CHAPTER VII.

ON SOME OTHER FORMS OF CHRONIC SYNOVITIS.

THE Strumous and Rheumatic diatheses are those which chiefly produce or maintain a chronic inflammation of the synovial membrane; but there are besides two other conditions having the same effects: these are Syphilis and Gout.

Syphilitic Synovitis, although rather rare, is sufficiently common to deserve some notice. A case of this disease, rather more acute than usual, was detailed at p. 34. I have seen three others whose origin was undoubted, and several where such cause might be suspected. The previous and immediate symptoms of these cases have led me to the belief, that the inflammation always spreads from the neighbouring periosteum, with which, as we have seen, the subsynovial tissues are continuous. In two cases, reported at the end of this short section, nodes on the shin were actually present at the time, and were giving severe nightly pain; in others the characteristic sensations produced by these swellings had only just subsided; one of them, close to the joint, had been opened and the wound had just healed.

Syphilitic eruptions are generally present at the very time when the joint-attack commences, and by proper enquiry a specific history can always be made out. I am not aware of case in which this disease has occurred previous to other constitutional effects of the lues.

any

The disease is confined to the middle period of life; its usual history is this.-The patient having been subject to the usual secondary and tertiary symptoms of syphilis, labors during some days or weeks, previous to any complaint having been made of joint disease, from nightly pains of the bones; probably also from swellings along the course of the shin bones; with whose aspect and history every surgeon is but too well acquainted; then at some period a joint becomes painful, and swells. At

first the tumefaction of the part is slight, and is not so much due to effusion of fluid into the cavity as to an exsudation into the periarticular tissues: this is evidenced by the want of fluctuation and the softness of the parts beneath the skin; they do not pit, but they have a tendency to do so; very slight pressure with the finger whitens the part. Soon after the commencement of the disease, an augmented effusion of fluid into the synovial sac takes place; increased heat is perceptible, and occasionally the skin has a pink flush. The pain is, at the early stage, very severe, particularly while the patient is in bed, and at the first commencement of the disease; when increased secretion into the cavity has taken place the pain very much subsides.

The course of the cases is various; sometimes they are quite chronic, at others subacute; but I have never seen one advance to ulceration of cartilages, or permanent injury of the joint, though it is perfectly conceivable that a constitution, combining both the scrofulous and syphilitic taint, might set up an action in the synovial membrane whose termination would be destructive. The disease is most prone to attack the knee and ankle; once I have seen it in the elbow, and once have observed a suspicious case at the wrist; neither of these however were under my care, the former was one of Mr. Canton's patients, the latter I only saw for a few minutes, and, as the gentleman was homoeopathically treated, declined to give any opinion. It appears probable, if we may build on the history of a single case, that the joint malady may recur when the other secondary events of syphilis return.

The general treatment of this disease is the treatment of syphilis: it is well however to remark that considerable debility may be combined with the synovial disease; such state was evident in two out of the four cases quoted, and I have observed it in some which were not under my own care. Mercury, if not already pushed sufficiently far, should be given in small repeated doses, and the value of the iodide of potassium need hardly be insisted on. The combination of tonics with these remedies is most desirable. In one case quinine and mercury, in pill, twice a day was productive of great benefit. The bichloride of mercury with iodide of potassium and gentian form a valuable

mixture. The local treatment is first of all rest, with a fitting splint to secure immobility of the joint, and superficial counterirritation by means of blisters, or of flying blisters, only kept on long enough to produce considerable redness of the surface without vesication; the redness may afterwards be kept up by the tincture of iodine. It would seem, from the fact of pain being most severe when the patient gets warm in bed, that cold would be a soothing application; this, however, is far from the fact; heat, by means of hot salt or hot-water bags, although producing pain for the first few minutes, procures a more rapid relief than cold. The cases are quite amenable to antisyphilitic treatment combined with the above simple local management.

CASE XL.-William E., aged 33, tailor, came to my house with pains and swelling in the knee, 22nd January, 1856. He is a pale, sickly-looking man: the swelling of the knee began two days ago, with much pain, which increased at night; the tumefaction has not the shape of an acute synovitis, but is more diffuse, without defined edge, and conceals the shape of the bones. There appeared to me something anomalous in his symptoms which I did not make out clearly at the time. I ordered him a purge, and a blister above the joint, and to keep his bed until he came again.

26th. When he came to-day I observed an eruption, which turned out to be syphilitic lichen. On examining the tibia I found two dusky spots which had been the seat of abscess from nodes; no recent nodes were apparent, but the edge of the tibia was rough with old ones. I ordered him three grains of iodide of Potassium and infusion of Gentian three times a day; applied a gutta-percha splint to the limb; told him to keep his bed and to come back in a week.

2nd Feb. He is in much the same condition; the man's appearance is very weakly, but it is doubtful if he can get well without mercury. Ordered to continue the mixture and to take the following pill night and morning :

Ṛ. Hydrarg. c. Cretâ

gr. ij. gr. ij.

