chondroma of, 487 cysts of, 477, 500 diseases of, 434 due to staphylococcus aureus, 438 endothelioma of, 492 exostoses of, 191, 481 fibroma of, 491 fragility of, 479 grafting, 16, 436 gumma of, 464 hydatid disease of, 467 hyperostosis, 435, 464 hypertrophic pulmonary osteo-arthropathy, 480 hypertrophy of, 435 lipoma of, 491 lipping of, 527 malacia of, 473 marrow, function of, 434 myeloma of, 491 myxoma of, 491 necrosis of, 438 neuropathic atrophy of, 479 osteoma of, 481 osteomalacia of, 473 osteomyelitis of, 65, 437, 438, 451, 453, 473 fibrosa, 476 osteoporosis of, 437 osteopsathyrosis, 479 ostitis deformans, 474 Paget's disease of, 474 periosteum, function of, 435 periostitis, 437 pulsating hæmatoma of, 498 pyogenic diseases of, 438 regeneration of, 436 rickety affections of, 468 sarcoma of, 492 sclerosis of, 435 scurvy affecting, 473 secondary tumours of, 499 surgical anatomy of, 434 staphylococcal diseases of, 438 syphilitic diseases of, 461, 465 transplantation of, 436 tuberculous diseases of, 454 tumours of, 480 malignant, 492, 499 metastatic, 499 thyreoid, 500 typhoid, infection of, 452 X-ray appearances in diseases of, 445, 455, 485, 491, 496

Bovine tuberculosis, 136

Brachial aneurysm, 318 artery, embolus of, 93 compression of, 269 birth-paralysis, 362 fibrositis, 413 neuralgia, 371 plexus, lesions of, 360

Brain, joint affections in lesions of, 537 syphilitic lesions of, 161

Branchial dermoids, 211

Brasdor's operation for aneurysm, 308

Brodie's abscess, 448

Bruises, 218

Bubo, 329 bullet, 153 of soft sores, 155

Bullet bubo, 153

Bullets, embedded, 231 varieties of, 230

Burnol, 238

Burns, 233 classification, of, 234 electrical, 239 pathology of, 233 by X-rays, 239

Bursæ. _See also_ Individual Bursæ adventitious, 426 affections of, 426 individual, 428 diseases of, 426, 428 hæmatoma of, 426 hydrops of, 427 hygroma of, 423 inflammation of, 426 injuries of, 426 loose bodies in, 427 syphilis of, 428 tuberculosis of, 428 tumours of, 427, 428

Cachexia, cancerous, 207

Calcanean bursa, 432

Calcification in arteries, 282 in muscles, 416 in tuberculosis, 136

Callosities, 376

Callous ulcers, 79, 84

Cancer, 202 arsenic, 395 of bone, 499 cachexia in, 207 chimney-sweep's, 395 colloid, 210 columnar epithelial, 209 contagiousness of, 205 cystic, 210 definition of, 202 degeneration of, 205 encephaloid, 210 _en cuirasse_, 204 glandular, 210 glandular infection in, 203 increase of, 207 of lymph glands, 340 medullary, 210 melanotic, 210, 341, 397 paraffin, 395 pigmented, 210 radium treatment of, 208 rodent, 210, 395 scirrhous, 210 of skin, 394 spread of, 204 squamous epithelial, 208 ulceration of, 205 varieties of, 208 X-ray, 208

Cancrum oris, 102

Cantharides plaster, 42

Capillaries, anatomy of, 258

Capillary angioma, 294 loops, 3

Carbolic gangrene, 95

Carbon-dioxide snow, 297

Carbuncle, 380

Carcinoma. _See_ Cancer

Caries, 437, 438 of articular surfaces, 502, 514 sicca, 438 syphilitic, 462 tuberculous, 455

Carotid aneurysm, 314 artery, compression of, 269 tubercle, 269

Carpal ganglion, 214

Carron oil, 238

Cartilage, grafting of, 16 repair of, 7 ulceration of, 502, 514

Cartilaginous exostosis, 191, 481

Caseation in tuberculosis, 136

Catalepsy, 116

Catgut, infection by, 51 preparation of, 245

Cautery in hæmorrhage, 271

Cavernous angioma, 298 lymphangioma, 327

Cellulitis, 52 in different situations, 58 diffuse, 52

Cephalic or Kopf tetanus, 116

Cerebro-spinal meningitis, 115

Cervical adenitis, 332 rib, 360

Chalk stones in gouty joints, 523

Chancre, concealed, 152, 153, 157 erratic, 153 extra-genital, 153 hard, 151 meatal, 152 multiple, 152 relapsing false indurated, 172 soft, 154 urethral, 152

Chancroid, 154

Charcoal poultice, 84

Charcot's disease, 533

Cheloid. _See_ Keloid

Chemiotaxis, 32

Chigoe, 130

Chilblain, 378

Chimney-sweep's cancer, 395

Chloroma, 200

Chondroma, 189, 487 multiple, 544

Chondromatosis, 488

Chondro-sarcoma, 189, 200, 487

Chordoma, 200

Choroiditis, syphilitic, 177

Chylorrhœa, 325

Chylo-thorax, 325

Chylous ascites, 325

Cicatrices, varieties of, 400

Cicatricial contraction, 4 tissue, 4

Circumflex nerve. _See_ Axillary Nerve

Cirsoid aneurysm, 299

Claw-hand, 369

Cloacæ in bone, 443

Cocci, 18

Cœliac artery, aneurysm of, 313

Coley's fluid, 201

Collapse, 254

Collateral circulation, 267

Colles' law, 178

Colloid cancer, 210

Common peroneal nerve, 370

Compound palmar ganglion, 217, 423

Condylomata, 158, 174

Congenital fistulas, 60 telangiectasis, 294

Connective tissue, repair of, 6

Contracture of joints, 502 of muscles, 415 paralytic, 347

Contusions, 218

Cornea, syphilitic ulceration of, 177

Corns, 377

Corpora oryzoidea, 539

Counter-irritants, 37, 42

Craniotabes, 175, 176, 465

Crural fibrositis, 413

Crutch paralysis, 351

Cupping dry, 39 wet, 42

Cutis anserina, 36

Cyanosis, traumatic, 254

Cyst, 212 atheromatous, 389 Baker's, 539 blood 214, 220 of bone, 477, 500 dentigerous, 193 derma, 210 exudation, 212 ganglionic, 215 hæmorrhagic, 220 hydatid, 213 implantation, 212 of joints, 538 lymph, 214 lymphatic, 219, 328 omental, 329 parasitic, 213 retention, 212 sebaceous, 212, 389 serous, 219 venous, 289

