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Preface

Purpose
One look at today’s headlines is all it takes to see that every American
citizen needs to be able to think critically about what is going on in the
nation and in the world. Biased reporting slants the news, and it is hard
even to discern what is fact. More than ever, people of conscience need to
be able to take a stand and articulate a position.
College has long been a place where values and beliefs are tested.
Exposure to new ideas and new perspectives is a part of coming of age. A
course in argumentation is a place where students can learn the tools to
critically examine the ideas they come in contact with. It is also a place
where they can learn to construct their own arguments in defense of what
they believe.
In order to get our students really thinking critically about argument,
we have to get them to slow down and practice the art of critical reading
— and listening. We have to provide timely, accessible readings, we have
to get them to analyze sustained argumentative discourse, and we have to
give them a vocabulary to be able to talk about it. The vocabulary we use
in this text incorporates Aristotle’s ancient rhetoric, the stasis theory
questions, Carl Rogers’s notion of common ground, and Stephen
Toulmin’s three principal elements of argument: claim, support, and
assumption (warrant). In addition, we present the concepts of definition,
language, and logic as critical tools for understanding and responding to
arguments.
We also have to get our students to write sustained argumentative
discourse. They have to learn to apply their knowledge of claim, support,
and warrant. They have to learn to define key terms and to recognize,
write, and support claims of fact, value, and policy, or, in the language of
stasis theory, they have to be able to consider Questions of Fact, Questions
of Definition, Questions of Quality, and Questions of Policy. They have to
understand that successful arguments require a blend of logos, pathos, and
ethos.

8
 They have to appreciate the significance of audience as a practical
matter. In the rhetorical or audience-centered approach to argument, to
which we subscribe in this text, success is defined as acceptance of the
claim by an audience. Arguers in the real world recognize intuitively that
their primary goal is not to demonstrate the purity of their logic, but to win
the adherence of their audiences.
To do so, students must read critically and think critically about what
others have to say. The Internet has redefined what research means to our
students. A large part of the challenge is not to find sources but to
eliminate the thousands of questionable ones. Faced with the temptation to
cut and paste instead of read and understand, students need more help than
ever with accurate and fair use of sources. We provide that help in the
context of an increasingly digital world.

Organization
Part One of Elements of Argument begins with an introduction to
Aristotelian, Rogerian, and Toulmin approaches to argumentation and to
stasis theory. Next, it addresses the critical reading of written as well as
visual and multimodal arguments. It then provides instruction on writing
responses to arguments and writing arguments, particularly in an academic
context. Part One is rich in selections that both illustrate various arguments
and offer practice for student analysis.
Part Two devotes one chapter apiece to the chief elements of argument
— claim, support, and assumption (warrant). Straightforward explanations
simplify these concepts for students, and examples are drawn from
everyday print and online sources — essays, articles, graphics, reviews,
editorials, and advertisements — by both student and professional writers.
Part Three details important matters of reading and writing effective
argument: definition, language, and logic. Chapter 9 teaches students the
importance of defining key terms as well as the nature of the extended
definition essay. Chapter 10 deals with the power of word choice, and
Chapter 11 covers the various logical fallacies as well as how to identify
and avoid logical errors in arguments.
The first three parts of the book — comprising Chapters 1 through 11
— include four unique feature boxes to enhance and reinforce the text.
“Writer’s Guide” boxes give practical advice on how to write effective
arguments and response essays; “Strategies” boxes provide more in-depth

9
information on important skills such as prereading and annotating texts.
“Essentials” boxes summarize and reinforce basic argument concepts, and
“Research Skills” boxes explain a variety of academic research tasks
Coverage of traditional rhetorical issues such as audience and purpose
spans all chapters, helping students grasp the importance of clear
communication in a variety of situations. And student essays, with
documented sources, serve as models for effective writing and proper
form. This twelfth edition of Elements of Argument shows students how to
apply concepts of rhetoric and logic to spoken, visual, online, and other
multimedia arguments. Throughout the text, an abundance of visual
arguments — including ads, photographs, screen shots, and graphics —
provide visual examples and opportunities for analysis.
Part Four takes up the process of planning, writing, and documenting
arguments based on independent research. Chapter 12 focuses on planning
and research, including how to narrow a topic as well as how to find and
evaluate sources. Chapter 13 addresses drafting and revising written
arguments as well as oral presentations. Chapter 14 covers documentation
and provides two sample research papers, one employing the Modern
Language Association (MLA) documentation system and the other
employing the American Psychological Association (APA) documentation
style.
Part Five, “Debating the Issues,” includes a pair of readings related to
each of five current debatable topics: student evaluation of faculty, gender-
neutral bathrooms, trigger warnings, princess culture, and paying college
athletes. Each pair illustrates contrasting opinions on the same issue and is
followed up with discussion questions and writing suggestions.
Part Six, “Multiple Viewpoints,” expands the concept of debate to
present multiple arguers in action. Each of the six chapters in this part
includes five to six readings on a single controversial issue, presenting that
issue from a range of perspectives. The topics are ones now in the news
and on engaged citizens’ minds: social networking, keeping schools safe
from violence, climate change, the risks of competitive sports, freedom of
speech, and police violence.
Part Seven, “Classic Arguments,” includes such class-tested
arguments as Jonathan Swift’s “A Modest Proposal,” Henry David
Thoreau’s “Civil Disobedience,” and Sojourner Truth’s “Ain’t I a
Woman?”
For instructors who want to apply current events to their argument