M.

Another blister to the knee; complains of very great pain in the joint at night; told him to apply cold water.

6th.-Cold water increases the pain, although the same effect is produced by the warmth of bed: to apply very hot salt bags; this relieved the pain after the first few minutes: add to each pill half a grain of opium.

13th. The knee is much better; is still swollen, but is almost free from pain: the eruptions continue.

19th. The gums slightly sore; the eruption fading; to take the pill only at night.

26th.-Eruption nearly gone; to leave off the pill; the joint being still swollen it was tightly strapped.

March 3rd.-Joint nearly reduced to its normal size; strapped once more; to continue the mixture for another fortnight.

April 7th, 1857.—This man came to me again with sore throat, syphilitic eczema, nodes, and pain of the right knee, close to which one of the nodes is situated; the knee is very slightly swollen, is also slightly tender; he is in a very weak condition; has been feeling ill for the last fortnight, and has given up beer, thinking it better to do so, although he has been used to take about a quart (?) a day.

Ordered that he should take a pint and a half of stout a day, and the following draught thrice a day :

I put a pasteboad splint on the outside of the limb and told him to paint it with Iodine.

12th. The knee is more swollen, but is rather less painful and tender; it does not fluctuate, is rather red, and has slight tendency to pit; the tumefaction is more around than in the joint. Add to the draught

Leave off the Iodine paint and apply hot dry fomentations by means of salt-bags.

19th. The knee is greatly better.

The splint was only necessary for a fortnight longer; the same treatment was pursued: the rest of this history is merely that of syphilis.

CASE XLI. John Stedman, aged 19, came to me at the Charing-Cross Hospital with syphilitic lepra, and with nodes on the shins.

7th April, 1858.-He is a robust, coarse-featured lad, and it seems that he has had the eruptions a fortnight, and thinks little about them, but he wants to be cured of the pains in the shins, which came on about a week ago: the chancre has only just healed; he is very uncertain about the time of its appearance, and has had no treatment besides taking an occasional dose of salts and using a lotion.

Ordered five grains of blue pill every night, and

Mist. Potassii iodidi comp. 3j. three times a day.

14th. He complains of pain in the right ankle, which is swollen; there is a slight increase of fluid in the joint, but the chief swelling is external; it has not that anklet-like form over the junction of leg and instep which effusion into the joint causes; the pain seems very severe; there is a node, which is very tender, close to the ankle on the outer side of the tibia, or anterior edge of the malleolus, which is involved in the general swelling. He was ordered a blister over the front of the tibia; a gutta-percha splint; to rest in bed and to come in a week.

21st. The ankle is rather better; the nightly pains still continue

severe; the gums not all touched by the mercury: to discontinue the blue pill. Add to the mixture:

Liq. Hydrargyri bichloridi 3j.

To paint the tibia and the painful joint with tincture of Iodine.

26th.-The gums are slightly affected; the ankle is better; the nightly pains have almost disappeared, but still keep him awake: to take a grain of Opium, in pill, every night.

3rd May. The nodes are nearly gone, and he has but little pain either about the ankle or shin-bone; the swelling about the ankle not diminished as much as could be wished; the gums are sufficiently affected; the bichloride of Mercury is to be left out of the mixture; to continue the application of Iodine.

17th. The eruptions, which have been diminished, are now nearly gone; inflammation of the ankle and the nodes are well to continue his medicine another week.

CASE XLII.-Valentine Mayer, aged 38, an obese Alsatian, came to me at the Charing-Cross Hospital in the early part of May, 1860, with violent pains in the shin-bones; nodes plainly to be felt beneath the skin of the tibia; the dark marks of old ones still left. She had Plummer's pill night and morning, iodide of Potass thrice a day, and the shins were painted with Iodine at night. For the first fortnight she got better, but after that time was worse again; I strongly suspect she drank a good deal; the medicine had but little effect.

4th June. Began to take notes of the case because the knee-joint became affected with violent pain; there was little else than this fact to be made out the knees were both so fat and fleshy that I could not determine the presence of any swelling; the joint was apparently tender, but her gestures and expressions seemed highly exaggerated: she said the pain came on chiefly at night, and walking only hurt her a little there was no fever nor any symptom of acute rheumatism. Being willing rather to see whether these symptoms were real or not, I merely ordered a local application of Arnica lotion, and told her to continue the medicines.

6th. Just the same: she says the cold gives her more pain; there is, perhaps, a little swelling, but it is still doubtful: to bathe the knee in hot water.

8th. The joint-cavity is now evidently full of fluid, and the pain has very much decreased: a blister to be applied across lower part of femur ; a gutta-percha splint at the back of the limb; the mercury has no effect: to take the following pill every night:

15th. The swelling in the joint has decreased; the skin where the