Cystic adenoma, 202 carcinoma, 210 hygroma of neck, 328 lymphangioma, 327, 328

Dactylitis, syphilitic, 176, 460, 466 tuberculous, 460

Dancer's sprain, 406

Deafness, syphilitic, 178

Deformities. _See_ Individual Regions

Delhi boil, 129

Delirium, in surgical patients, 255 traumatic, 257

Delirium tremens, 256

Dentigerous cyst, 193

Dercum on adiposus dolorosa, 186

Derma-cysts, 210

Dermatitis, 239, 292

Dermoids, 210

Diabetic gangrene, 96

Diarsenol, 163

Diapedesis of red corpuscles, 32

Diaphysial aclasis, 483

Diffuse aneurysm, 302 cellulitis, 52 fibromatosis, 194 lipomatosis, 187 neuro-fibromatosis, 355 osteoma, 485 suppuration, 52

Diphtheria, 109 antitoxin in, 111 intubation in, 111

Diplococci, 19

Dislocation of nerves, 351, 369 pathological, 514 of tendons, 408

Double cyanide gauze, 247

Drainage of wounds, 222

Dressings, surgical, 247

Drill-bone, 418

Drop-finger, 411 -foot, 370 -wrist, 365

Drunkard's palsy, 351, 364

Duchenne's paralysis, 361

Ducrey's bacillus, 154

Duodenum, ulceration of, in burns, 236

Dwarf, rickety, 469 syphilitic, 178

Eburnation of articular surfaces, 557

Ecchondroses, 527

Ecchymosis, 218

Echinococcus, 213

Echthyma, 158

Eczema, varicose, 292

Elbow, angler's, 406 cellulitis of, 58 tennis, 406

Electricity, injuries by, 239

Electrolysis in angioma, 297

Elephantiasis, varieties of, 360, 384, 386

Embolism, 281 air, 265

Embolism, fat, 254 of individual arteries, 93

Embolus, 281

Emigration of leucocytes, 32

Emotional shock, 251

Emphysema, 99, 102

Emprosthotonos, 214

Empyema of joints, 501, 518

Encephaloid cancer, 210

Endarteritis obliterans, 282 syphilitic, 161

Endo-aneurysmorrhaphy, 307

Endothelioma, 196 of bone, 492

Epicritic sensibility of nerves, 343

Epidermis, grafting, 12 repair of, 4

Epiphysial cartilage, 434 junction, 434 in rickets, 469

Epiphysiolysis, 440

Epiphysitis, 437 syphilitic, 465

Epithelial tumours, 201

Epithelioma, 208 chimney-sweep's, 395 lupus, 384 paraffin, 395 in scars, 402 sinus, 500 of skin, 394 trade, 395 varieties of, 208 X-ray, 395

Epithelium grafting, 12 repair of, 6

Epulis, 491

Erb's paralysis, 361

Erysipelas, varieties of, 107

Erythema pernio, 378 nodosum, 442

Evaporating lotions, 41

Exfoliation, 438

Exophthalmos, pulsating, 317

Exostosis, 191, 481 bursata, 481 cancellous, 481 cartilaginous, 191, 481 false, 192 ivory, 481 multiple, 483 spongy, 191, 481 subungual, 191, 404, 481

Explosives, wounds by, 231

External iliac artery, embolus of, 93

External popliteal nerve. _See_ Common Peroneal Nerve

Extravasation of blood, 259

Exudates, varieties of, 33

Exudation cysts, 212

Eye, syphilitic lesions of, 160, 176, 177

Facial artery, compression of, 269 erysipelas, 107

Fainting, 249

Farcy, 125

Fascia, grafting of, 16

Fat embolism, 254 grafting of, 16

Fatty hernia, 187 tumours, 184

Feet, trench, 96

Femoral aneurysm, 318 artery compression of, 269 embolus of, 93 lymph glands, 323

Fever, 35

Fibro-adenoma, 202

Fibroblasts, 3

Fibroid, recurrent, of Paget, 199, 392, 420 uterine, 195

Fibroma, 194 of bone, 491 diffuse, 194 recurrent, of Paget, 199, 392, 420 of skin, 391 varieties of, 194