10
course, see our blog, “Argument in the Headlines.” In our regularly
updated posts, we use argument concepts to frame issues in the news,
helping students relate the text and the course to their everyday lives.
Students are encouraged to visit the blog at the end of each chapter. You
can find the blog at blogs.bedfordstmartins.com/bits.

New to This Edition

In this edition, a new Chapter 5 focuses early in the text on how to write
arguments, particularly in an academic context. This new chapter provides
a clearer distinction between writing arguments generally and writing
researched arguments, which is the focus of Chapters 12-14. It also makes
it possible to make a clearer distinction between analyzing argument
(Chapter 4) and writing argument (Chapter 5).
An introduction to stasis theory has been added to Chapter 1. This
instruction is intended to help students further understand how logical
questions can be used as a means of invention and to structure arguments
effectively.
The concept of the warrant has always been a difficult one for
students. In this edition we use the term assumption to make the concept
more accessible.
As is the case with each edition of Elements of Argument, we have
updated readings throughout to keep information current and subjects
interesting. In this twelfth edition, over one-third of the readings are new.
In the Debating the Issues section, new issues include the value of student
evaluations of faculty, the pros and cons of gender-neutral bathrooms, and
wisdom of providing trigger warnings in college classes. In Part Six, two
of the Multiple Viewpoints topics are also new; they explore the effects of
climate change beyond the physical changes to our planet and police
violence against civilians. In the Classic Arguments section, we have
added Nelson Mandela’s “Black Man in a White Court.”

Also Available
A briefer edition, The Structure of Argument, Ninth Edition, is available
for instructors who prefer a shorter text with fewer readings. It includes
Chapters 1 through 19, excluding the Multiple Viewpoints and Classic
Arguments. See macmillanhighered.com/structure/catalog for details.

11
Acknowledgments
This book has profited by the critiques and suggestions of instructors who
responded to a questionnaire: John Adrian, University of Virginia; Patricia
Andujo, Azusa Pacific University; Carol Bledsoe, Florida Gulf Coast
University; Rebecca Briley, Midway University; Joe Davis, North Iowa
Area Community College; Hedda Fish, San Diego State University;
Deanna Gabrielson, Morehead State University; Steve Holland,
Community College; Jeffrey Hotz, East Stroudsburg University; Tammy
Jabin, Chemeketa Community College; Jess Koski, Hibbing Community
College; Mark Meritt, University of San Francisco; Steven Mohr, Terra
State Community College; Daniel Powell, Florida State College at
Jacksonville; Jennifer Roscher, De Anza College; Kent Ross, Northeastern
Junior College; and Guy Shebat, Youngstown State University. We also
thank those reviewers who chose to remain anonymous.
We are grateful to those at Bedford/St. Martin’s and Macmillan
Learning who have helped in numerous ways large and small: John
Sullivan, Leasa Burton, Jennifer Prince, Kalina Ingham, Jennifer Kennett,
Angie Boehler, Richard Fox, Kerri Cardone, and, most especially, Alicia
Young.

We’re all in. As always.

Bedford/St. Martin’s is as passionately committed to the discipline of
English as ever, working hard to provide support and services that make it
easier for you to teach your course your way.
Find community support at the Bedford/St. Martin’s English
Community (community.macmillan.com), where you can follow our Bits
blog for new teaching ideas, download titles from our professional
resource series, and review projects in the pipeline.
Choose curriculum solutions that offer flexible custom options,
combining our carefully developed print and digital resources, acclaimed
works from Macmillan’s trade imprints, and your own course or program
materials to provide the exact resources your students need.
Rely on outstanding service from your Bedford/St. Martin’s sales
representative and editorial team. Contact us or visit
macmillanlearning.com to learn more about any of the options below.

