In general, then, all these conditions are evidenced by joint deformity, especially by irregularities, by more or less effusion, by considerable tenderness, by creaking of the joints when used, by pain which is a variable feature and may be referred to nerve disturbances, occasionally by muscle spasm, but always, in cases of long standing, by muscle atrophy. A view of the interior of joints thus affected will give a complex picture of atrophy here and hypertrophy there of each or all of the component structures of the joint, sometimes with a gradual overgrowth of articular bone surfaces, sometimes with more or less complete disappearance of the same, e. g., in the acetabulum.
Treatment.
—So far as treatment of these conditions is concerned, it should be recalled, first of all, that the disease itself is exceedingly chronic in its tendency, and due to conditions which have probably been of long standing. Constitutional treatment is as essential as local, and must consist in restoring the environment and the nutrition of the patient to normal standards. Elimination is deficient in such cases, and should be stimulated by hot-air baths, massage, and such exercise as may be possible, as well as by the use of diuretics and laxatives to the degree indicated. The local treatment may consist also of massage, elastic compression, aspiration in rare instances, the use of wet packs, and, in many cases, the use of hot, dry air. Various forms of apparatus are now upon the market by which almost any of the joints may be subjected to the influence of dry, hot air at a temperature of 280° F. When properly used, great relief and improvement may be expected. Their use, however, calls for the best of judgment and a combination of the measures already mentioned.[31]
[31] The following types of arthritis bear little, if any, relation to true rheumatic disease, though often spoken of as rheumatoid:
The chronic villous form, most common in the knee, purely local, without effusion, and giving dry crepitus or creaking. The joint fringes are numerous, and sometimes vascular. If the crepitus be marked and the fringes too extensive the latter may be relieved by operation. Otherwise this form is to be treated by early local stimulation, with some support, at least with a bandage.
The atrophic form, of unknown etiology, causing progressive and finally crippling swelling, with later atrophy. There is little if any fluid present. Here the changes occur in both bone and cartilage, with a tendency to abnormal calcification. In this form rest and hypernutrition, especially with normal proteids, are called for, and every possible stimulus to elimination through all the emunctories.
The hypertrophic arthritis, by which cartilages are first thickened and then ossified, interfering with motion and with contour. This form causes great limitation of motion and sometimes pressure on nerves, with referred pains. It seems to have some relation to cold, exposure, and injury. Detachment of pieces of cartilage is not uncommon, so that there are loose bodies in the joint cavity. Treatment here consists of fixation, with improvement of nutrition and elimination. This form may subside under proper treatment.
The chronic, gouty arthritis, with deposits of sodium urate in and around the joint tissues, with perhaps some bone absorption beneath them, which are not connected with the bone. In the digits entire phalanges may disappear by absorption. The treatment here is essentially constitutional and directed toward the gouty diathesis.
NEUROPATHIC JOINT DISEASE.
This received its first full and classical description from Charcot in 1868. The term refers to joint lesions which follow and are apparently connected with certain injuries and diseases of the spinal cord, or the peripheral nervous system. The non-traumatic forms are mostly associated with locomotor ataxia and syringomyelia. Some of them have an abrupt onset, while others come on very insidiously. Pain is usually notable by its absence, and the involved joints show few, if any, evidences of hyperemia or inflammation. They become unnaturally mobile and relaxed and usually much, sometimes enormously, distended with fluid. The morbid changes within the joints comprise imaginary combinations of atrophy and hypertrophy, with proliferative formations in bone cartilages. Osteophytes and exostoses are met with, and ossification may occur in the neighboring tendons and ligaments. Surprising alterations take place in certain joints; thus, as shown in [Fig. 197], the head of the humerus may disappear and corresponding changes may occur in other joints. While it is the knee which suffers most frequently, no joints, not even those of the spine or jaw, are exempt.