Fibromatosis, diffuse, 194

Fibro-myoma, 195

Fibro-sarcoma, 199

Fibrositis, varieties of, 372, 412

Filaria Bancrofti, 326

Filarial disease, 326

Finger, chancre of, 154 drop-, 411 mallet-, 411

Fingers, gouty affections of, 523 whitlow of, 55

Finsen light treatment, 138

Firearms, wounds by, 225, 227, 230

First intention, healing by, 2

Fistula, 60 congenital, 60 lymphatic, 325 varieties of, 60

Fluctuation, 49

Fomentations, 37, 41

Foot, cellulitis of, 58 drop-, 370 Madura, 129 perforating ulcer of, 73

Forci-pressure in hæmorrhage, 271

Forearm, aneurysm of, 318 cellulitis of, 58

Foreign bodies, embedded, 6, 231

Fracture, pathological, 444

Fraenkel's pneumococcus, 28

Fragilitas ossium, 479

Friedländer's pneumo-bacillus, 28

Frost-bite, gangrene from, 95

Furunculus orientalis, 129

Galyl, 163

Ganglion, 214, 215, 217 compound palmar, 217, 423

Ganglionic neuroma, 353

Gangrene, 86 acute infective, 99 emphysematous, 102 from angio-sclerosis, 98 bacterial varieties of, 99 from burns and scalds, 95 cancrum oris, 102 carbolic, 95 from chemical agents, 95 clinical types of, 86 varieties of, 88 from constriction of vessels, 94 diabetic, 96 dry, 86 embolic, 92 from ergot, 98 from frost-bite, 95 gas, 102 from interference with circulation, 86 following ligation of arteries, 94 line of demarcation in, 87 malignant œdema, 101 moist, 87 noma, 102 phagedæna, 153 Raynaud's disease, 97 senile, 88 traumatic, 94 from trench feet, 96 white, 93 from whitlow, 99

Gas gangrene, 102

Gasserian ganglion, removal of, 375

Gauze, varieties of, 247

Gauze, sterilisation of, 245

Gelatin, injection of, in aneurysm, 309 in hæmophilia, 280

Gelatinous degeneration of joints, 515

Giant cells, 3

Glanders, 123

Glands, lymph. _See_ Lymph Glands

Glioma, 196

Gliomatous arthropathies, 534

Glio-sarcoma, 200

Gloves in surgery, 244

Gluteal aneurysm, 319 fibrositis, 372, 413

Glycogen reaction, 30

Glycosuria in perforating ulcer, 73

Golfer's back, 405

Gonorrhœal bursitis, 428 joint lesions, 510 lymphangitis, 325 myositis, 416 ophthalmia, joint lesions following, 510 rheumatism, 510 teno-synovitis, 423

Gout, joint affections in, 522

Gouty bursitis, 428 joints, 522 teno-synovitis, 422 tophi, 523 ulcers, 77

Grafting of bone, 436 of epithelium, 12 of mucous membrane, 16 of skin, 11 of tissues, 10

Granulation, healing by, 5 tissue, formation of, 2 syphilitic, 146 tuberculous, 136

Granulations, 2

Granuloma, 42

Groin, cellulitis of, 59 filarial disease in lymphatics of, 326

Growing pains, 451

Growth fever, 451

Gumma, 168 of bone, 464 peri-bursal, 521 periosteal, 521 peri-synovial, 521 subcutaneous, 76 syphilitic, 168

Gummatous infiltration, 168

Gunshot wounds, 225, 227, 230

Hæmatemesis, 259 post-operative, 275

Hæmatoma, 220 bursal, 426 pulsating, of bone, 498

Hæmaturia, 259

Hæmophilia, 277

Hæmophilic joint, 531

Hæmoptysis, 259

Hæmorrhage, 266 arrest of, 266, 270, 272, 274 arterial, 259 capillary, 260 cautery in, 271 constitutional effects of, 275 digital compression in, 269 external, 259 forci-pressure in, 271 intermediate, 272 internal, 259 ligature in, 270 in operations, 269 prevention of, 269 primary, 266 reactionary, 272 saline infusions in, 276 secondary, 273 styptics in, 271 torsion in, 271 tourniquets in, 270, 272 toxic, 275 from varicose veins, 292 venous, 259

Hæmorrhagic diathesis, 277

Hæmostatics, 271

Hair, syphilitic lesions of, 159

Hand, claw-, 369

Hands, disinfection of, 244

Hard chancre, 151

Healing by blood-clot, 6 by first intention, 2 by granulation, 5 by primary union, 2 rate of, 9 under scab, 6 by second intention, 5 sore, 69, 81 ulcer, 77 by union of granulating surfaces, 5

Heart, massage of, 265

Heberden's nodes, 529

Hectic fever, 62

Heliotherapy, 139

Hernia, fatty, 187 of muscle, 408

Herpes, syphilitic, 156

Hilton's method of opening abscess, 50

Hodgkin's disease, 377

Horns, varieties of, 389, 391

Housemaid's knee, 426, 431

Hunter's operation for aneurysm, 307

Hutchinson's teeth, 177

Hydatid cysts, 213 of bone, 467 of muscle, 421 thrill, 214

Hydrocele of neck, 328

Hydrophobia, 115, 118

Hydrops, 501, 518

Hygroma of axilla, 328 bursal, 427 of neck, 328

Hyperæmia, 32 active, 39 artificial, 36 passive, 38 in tuberculosis, 138

Hyperostosis, 435 syphilitic, 464

Hypertrophic pulmonary osteo-arthropathy, 480

Hysterical joint affections, 537

Ice-bags, 41

Ichthyma, syphilitic, 158

Igni-puncture in nævus, 297

Iliac aneurysm, 318

Immunity, 22

Imperial drink, 40

Implantation cysts, 212

Infantile scurvy, 473

Infection, accidental, 241 by catgut, 51 mixed, 20 prevention of, 243 of wounds, 241

Inflammation, 31 changes in, 32 chronic, 42 clinical aspects of, 33 constitutional disturbance in, 35 general principles of treatment in, 36, 39

Inflammation, leucocytosis in, 36 stages of, 32

Infusion of saline solution, 276

Ingrowing toe-nail, 403

Inguinal aneurysm, 318 lymph glands, 323

Injuries, 218. _See also_ Individual Tissues and Regions constitutional effects of, 249

