The effect of the heat is to induce arterial instead of venous hyperemia, and to cause profuse local and general perspiration. Active hyperemia is not suitable for the treatment of acute 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, chronic arthritis, and the like in which the circulation is deficient.

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.

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CHAPTER VI.

NON-TUBERCULOUS DISEASES OF THE JOINTS.

SYPHILITIC DISEASES OF THE JOINTS.

Ix early infancy the characteristic manifestations of congenital syphilitic disease of the bones is a form of osteochondritis. Sensitive swellings appear at the epiphyseal junctions, either as small, hard tumors or as general enlargements, resembling those of rhachitis (Fig. 186). 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. Necrosis may result as shown by a zone of hard, dry, yellow substance in the ossifying layer of the cartilage, about which newly formed bone is softened and 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 in a child three months of age 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 enlargements, and by the age of the patient and the absence of the other symptoms of rhachitis.

In the later manifestations of hereditary syphilis, 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 joint. In this form of disease the synovial membrane is usually hypertrophied to such degree as to 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. In other instances one or more of the joints may be involved before the enlargement of the neighboring bone is apparent, the symptoms being those of chronic synovitis.

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

In tertiary syphilis the joint may be invaded by disease in the neighboring bones, or the joint itself may be primarily implicated.

There is general thickening of the synovial membrane, effusion and later destruction of cartilage. Pain is as a rule not severe.1

The joint manifestations of acquired syphilis are pain, most marked at night, during the exanthematous stage. In some instances effusion may be present which if persistent may be accompanied by hypertrophy of the synovial membrane. The knee, shoulder and elbow joints are most often involved.

1 Bona, Berlin. klin. Woch., n. 43 and 44, 1907.

The diagnosis of syphilitic joint disease is usually suggested by the history and is confirmed by the other signs of syphilitic disease. The most important of the confirmatory signs of hereditary syphilis is keratitis. In a series of 77 cases in which this was present there was involvement of the joints in 56 per cent., the knee being most often affected.1 Spina ventosa (Fig. 1S8), which is classed as one of the evidences of syphilis, is far

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Syphilitic osteoperiostitis of the tibiae resembling anterior bow-leg. This is the most characteristic manifestation of hereditary syphilis. lt induces not only deformity and hypertrophy, but elongation of the bones as well.

more commonly of tuberculous origin, as is illustrated by the statistics of Karewski,2 of 157 cases, in which but three were due to syphilis.

Syphilitic disease of the joints is comparatively rare in orthopedic clinics as contrasted with those of tuberculous origin.

•Hippel, Munch, med. Woeh., No. 31, 1903.
1 Chir. Krank. des Kindesalters.

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 among those that survive,

Fig. 188. Fig. 189.

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Hereditary syphilitic disease of the Hereditary syphilitic disease of the

metacarpus and phalanges. joints. ln this case the interior of

the right knee-joint was lined with hypertrophied folds of synovial membrane. A complete cure followed the administration of appropriate reme dies.

disease of the bones or joints, in the form that could be confounded with tuberculosis, is uncommon as compared with its other manifestations. Disease of the bones is more common than

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