Choose from Alternative Formats of Elements of Argument

12
Bedford/St. Martin’s offers a range of formats. Choose what works best
for you and your students:
Popular e-Book formats For details of our e-Book partners, visit
macmillanlearning.com/ebooks.

Select Value Packages

Add value to your text by packaging any Bedford/St. Martin’s, such as
Writer’s Help 2.0 or LaunchPad Solo for Readers and Writers, with
Elements of Argument at a significant discount. Contact your sales
representative for more information.
LaunchPad Solo for Readers and Writers allows students to work on
what they need help with the most. At home or in class, students learn at
their own pace, with instruction tailored to each student’s unique needs.
LaunchPad Solo for Readers and Writers features:
Pre-built units that support a learning arc. Each easy-to-assign
unit is comprised of a pre-test check, multimedia instruction and
assessment, and a post-test that assesses what students have learned
about critical reading, writing process, using sources, grammar,
style, and mechanics. Dedicated units also offer help for
multilingual writers.
Diagnostics that help establish a baseline for instruction. Assign
diagnostics to identify areas of strength and for improvement and to
help students plan a course of study. Use visual reports to track
performance by topic, class, and student as well as improvement
over time.
A video introduction to many topics. Introductions offer an
overview of the unit’s topic, and many include a brief, accessible
video to illustrate the concepts at hand.
Twenty-five reading selections with comprehension quizzes.
Assign a range of classic and contemporary essays each of which
includes a label indicating Lexile level to help you scaffold
instruction in critical reading.
Adaptive quizzing for targeted learning. Most units include
Learning-Curve, game-like adaptive quizzing that focuses on the
areas in which each student needs the most help.
Order ISBN 978-1-319-19273-0 to package LaunchPad Solo for Readers

13
and Writers with Elements of Argument at a significant discount. Students
who rent or buy a used book can purchase access and instructors may
request free access at macmillanlearning.com/readwrite.
Writer’s Help 2.0 is a powerful online writing resource that helps
students find answers, whether they are searching for writing advice on
their own or as part of an assignment.
Smart search. Built on research with more than 1,600 student
writers, the smart search in Writer’s Help provides reliable results
even when students use novice terms, such as flow and unstuck.
Trusted content from our best-selling handbooks. Choose
Writer’s Help 2.0, Hacker Version, or Writer’s Help 2.0, Lunsford
Version, and ensure that students have clear advice and examples for
all of their writing questions.
Diagnostics that help establish a baseline for instruction. Assign
diagnostics to identify areas of strength and areas for improvement
and to help students plan a course of study. Use visual reports to
track performance by topic, class, and student as well as
improvement over time.
Adaptive exercises that engage students. Writer’s Help 2.0
includes LearningCurve, game-like online quizzing that adapts to
what students already know and helps them focus on what they need
to learn.
Student access is packaged with Elements of Argument at a significant
discount. Order ISBN 978-1-319-19254-9 for Writer’s Help 2.0, Hacker
Version, or ISBN 978-1-319-19257-0 for Writer’s Help 2.0, Lunsford
Version, to ensure your students have easy access to online writing
support. Students who rent or buy a used book can purchase access and
instructors may request free access at
macmillanlearning.com/writershelp2.

Instructor Resources
You have a lot to do in your course. We want to make it easy for you to
find the support you need—and to get it quickly.
Resources for Teaching Elements of Argument is available as a PDF
that can be downloaded from macmillanlearning.com. Visit the instructor
resources tab for Elements of Argument. In addition to chapter overviews
and teaching tips, the instructor’s manual includes sample syllabi,

14
classroom activities, additional research assignments, discussion questions,
teaching tips and ideas, and classroom activities.

How This Book Supports WPA Outcomes for First-Year

Composition
In 2014, the Council of Writing Program Administrators updated its
desired outcomes for first-year composition courses. The following chart
provides information on how Elements of Argument helps students build
proficiency and achieve the learning outcomes that writing programs
across the country use to assess their students’ work.

Rhetorical Knowledge
Learn and use key rhetorical The organization of Elements of Argument
concepts through analyzing supports students’ understanding of
and composing a variety of rhetorical strategy. Part One (Chapters 1–
texts. 5) introduces students to the Aristotelian,
Rogerian, and Toulmin approaches to
argumentation and to stasis theory. Next, it
addresses the critical reading of written as
well as visual and multimodal arguments. It
then provides instruction on writing
analytical responses to arguments and
writing arguments, particularly in an
academic context. Part Two (Chapters 6–
8) devotes one chapter apiece to the chief
elements of argument: claim, support, and
assumption. Part Three (Chapters 9–11)
details important matters of reading and
writing effective argument: definition,
language, and logic. Part Four (Chapters
12–14) takes up the process of planning,
writing, and documenting arguments based
on independent research, and Parts Five,
Six, and Seven provides a wealth of
selections that show different kinds of
arguments in action.
Coverage of traditional rhetorical issues
such as audience and purpose spans all