Innominate aneurysm, 314

Inoculation tubercle, 382

Insects, poisoning by, 130

Instruments, sterilisation of, 245

Intercostal fibrositis, 413

Intermittent claudication of vessels, 98

Internal popliteal nerve. _See_ Tibial Nerve

Interstitial keratitis, 177

Intestine, repair of, 9

Intoxication, bacterial, 21

Intracranial aneurysm, 316

Intra-cystic growths, 202

Intubation of larynx, 111

Involucrum, 443

Iodine, catgut, 246 for disinfection of skin, 245 reaction, 30

Iodoform gauze, 247 injection of, 142 in joint diseases, 519

Iritis, syphilitic, 160

Irrigation, continuous, 54

Irritable ulcers, 79

Ischæmic contracture of muscles, 415

Ischial bursa, 430

Ischias scoliotica, 372

Ivory exostosis, 481

Jaws, actinomycosis of, 127 changes in, in rickets, 470 cystic tumours of, 193

Jigger, 130

Joints. _See also_ Individual Joints ankylosis of, 503 bacterial diseases of, 506 bleeder's, 531 Charcot's disease of, 533 chondromata, multiple, of, 544 contracture of, 502 cysts of, 538 developmental errors of, 505 diseases of, general, 501, 506 disorganisation of, 502 empyema of, 501 gelatinous degeneration of, 515 gliomatous arthropathies, 534 gonococcal affections of, 510 gouty affections of, 522 hæmophilic, 531 hydrops of, 501 hysterical affections of, 537 impaired mobility of, 502 iodoform in diseases of, 519 loose bodies in, 529, 539 mimetic affections of, 537 nerve lesions affecting, 532 neuro-arthropathies, 532 osteo-arthritis, 524 pneumococcal infection of, 509 pyæmic affections of, 508 pyogenic diseases of, 506 rheumatic affections of, 523, 524 rigidity of, 502 scarlet fever, infection of, in 508 spinal diseases affecting, 532 starting pains in, 502, 517 synostosis, 503 syphilitic diseases of, 521 tuberculous diseases of, 512 tumours of, 538 typhoid infection of, 508 white swelling of, 515, 518

Jumper's sprain, 406

Keloid, 194, 401

Keratitis, interstitial, in syphilis, 177

Keratoma of nail bed, 391

Kharsivan, 163

Klapp's suction bells, 39

Klebs-Löffler bacillus, 109

Klumpke's paralysis, 361

Knee, cellulitis of, 58 ganglion of, 215 housemaid's, 426, 431

Kopf or cephalic tetanus, 116

Kyphosis, 471

Labourer's back, 405

Larynx, syphilis of, 177

Leeches, 41

Leg ulcer, 72 varicose veins of, 287

Leiter's lead tubes, 41

Leontiasis ossea, 485

Leucocytes, emigration of, 32 varieties of, 29 wandering, 3

Leucocythæmia, 340

Leucocytosis, 22, 29 absence of, 30 digestion, 30 after hæmorrhage, 30 local, 32 physiological, 29, 30 post-operative, 30

Leucopenia, 30

Leucoplakia, 167

Lightning stroke, 240

Line of demarcation in gangrene, 87

Lingual dermoids, 211

Lipoma, 184 arborescent, 423 of bone, 187, 491 diffuse, 187 intra-muscular, 188 multiple, 186 nasi, 393 periosteal, 187 subcutaneous, 184, 186 subserous, 187 subsynovial, 187

Lipomatosis, diffuse, 187

Lipping of bone, 527

Liquor epispasticus, 42 puris, 45

Listerian methods of wound treatment, 242

Locking of joints, 505

Lock-jaw, 113

Locomotor ataxia, joint lesions in, 532

Long thoracic nerve, injuries of, 363

Loose bodies in bursæ, 427 in joints, 529, 539 in tendon sheaths, 423 varieties of, 539

Lotion, evaporating, 41

Luargol, 163

Luetin, 149

Lumbago, 412

Lumbo-sacral fibrositis, 412

Lupus, 134, 382 epithelioma, 384 syphilitic, 169 tuberculous, 382 varieties of, 383, 393

Lymph, 321 cysts, 214 glands, cancer of, 340 diseases of, 329 functions of, 221 sarcoma of, 341 surgical anatomy of, 321 syphilitic diseases of, 337 tuberculosis of, 331 tumours of, 340 œdema, 325 scrotum, 389 vessels, diseases of, 325 injuries of, 323

Lymphadenitis, 53, 329

Lymphadenoma, 337

Lymphangiectasis, 214, 326

Lymphangioma, varieties of, 327

Lymphangioplasty, 325, 386

Lymphangio-sarcoma, 199

Lymphangitis, 325 septic, 53 varieties of, 325

Lymphatic cyst, 328 fistula, 324 œdema, 325

Lymphatics, 321

Lymphocytosis, 29

Lymphorrhagia, 323

Lympho-sarcoma, 199, 340

Macewen's method of compressing abdominal aorta, 269

Macrophages, 22

Madura foot, 129 _Main en griffe_, 369

Malacia of bones, 473

Malignant adenoma, 209 cachexia, 207 œdema, 101 pustule, 120 tumours, 183 ulcers, 77

Mallein test, 125

Mallet-finger, 411

Malum senile, 524

Marriage and syphilis, 167

Matas' operation for aneurysm, 307

Median nerve, lesions of, 367

Medullary cancer, 210

Melæna, 259

Melanotic cancer, 210, 397 sarcoma, 200

Melon-seed bodies, 539

Meningitis, basal, 115 cerebro-spinal, 115

Mercury in syphilis, administration of, 165

Metchnikoff's cream, 157

Michel's clips, 222

Micrococci, 18

Micrococcus tetragenus, 29

Micro-organisms, 18

Microphages, 22

Mimetic joint affections, 537

Miner's elbow, 426

Mitchell's operation for varicose veins, 294

Mixed infection, 20 nævus, 295 venereal infection, 156

Moist gangrene, 87

Moles, 390 nævoid, 295

Molluscum fibrosum, 194, 359, 391

Moore-Corradi method of treating aneurysm, 308

Mosetig-Moorhof on filling of bone cavities, 447

Mother's mark, 294

Muco-pus, 52

Mucous membrane, grafting of, 16 suppuration in, 51 patches, 160, 174

Multilocular cystic tumours of jaw, 193

Mummification, 86

Muscle, affections of, 405 atrophy of, 412 calcification of, 416 congenital absence of, 411 contracture of, 415 contusion of, 405 diseases of, 411 gonorrhœa of, 416 grafting of, 16 hernia of, 408 hydatid cysts of, 421 inflammation of, 415 injuries of, 405 ossification in, 416 repair of, 8 rheumatism of, 412 rupture of, 405, 406 sprain of, 405 syphilis of, 416 tuberculosis of, 416 tumours of, 420 wounds of, 409

