Surgical treatment of these lesions is less discouraging than would at first appear, as even in these patients serious wounds heal readily, while in healthy tissues primary union may occur. The wisdom, therefore, of incision, resection, or even amputation may be decided on their merits, and there can be no objection to open drainage when it would otherwise be indicated. Even in cases of spontaneous fracture proper treatment usually gives good results, although the amount of callus may seem disproportionate.
In any of the joints distorted by deforming osteoarthritis or neuropathic lesions, the question of partial or complete resection or exsection may be discussed upon its merits, since these operations, when duly indicated, have often given satisfactory results, even in elderly people.
Diagnosis.
—Differential diagnosis will be made more easy by the exclusion of syphilis and of the acute or ordinary infectious forms of disease. The relative freedom from pain, the relaxation of the joint structures, the large amount of fluid present, and the age of the patient will aid in excluding all but the neuropathic elements associated with spinal disease.
Treatment.
—Treatment is rarely curative; usually it can be palliative at best. Measures above mentioned, when they seem indicated, coupled with mechanical support, by which the parts may be maintained as nearly as possible in their proper position, will give the best result. If the disease be monarticular, exsection will frequently give a satisfactory result. Multiple lesions rarely permit of serious operations.
HYSTERIA AND HYSTERICAL JOINTS.
A different form of distinctly neuropathic joint affection is the so-called hysterical joint. This is characterized by the absence of every objective and the presence of nearly every subjective symptom. It occurs most often in young women and girls, follows perhaps some trifling injury, and involves most commonly the joints of the lower limbs. These cases are characterized by a disproportion between the character of the complaint and the actual condition. Imitation of organic trouble is a predominant feature of all hysterical complaints, and is nowhere seen to better advantage than in these cases. The pain, the tenderness, the loss of ability and even the muscle spasm and muscle atrophy of genuine lesions will be simulated. So true is this that diagnosis largely rests on the exaggeration of symptoms which have no apparent existence. Hyperesthesia is sometimes extreme, but pertains usually to the waking hours. Rarely is there actual swelling or thickening, or any objective evidence whatever of disease, save perhaps muscle atrophy due to disuse. It is possible to have the hysterical element as a complication of actual joint disease, but the truly hysterical joints usually are easily recognizable.
Treatment.
—The treatment of such a joint should be psychical as well as physical. Sometimes appeals to reason, at other times to fear or necessity, will be the wiser course. Restoration of self-confidence is an important feature, and these are the cases where any form of faith cure will produce its most brilliant results. Many of these cases are bedridden, and need to have elimination stimulated in every possible way. They also need sunlight, fresh air, massage, and renewed use of the parts. Hyperesthesia is best treated by continuous application of ice-cold compresses, intermitted perhaps daily for the purpose of using the “flying cautery,” as already described.