DR. HATCH'S PAPER.

DR. HATCH'S PAPER.

the normal fossa on either side of the patella may be obliterated, If the lipomata are present they can be distinctly palpated. The second type, atrophic arthritis, is, according to Dr. Goldthwaite, "a progressive disease, resulting in marked distortion and great crippling, with the pathology one of atrophy, in which the joint membrane, the cartilage and the bone show the change." There is nothing known definitely about the etiology, but it seems to be due possibly either to an acute auto-intoxication due to defective assimilation, or of neural origin. Sometimes, in taking the history of a case, we can get as exciting causes some of the following: worry, grief, overwork, mental shock, or poor and insufficient food, young women are the most common sufferers of the atrophic type. In the early stages the joints affected have a spindle-shaped swelling which is caused by an increase in the synovial fluid, and the overlying skin is white and moist from perspiration.

This type very commonly starts in the hands and wrists, and is sometimes limited to the fingers of one or both hands, the second interphalangeal joints are usually involved first, in contradistinction from the first plalangeal joint, which are often the seat of the hypertrophic type. Later, other and larger joints become involved. At this stage the atrophy of the cartilages can be seen from the radiograph. As the disease progresses, for example, in the finger, there is often found flexion, contraction and deviation towards the inner side. The joints go on to ankylosis slowly, and the disease may progress steadily or may remain in a few joints for some time and then later become more general. I have seen one case with all the joints in the body, including the jaws, affected, and this is the class of cases which we see in our poor houses which are so crippled that they cannot care for themselves.

The third type, hypertrophic arthritis, is, as the name implies, a true overgrowth of cartilage and bone.

The cause of this type is unknown, but it is more common in men than in women, and in late middle life. Exposure to damp and cold and traumatism seem to be exciting causes. The process consists in a thickening of the edges of the articular cartilages, these form ridges or small prominences and then become ossified and mechanically interfere with motion. The ridges of bone can be distinctly felt in well marked cases. This is the type that causes the so-called

Heberden's nodes, and as can be seen by some of the pictures that are passing around, the new bone formation can be very beautifully traced in the radiograph. The joints usually affected are the terminal finger joints, the knees, hips, spine, and shoulders. The hypertrophic spine is very commonly found, and the process usually takes place more on one side of the vertebrae than on the other, this gives a stiff spine without kyphosis, which shows well when the patient tries to bend laterally, this one-sided affair also accounts for the fact that the patients nearly always say that the pain is only in one leg. These pains are due to nerve root pressure caused by the new bony outgrowth, and will account for many of the cases of so-called sciatica. This type is often called osteo-arthritic, and is sometimes confined to one joint and is not geenrally progressive, and is not nearly so crippling as the atrophic type.

The fourth type, infectious arthritis, is more common than the others, and is due to the presence in the joint of whatever infectious organism is causing the trouble, or to the toxines produced by the infection which is situated in some other region of the body. This is the type of arthritis in children which is called Still's disease. The onset is generally sudden, and two or more joints become affected at the same time, it usually does not progress to other joints, but this is occasionally the case. The symptoms are those of infection elsewhere in the body, namely, high temperature and pulse, with enlarged glands, and spleen, and a leucocytosis. We often see cases in which we cannot trace the infection, probably because the causative trouble was very slight and all out of proportion to the joint condition.

As an example of this I might briefly relate the following case: The patient, E. H., suffered from a very mild attack of intestinal la grippe, this lasted four days with slight fever, diarrhea, and malaise.

Several days later, in the evening, patient turned his right ankle in walking; this caused no pain at the time, but the following morning it was somewhat swollen and painful; this grew steadily worse, so that by the following morning he was unable to bear any weight on the foot; at that time the foot was very much swollen, and tender to the slightest pressure, and the patient had a slight increase in temperature and pulse, and a leucocytosis. A few days later the left wrist became swollen, painful, and stiff, and still later the right