Muscular rheumatism, 412

Musculo-cutaneous nerve, 364

Musculo-spiral nerve. _See_ Radial Nerve

Mustard leaves, 42

Mycetoma, 129

Myelitis, syphilitic, 161

Myeloma, 195, 491 of bone, 491 of tendon sheaths, 424

Myoma, 195

Myo-sarcoma, 200

Myositis ossificans, 416, 418 varieties of, 415

Myxo-adenoma, 202

Myxoma, 194 of bone, 491

Myxo-sarcoma, 200

Nævoid mole, 295

Nævus, 294 electrolysis of, 297 operations for, 298 radium treatment of, 297 varieties of, 294

Nail fold, whitlow of, 56 horns, 391

Nails, affections of, 402 ingrowing, 403 regeneration of, 7 syphilitic lesions of, 159, 402

Nasal bones, syphilitic disease of, 188, 462

Naso-pharyngeal polypus, 491

Natal sore, 129

Neck, cystic hygroma of, 328 glands of, diseases, 332 hydrocele of, 328 lipomatosis of, 187 painful stiff-, 413

Necrosis, acute, 439 of bone, 438 quiet, of Paget, 452 syphilitic, 462

Neo-diarsenol, 163 -kharsivan, 163 -salvarsan, 163

Neoplasms, 181

Nerve of Bell. _See_ Long Thoracic Nerve

Nerves, 342. _See also_ Individual Nerves alcohol injections of, 374 anatomy of, 342 avulsion of, 375 blocking of, 251, 252 bullet wounds of, 346 contusion of, 345 crushing of, 345 diseases of, 352 dislocation of, 351, 369 effects of division of, 344 gun-shot wounds of, 346 grafting of, 16 implicated in scar tissue, 345 individual, surgery of, 360 injuries of, 344 joint affections in lesions of, 532 reaction of degeneration, 347 regeneration of, 9, 346 in scar tissue, 345 sensibility, forms of, 343 subcutaneous injuries of, 350 suture of, primary, 348 secondary, 349 Tinel's sign, 349 torn, 345 tumours of, 353 ulcers in lesions of, 73, 82

Neuralgia, varieties of, 371

Neurectomy, 375

Neuritis, multiple peripheral, varieties of, 352 traumatic, 352

Neuro-arthropathies, 352. _See also_ Individual Joints

Neuro-fibromatosis, 355, 359

Neurolysis, 345

Neuroma, stump, 344 varieties of, 353 "914," 613

Nodes, periosteal, 464 Heberden's 529

Noma, 102

Nose, sebaceous adenoma of, 393

Novo-arseno-billon, 163

Nucleinate of soda, 29

Odontoma, 192 varieties of, 193

O'Dwyer's intubation apparatus, 111

Œdema, 32, 34 angio-neurotic, 348 lymphatic, 325 malignant, 101 persistent, 109

Olecranon bursa, 428

Omental cyst, 329

Onychia, varieties of, 402

Operations during shock, 252

Opisthotonos, 114

Opsonins, 22

Orbital aneurysm, 317

Orthotonos, 114

Ossification in muscles, tendons, and fasciæ, 416

Ossifying junction, 434

Osteo-arthritis, 524 syphilitic, 522

Osteo-arthropathy, pulmonary, 480

Osteochondritis dessicans, 544

Osteogenesis imperfecta, 479

Osteoid sarcoma, 200

Osteoma, 191, 481 cancellous, 191 compact, 192 diffuse, 485 ivory, 192 multiple, 544 in muscles and tendons, 416 spongy, 191 subungual, 191, 404, 481

Osteomalacia, varieties of, 473

Osteomyelitis, 65, 437 acute, 65, 438, 451, 453 after amputation, 453 bipolar, 439 fibrosa, 476 gummatous, 462 from infection from soft parts, 453 pyogenic, 438 relapsing, 448 sequelæ of, 443 streptococcal, 451 tuberculous, 456, 458 in typhoid fever, 452

Osteophytes, 435

Osteoporosis, 437

Osteopsathyrosis, 479

Osteosarcoma, 200

Osteosclerosis, 435

Ostitis deformans, 474 rarefying, 474

Ovarian dermoids, 211

Ovary, grafting of, 16

Ozœna, 176

Pachydermatocele, 360

Paget's disease of bone, 474 of nipple, 397 recurrent fibroma, 199, 392, 420

Pain, starting, in joint disease, 502, 517 varieties of, 35

Painful subcutaneous nodules, 354, 392

Palate, syphilitic lesions of, 178, 462

Palmar ganglion, compound, 217, 423

Papilloma, varieties of, 201, 392

Paraffin cancer, 395

Paralysis, brachial birth, 362 Erb-Duchenne, 361 Klumpke's, 361 post-anæsthetic, 360 pseudo, of syphilis, 174, 466