15
 chapters, helping students grasp the
importance of clear communication in a
variety of rhetorical situations.
Gain experience reading and The 108 readings in the book span a
composing in several genres variety of topics and disciplines. Each
to understand how genre selection features apparatus that gives
conventions shape and are students practice analyzing and writing for
shaped by readers’ and a variety of purposes and in a range of
writers’ practices and styles. Throughout the text chapters,
purposes. Writers’ Guides, Research Skills boxes,
end-of-chapter Assignments, and post-
reading questions prompt students to
compose different kinds of arguments and
responses.

Develop facility in Chapter introductions for Chapters 1

responding to a variety of through 11 explain how each rhetorical
situations and contexts element and strategy helps to achieve an
calling for purposeful shifts author’s purpose. Throughout the text,
in voice, tone, level of post-reading questions call attention to the
formality, design, medium, form and function of different arguments.
and/or structure.
Understand and use a Chapter 3 shows students how arguments
variety of technologies to can be made using a variety of multimodal
address a range of contexts, including photographs, print
audiences. advertisements, political cartoons, graphics,
commercials, speeches, debates, broadcast
news, print news, social media, and
interactive Web sites.
Match the capacities of Chapter 3 shows students how a variety of
different environments (e.g., print and electronic environments can be
print and electronic) to used to build persuasive arguments.
varying rhetorical situations.

Critical Thinking, Reading, and Composing

Use composing and reading Part 1 guides students through the process
for inquiry, learning, critical of understanding how arguments function,
thinking, and reading them critically, analyzing them in

16
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communicating in various writing, and composing them effectively. In
rhetorical contexts. particular, Chapters 3 and 4 focus on
critical reading of different kinds of
arguments, and Part Four provides
guidance on researching and crafting
effective arguments using inquiry and
critical thinking.

Read a diverse range of Throughout the text, diverse selections

texts, attending especially to illustrate different rhetorical elements, and
relationships between post-reading questions prompt students to
assertion and evidence, to analyze the relationship between assertion
patterns of organization, to and evidence. Further, Chapter 3 shows
the interplay between verbal students how to analyze the relationship
and nonverbal elements, and between verbal and nonverbal elements of
to how these features multimodal texts. Chapter 6 explores
function for different different kinds of claims, and Chapter 7
audiences and situations. offers instruction on how to effectively
support assertions.
Locate and evaluate (for Chapter 12 offers practical instruction for
credibility, sufficiency, locating and evaluating primary and
accuracy, timeliness, bias secondary research materials, and Chapter
and so on) primary and 13 illustrates best practices for reviewing
secondary research research.
materials, including journal
articles and essays, books,
scholarly and professionally
established and maintained
databases or archives, and
informal electronic networks
and internet sources.
Use strategies—such as The questions and prompts that accompany
interpretation, synthesis, each reading ask students to interpret,
response, critique, and respond, and critique the writer’s choices,
design/redesign—to thereby engaging in academic conversation.
compose texts that integrate Chapter 13 helps students compose texts
the writer’s ideas with those that integrate the writer’s ideas with those
from appropriate sources. from appropriate sources.
Develop a writing project Chapter 12 illustrates best practices for

17
through multiple drafts. planning and research, and Chapters 13
and 14 take students through the process of
drafting, revising, and presenting effective
arguments.

Processes
Develop flexible strategies Part Four offers strategies for reading,
for reading, drafting, drafting, reviewing, revising, and rewriting
reviewing, collaborating, arguments.
revising, rewriting,
rereading, and editing.
Use composing processes Throughout each chapter, the text
and tools as a means to emphasizes the importance of rereading
discover and reconsider and rewriting to discover and reconsider
ideas. ideas. In particular, Chapter 2 provides
strategies for evaluating arguments and
ideas, and Chapter 13 reemphasizes
evaluation as part of the writing process.
Experience the collaborative Writer’s Guides and Research Skills
and social aspects of writing boxes throughout the text provide insights
processes. into the writing and research processes that
can be used as prompts for discussion of
the writing process.
Learn to give and to act on Post-reading questions, as well as the
productive feedback to Writer’s Guides, Research Skills boxes,
works in progress. and end-of-chapter Assignments in
Chapters 1 through 11, can be used as
prompts for peer feedback.
Adapt composing processes Chapter 3 shows students how a variety of
for a variety of technologies technologies and modalities can be used to
and modalities. build persuasive arguments.
Reflect on the development Post-reading questions and end-of-
of composing practices and chapter Assignments often encourage
how those practices students to reflect on their knowledge,
influence their work. assumptions, and writing habits.

