The treatment of acute infectious processes by passive congestion occupies a subordinate or experimental position.

Active Congestion. Active congestion is induced by the local ose of heat, ordinarily hot dry air.

In its simplest form the apparatus consists of an alcohol lamp provided with a long metal chimney reaching to a box of wood or metal, into which the limb is inserted through openings at either end. The box has one or more small openings for the escape of air and moisture. The limb is usually wrapped in sheet wadding, and is particularly well protected from the parts of the box which may come in contact with the skin. The heat is then applied, usually to about 250° or 300° F., for from thirty minutes to an hour daily. The degree of heat is indicated

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The application of tbe hot-air box for Inducing active congestion. The box. C, the thermometer. A, a metal pipe projecting from the box, into which the chimney of the lamp Is B, lamp chimney. (After Bier.)

by a projecting thermometer, and it is regulated by the comfort of the patient and by the observation of its effects.

Bier prefers simple boxes of wood of various shapes suitable for the different parts of the body, lined with packing cloth •soaked in a solution of water glass. He considers these as efficacious as the complicated and expensive appliances, and at the command of all who desire to employ the treatment (Fig. 162).

The effect of the heat is to induce arterial instead of venous hypenemia, and to cause profuse local and general perspiration. Active hyperemia is not suitable for the treatment of active or progressive joint disease. It exercises a dissolving and absorbing action on effused material and on the tissues of new formation causing limitation of motion within a joint. It increases local nutrition and it relieves pain. It is especially indicated in the treatment of local disability after injury, chronic effusions into joints, rheumatoid arthritis, chronic rheumatism, and the like.

As a rule, the application of local heat should be supplemented by massage. The profuse general perspiration that is induced by it is a contraindication in weak individuals.

CHAPTER VI.

NON-TUBERCULOUS DISEASES OF THE JOINTS.
Syphilitic Diseases of the Joints.

lx early infancy the characteristic syphilitic disease of the bones is a form of osteochondritis. Painful, sensitive swellings appear at the epiphyseal junctions, either as small, hard tumors, or as general enlargements, resembling those of rhachitis (Fig. 163). As a rule, several epiphyses are involved, more often those at the distal extremities of the bones of the lower limbs, and in these cases the pain and discomfort may induce an appearance of helplessness of the part called pseudoparalysis (Parrot). In osteochondritis there is a multiplication and irregularity of the cartilage cells of the ossifying layer and premature calcification. As a result, the circulation is insufficient and necrosis of a part of the cartilage may follow, which, acting as a foreign body, sets up inflammatory changes in the adjoining parts. The process is shown by a zone of hard, dry, yellow substance in the ossifying layer, adjoining which is an inflammation of the tissues of the newly formed bone which is in part replaced by granulation tissue. If the disease is progressive, ulceration and suppuration may follow; the cartilage may be destroyed, and the epiphysis may be separated, causing deformity and cessation of growth. The neighboring joint is usually involved in the disease. In the milder cases there is a simple sympathetic synovitis; in the advanced class a destructive arthritis. In one case seen recently the symptoms of pain on motion combined with slight effusion into several joints were present without the epiphyseal enlargement. The affection may be distinguished from rhachitis by the accompanying evidences of inherited syphilis, by the irregularity of the epiphyseal involvements, and by the age of the patient and the absence of the other symptoms of rhachitis.

In the later man if citations of hereditary ityphilis, in which the bones in the neighborhood of the joint are involved in syphilitic osteoperiostitis, the joint may be sympathetically affected or the disease may actually perforate the joiut. In this form of disease the synovial membrane is usually hypertrophied and it may interfere with the function of the joint. The fluid is increased in quantity and the affection may resemble synovial tuberculosis. A slow, chronic, infiltrating gummatous form of disease appearing in later childhood may simulate very closely the appearances of so-called white swelling. It is more common at the knee, but other joints are often affected as well.

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Suppurative syphilitic epiphysitis at lower ends of radius and tibia in an infant aged one month. The child died shortly after the drawings were made, and the epiphyses were found lying loose in purulent cavities. (Tubby.)

In the secondary stage of acquired syphilis pain and swelling of the joints, resembling rheumatism, may l>e present, and in tertiary syphilis the joint may be involved in disease of the neighboring bones, or the joint itself may be primarily implicated.

In most instances the joint affections of syphilis are explained by the history and by the other signs of syphilitic disease. Spina ventosa (Fig. 1 <>;")), which is classed as one of the evidences of syphilis, is far more commonly of tuberculous origin, as is illustrated by the statistics of Karewski,1 of 157 cases, in which but three were due to syphilis.

Syphilitic disease of the joints is uncommon in orthopedic clinics as compared with those of tuberculous origin. This is as might be expected, for not only is tuberculosis far more common than syphilis, but a very large proportion, according to Fournier, 77 per cent., of the syphilitic children are stillborn or die shortly after birth. Even in those that survive, disease of the bones or joints in the form that could be confounded with tuberculosis, is uncommon as compared with its other manifestations.

'Chlr. frank, des Kindesalten.

Fig. 164.

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Syphilitic osteoperiostitis of the tibiae resembling anterior bow-leg. This Is the most characteristic manifestation of hereditary syphilis.

Treatment. Some writers consider hereditary syphilis to be a very important predisposing cause of tuberculous disease, and believe that many cases classed as tuberculous are in reality syphilitic, even if no history or confirmatory signs of syphilis are present. There is no reliable evidence to support this view. The possibility of the syphilitic taint, remote or direct, should be borne in mind, and in doubtful cases appropriate remedies should be employed.

In general, the treatment of the joint affection would be

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