Parasitic bacteria, 20 cysts, 213

Paronychia. _See_ Onychia

Parotid abscess in pyæmia, 66 lymph glands, 321 tumours, 195

Parotitis, 66

Parrot's nodes, 175, 465

Passive hyperæmia, Bier's, 38

Pasteur's treatment for hydrophobia, 119

Pelvis, rickety changes in, 471

Perforating ulcer, 73, 82

Perichondritis, syphilitic, 465

Peri-lymphangitis, 325

Periosteum, function of, 434 gumma of, 464 in rickets, 469

Periostitis, 437. _See also_ Osteomyelitis syphilitic, 461 tuberculous, 455

Peripheral neuritis, 352

Peroneal nerve, 370

Peronei tendons, dislocation of, 409

Petrifying sarcoma, 200

Phagedæna, 153

Phagedænic ulcers, 80, 85

Phagocytes, 3, 22

Phagocytosis, 22

Phimosis, with hard chancre, 152 with soft sores, 155

Phlebitis, 285, 292

Phlegmasia alba dolens, 286

Picric acid, 13, 237

Pigeon-breast, 471

Plantaris, rupture of, 408

Pleurodynia, 413

Pleurosthotonos, 114

Pneumo-bacillus, Friedländer's bacteria, 28

Pneumococcal arthritis, 509

Pneumococcus, 28

Polypi, 195

Popliteal aneurysm, 320 artery, embolus of, 93 bursæ, 432 lymph glands, 323 nerves. _See_ Common Peroneal Nerve and Tibial Nerve

Port-wine stain, 294

Post-anæsthetic paralysis, 360 -anal dimple, 211

Posterior auricular lymph glands, 322

Post-rectal dermoids, 211

Potato-nose, 393

Poultice, 37 charcoal, 84

Pre-auricular lymph glands, 322

Prepatellar bursa, 431

Pressure sores, 70, 82

Primary union of wounds, 2

Protopathic sensibility of nerves, 343

Proud flesh, 79

Psammoma, 200

Pseudo-leucæmia, 337

Pseudo-paralysis of syphilis, 174, 466

Psoas bursa, 430

Pulmonary osteo-arthropathy, 480

Pulsating aorta, 305, 314 exophthalmos, 317 hæmatoma of bone, 498

Punctured wounds, 222

Purpura, 280

Purulent blister, 55

Pus, 45 varieties of, 46

Pyæmia, 64 abscess in joints in, 508

Pyogenic bacteria, 24, 29

Quadriceps extensor femoris, rupture of, 408

Rabies, 118

Rachitis, 468 adolescentium, 472

Radial nerve, lesions of, 364

Radium, in lupus, 385 in cancer, 208 in nævus, 297 ulceration from, 239

Ranula, 329

Rarefying ostitis, 437

Ray fungus, 126

Raynaud's disease, 97

Reaction of degeneration, 347

Reactionary hæmorrhage, 272

Recklinghausen's disease, 355

Recurrent fibroid of Paget, 199, 392, 420

Repair. _See_ Individual Tissues conditions interfering with, 17 after loss of tissue, 4 modifications of, 4 of separated parts, 5

Rest, 17

Rests, fœtal, 181

Retention cysts, 212

Retro-pharyngeal lymph glands, 322

Reverdin's method of skin-grafting, 13

Rhabdomyoma, 196

Rheumatic arthritis, 524 fever, 509 gout, 524 torticollis, 413

Rheumatism, acute, 509 chronic, 523 gonorrhœal, 510 muscular, 412 scarlatinal, 508

Rheumatoid arthritis, 524

Rhinophyma, 393

Rickets, 468 bone lesions in, 469 changes in skeleton in, 470 late, 472 scurvy, 473

Rickety, dwarf, 469 pelvis, 471 rosary, 469 scoliosis, 471

Rider's bone, 418 sprain, 407

Rigidity of joints, 502

Rigor, 36

Risus sardonicus, 114

Rodent cancer, 210, 395 ulcer, 210, 395

Röntgen rays. _See_ X-rays

Rose or erysipelas, 107

Roseola, syphilitic, 158

Rupia, syphilitic, 158

Sabre-blade deformity of tibia, 466

Sacculated aneurysm, 302

Saddle-nose deformity, 174

Saline infusions in hæmorrhage, 276

Salvarsan in syphilis, 162

Sapræmia, 60 chronic, 62

Saprophytic bacteria, 20

Sarcoma, 197 of bone, 492 inoperable, 201 of joints, 538 of lymph glands, 341 melanotic, 200 periosteal, 493 of skin, 398 of synovial membrane, 538 of tendon sheaths, 424 varieties, 199

Scab, healing under, 6

Scalds, 233

Scapula, winged, 363

Scarlet fever, joint lesions in, 508

Scars. _See_ Cicatrices

Sciatic nerve, lesions of, 370

Sciatica, 371

Scirrhous cancer, 210

Sclavo's serum, 123

Scoliosis, rickety, 471 in sciatica, 372

Scorbutic ulcers, 77

Scrotum, elephantiasis of, 389

Sculler's sprain, 406

Scurvy, 473 rickets, 473

Sebaceous adenoma, 393 cysts, 389 horns, 389

Secondary hæmorrhage, 273 syphilis, 151, 147

Selenium in malignant tumours, 201, 208

Semilunar ganglion, 375

Semi-membranosus bursa, 432

Sepsis, 18

Septicæmia, 53, 63

Sequestrectomy, 446

Sequestrum of bone, 438

Serratus anterior muscle, paralysis of, 363

Serum, anti-diphtheritic, 109 anti-bacterial, 23 anti-tetanic, 117 disease, 23 in hæmophilia, 280 polyvalent, 23 Sclavo's, for anthrax, 123 treatment, 23

Seton, 217

Shell wounds, 231

Shock, 250 delayed, 252

Shoulder, fibrositis of, 413

Sinus, 59 epithelioma, 500 tuberculous, 143

"606," 162

Skewers for prevention of hæmorrhage, 270

Skin, 376 abscesses of, 382 actinomycosis of, 126 cancer of, 394, 398 dermoids, 210 grafting of, 11, 14 preparation of, for operation, 244 repair of, 6 sporotrichosis of, 385 structure of, 376 syphilitic lesions of, 157, 166 tuberculosis of, 382, 385 tumours of, 391

Skull, bossing of, 465 craniotabes of, 175, 176, 465 diffuse osteoma of, 485 natiform, 176 Parrot's nodes, 465 syphilitic disease of, 462 unilateral hypertrophy of, 487

Slough, 86

Snake-bites, 131

Snuffles, 173

Soft chancre, 154 corns, 377 sore, 154

Spas, 531

Spasmodic tic, 373

Sphagnum moss, 247

Spinal arthropathies, 532 cord, joint affections in lesions of, 532 repair of, 9 syphilis of, 161

Spine, changes in rickets, 471

Spirilla, 19

Spirochæte pallida, 147

Spironema pallidum, 147

Splenic fever, 119

Spores, 18

Sporotrichosis, 385

Sprain of muscle, 405, 407

Sprinter's sprain, 406

Staphylococci, 19, 24, 438

Staphylococcus albus, 26 aureus, 25

Starting pains in joints, 502, 517

Stasis, 32

Sterilisation, surgical, 243

Sterno-mastoid lymph glands, 322

Stitch abscess, 51

Stitches. _See_ Sutures

Streptococci, 19, 24

Streptococcus pyogenes, 26

Streptothrix actinomyces, 126

Strychnin poisoning, 115

Stump neuroma, 344

Styptics, 271

Sub-acromial bursa, 429

Sub-calcanean bursa, 433

Subclavian aneurysm, 317

Sub-crural bursa, 430

Sub-deltoid bursa, 429

Submaxillary lymph glands, 322

Submental lymph glands, 322

Sub-patellar bursa, 431

Subscapularis bursa, 430

Subungual exostosis, 191, 404, 481

Suction bells, 39

Suppuration, 45 chronic, 59 diffuse, 52 in mucous membranes, 52 in wounds, 50

Supra-clavicular lymph glands, 322

Supra-hyoid lymph glands, 322

Supra-scapular nerve, lesions of, 364

Surgery, definition of, 1 Listerian, 242

Surgical anatomy of blood vessels, 258 of bone, 434 of epiphyses, 434 of lymphatics, 321 of nerves, 342 of skin, 376

Surgical bacteriology, 17, 18 shock, 250

Sutures, 221 sterilisation of, 245

Sweat-glands, tumours of, 393

Syncope, 249 local, 97

Synostosis, 503

Synovial membrane, tumours of, 538

Synovitis, 501, 506 gonococcal, 510 septic, 506 serous, 506, 507 suppurative, 507 syphilitic, 521

Syphilis, 147. _See also_ Individual Tissues and Organs

Syphilis, acquired, 146, 149 in infants, 179 arsenical preparations in, 162 arteritis in, 282 bones, lesions in, 461, 465 brain, lesions in, 161 of bursæ, 428 cirrhosis in, 168 Colles' law, 178 contracture of muscle in, 416 dactylitis in, 176, 460, 466 epiphysitis of infants, 465 extra-genital, 153 in female, 152, 164 gumma, 168, 462 hydrops in, 521 incubation of, 151 in infants, 179 inherited, 146, 172 contagiousness of, 178 diagnosis of, 178 facies of, 174, 175 lesions of bone in, 465 eyes in, 176, 177 joints in, 522 skin in, 173, 174 teeth in, 177 treatment of, 179 insontium, 153 intermediate stage of, 167 interstitial keratitis in, 177 iodides in, 171 iritis in, 166 joint lesions in, 521 of larynx, 177 lupus, 169 lymphadenitis, 153, 337 lymphangitis, 326 in male, 152 malignant, 161 and marriage, 167 mercury in, 164 mixed infection, 156 of mouth, 166 of mucous membranes, 160, 173, 174 mucous patches, 160, 174 of muscle, 416 of nails, 159 of nose, 188 onychia in, 403 osteo-arthritis, 522 of palate, 178, 462 phagedæna, 153 phimosis in, 152 in pregnant women, 164 primary, 151 diagnosis of, 155 lesion of, 146, 151 treatment of, 163 prophylaxis of, 149 pseudo-paralysis of, 174, 466 reminders, 167 second attacks of, 172 secondary, 151, 157 diagnosis of, 161 lesions of eye in, 160 hair in, 159 nails in, 159, 402 skin in, 162 treatment of, 162 serum diagnosis, 149 skin affections in, 157, 166 skull, lesions of, 462 spirochæte pallida in, 147 stages of, 150 stomatitis, 174 synovitis, 521 teeth in, 177 of tendon sheaths, 424 tertiary, 151, 167 diagnosis of, 167 general manifestations of, 167 lesions of mucous membrane in, 171 skin in, 168, 169 treatment of, 171 ulcer, 169 ulcers in, 76, 83, 169 virus of, 147 Wassermann reaction in, 156

Syphiloma, 168

Syringomyelia, joint lesions in, 534

Tabes dorsales, joint lesions in, 532

Tænia echinococcus, 213

Tailor's ankle, 432

Tailor's bottom, 426, 430

Tarsal ganglion, 215

Tarsus, tuberculosis of, 459

Teeth in inherited syphilis, 177

Telangiectasis, congenital, 294

Temperature in surgical diseases, 35, 40

Temporal artery, compression of, 269

Tenderness, 34

Tendinitis, 416

Tendon sheaths, affections of, 421 syphilitic affections of, 424 tuberculosis of, 423, 424 tumours of, 424 whitlow of, 57

Tendons. _See also_ Individual Tendons avulsion of, 411 calcification in, 416 diseases of, 411 dislocation of, 408 ganglion of, 217 grafting of, 16 inflammation of, 416 ossification of, 416 repair of, 8 rupture of, 406, 408 tumours of, 420 wounds of, 409

Tennis-player's elbow, 406

Teno-synovitis, varieties of, 421

Teratoma, 212

Tertiary syphilis, 151, 167

Tetanus, varieties of, 112

Tetany, 116

Thiersch's method of skin-grafting, 12

Thirst, treatment of, 40

Thoracic aneurysm, 312 duct, subcutaneous rupture of, 325 surgical anatomy of, 324 wounds of, 325

Thorax, rickety changes in, 469

Thrombo-phlebitis, 285

Thrombosis, 32, 281, 285, 292

Thyreoid gland, grafting of, 16 secondary tumours derived from, 500

Tibia, sabre-blade deformity of, 466

Tibial nerve, lesions of, 371

Tic, spasmodic, 373

Tinel's sign, 349

Toe-nail, ingrowing, 403

Toes, gouty affections of, 522 syphilitic dactylitis of, 176, 460, 466 tuberculous dactylitis, 460

Tomato tumour, 393

Tophi, gouty, 523

Torsion of blood vessels, 271

Torticollis, rheumatic, 413

Tourniquet, varieties of, 270, 272

Toxæmia, 21

Toxins, 21, 33

Tracheal tug in aneurysm, 312

Tracheotomy, 111

Trade arthritis, 525 bursitis, 426 epithelionia, 395

Transfusion of blood, 276

Transplantation of tissues, 10

Trench feet, 96

Trendelenburg's operation for varicose veins, 293

Treponema pallidum, 147

Trifacial neuralgia, 373

Trigeminal neuralgia, 373

Trismus, 117

Trochanteric bursa, 430

Trophic changes after nerve injuries, 348 ulcer, 73

Tropical elephantiasis, 386

Trunk neuroma, 354

Tubercle, anatomical, 134 bacillus, 133

Tuberculin, 138

Tuberculosis, 133. _See also_ Individual Tissues and Organs bacillus of, 133 of bone, 454, 456, 458 bovine, 136 of bursæ, 428 calcification in, 136 caseation in, 136 general, 135 human, 136 of joints, 512 of lymph glands, 331 of lymph vessels, 326 modes of infection, 136 of muscle, 416 of nails, 403 open-air treatment of, 137 passive hyperæmia in, 138 principles of treatment of, 137 of skin, 382, 385 of tendon sheaths, 423, 424 trauma in causation of, 135 vaccine treatment in, 138

Tuberculous abscess, 139 arthritic fever, 516 dactylitis, 460 granulation tissue, 136 lupus, 382 lymphadenitis, 331 lymphangitis, 326 onychia, 403 sinus, 143

Tuberculous ulcers, 73, 83

Tubulo-dermoids, 211

Tumor albus, 518

Tumours, 181. _See also_ Individual Tumours and Tissues

Typhoid, joint lesions in, 508 osteomyelitis in, 452

Ulceration, of cartilage, 502, 514 definition of, 68

Ulcers, 68 ambulatory treatment of, 85 Bazin's disease, 74, 169 bone changes in, 79 callous, 79, 84 cancerous, 205 classification of, 70 clinical examination of, 68 conditions of, 77 crateriform, 395 duodenal, in burns, 236 epithelioma in, 500 healing, 77 gouty, 77 due to imperfect circulation, 71, 82 due to imperfect nerve-supply, 73, 82 inflamed, 79, 85 irritable, 79, 85 leg, 72, 169 malignant, 77 perforating, 73, 82 phagedænic, 80, 85 pressure, 70 from radium, 70 rodent, 395 from Röntgen rays, 70 scorbutic, 77 skin-grafting, 14 spreading, 79 syphilitic, 76, 83, 158, 160, 169 traumatic, 70, 81 treatment of, 80 trophic, 73 tuberculous, 73, 83 varicose, 72 weak, 77, 83

Ulnar nerve, lesions of, 368

Uterine fibroids, 195

Vaccine treatment, 23, 40

Varicose aneurysm, 311 eczema, 292 ulcer, 72 veins, 287

Varix, 287

Veins, anatomy of, 258 entrance of air into, 265 injuries of, 264 repair of, 269 rupture of, 264 thrombosis of, 281 varicose, 287 wounds of, 264

Veldt sores, 382

Venereal disease. _See_ Syphilis soft sore, 154

Venesection, 42

Venous cysts, 289

Verruca, 392

Vibrion septique, 101

Villous papilloma, 201

Volkmann's ischæmic contracture, 415

Vulva, diphtheria of, 111

Wardrop's operation for aneurysm, 308

Wart, 201, 392 venereal, 393 X-ray, 239

Wassermann's reaction, 156, 162

Weaver's bottom, 426, 430

Weir-Mitchell treatment in hysterical joint affections, 538

Wens, 389

Wet-cupping, 42

White swelling of joints, 515, 518

Whitlow, 55 gangrene from, 99 at nail fold, 56 purulent blister, 55 subcutaneous, 56 subperiosteal, 58 of tendon sheaths, 57 thecal, 57

Whitlow, of toes, 55 varieties of, 55

Winged scapula, 363

Wool-sorter's disease, 121

Wounds, 220. _See also_ Individual Tissues and Regions acute suppuration in, 50 bullet, 229 contused, 218, 223 drainage of, 222 by electricity, 239 by explosives, 231 by firearms, 225, 227, 230 incised, 221 infection of, 107 lacerated, 223 open method of treating, 247, 248 pistol-shot, 226 punctured, 222 shell, 231 treatment, 241 in warfare, 225, 230

Wrist, drop-, 365

Wry-neck, rheumatic, 413

Xanthoma, 188

X-rays, burns by, 239 cancer from, 395 dermatitis from, 239 ulcers from, 239 warts from, 239 in diagnosis of aneurysm, 304 arthritis deformans, 530 bone diseases, 445 tumours, 485, 491, 496 tuberculosis, 455 foreign bodies, 233 joint tuberculosis, 516 in treatment of cancer, 208 lupus, 385 sarcoma, 201 tuberculosis, 138