Knowledge of Conventions

18
Develop knowledge of Chapter 9 teaches the importance of
linguistic structures, defining key terms to build effective
including grammar, arguments. Chapter 10 focuses on
punctuation, and spelling, language, drawing students’ attention to the
through practice in rhetorical effectiveness of connotation,
composing and revising slanting, concrete and abstract language,
clichés, and figurative language. Chapter
11 helps students to understand logical
linguistic structures. LearningCurve
activities (available in LaunchPad Solo for
Readers and Writers) provide extensive
practice with grammar, punctuation, and
spelling.
Understand why genre The text’s overarching emphasis on
conventions for structure, rhetorical context and situation in the text
paragraphing, tone, and chapters fosters critical thinking about
mechanics vary genre conventions. In particular, Chapter 2
teaches students how to read arguments for
content and structure, and chapter
introductions for Chapters 1 through 11
explain how each element of argument
serves a writer’s purpose.
Gain experience negotiating The variety of formats and genres
variations in genre represented in the 108 selections gives
conventions students plenty of experience negotiating
variations in genre conventions. Post-
reading questions encourage students to
apply the rhetorical strategies to real-world
genres and situations.
Learn common formats Annotated selections throughout the text,
and/or design features for including student essays, impart awareness
different kinds of texts of common formats and/or design features
for difference kinds of texts, and Chapter
14 provides specific instruction on
formatting and design, including MLA-
and APA-style student research papers with
annotations highlighting the genre
conventions.
Explore the concepts of Chapter 13 teaches students how to avoid

19
intellectual property (such plagiarism, and Chapter 14 on
as fair use and copyright) documenting sources raises issues of
that motivate documentation different documentation conventions,
conventions specifically MLA and APA formats.
Practice applying citation Chapter 13 offers detailed guidance on
conventions systematically avoiding plagiarism, and Chapter 14
in their own work shows students how to apply citation
conventions of MLA and APA styles in
their own writing.

20
Brief Contents

Preface
PART ONE Understanding Argument
1 Approaches to Argument
2 Critical Reading of Written Arguments
3 Critical Reading of Multimodal Arguments
4 Writing Argument Analysis
5 Writing Arguments
PART TWO Analyzing the Elements
6 Claims
7 Support
8 Assumptions
PART THREE Using the Elements
9 Definition: Clarifying Key Terms
10 Language: Using Words with Care
11 Logic: Understanding Reasoning
PART FOUR Researching and Crafting Arguments
12 Planning and Research
13 Drafting, Revising, and Presenting Arguments
14 Documenting Sources
PART FIVE Debating the Issues
15 Rating Your Professors: Do Course Evaluations Matter?
16 Public Restrooms: Should They Be Gender Neutral?
17 Trigger Warnings: Have Some Schools Gone Too Far?
18 Gender Stereotypes: Is the “Princess” Phenomenon Detrimental to
Girls’ Self-Image?
19 Economics and College Sports: Should College Athletes Be Paid?
PART SIX Multiple Viewpoints

21
Exploring the Variety of Random
Documents with Different Content
while very early in most, and promptly in all, there will occur reflex
spasm of those muscles which have to do with motion of the
affected parts, by which they become more or less fixed and beyond
voluntary control of the patient. This condition has been described
by Sayre as “muscles on guard.” It is a significant feature, and has
as much to do with active joint disease as has abdominal rigidity
with surgical intra-abdominal conditions. Swelling will be
proportionate to the acuteness of the case. Tenderness is nearly
always extreme, especially along the articular line. The joint capsule
is frequently distended to its extreme and the normal contour of the
part completely obliterated.
The most common position in which limbs are held is midway
between extremes; thus when the knee is involved the leg will
become flexed upon the thigh, at about 75 degrees. If the shoulder
be at fault the arm is maintained close to the body. In disease of the
elbow the forearm is carried midway between the right angle and
complete extension. This is partly due to the fact that the flexors are
always stronger than the extensors, as it represents a compromise
between the antagonism of the opposing groups of muscles.
Pus, when present, is commonly also manifested by the usual
signs of its existence. There will be pitting on pressure or edema of
the overlying parts, while an acutely inflamed joint may be at any
time so swollen as to impede return circulation and lead to edema of
the parts beyond. To the local signs of phlegmon, then, we simply
have to add in greater detail those mentioned above. Along with
these there will be constitutional septic disturbances, usually
proportionate to the gravity of the local condition. The opportunities
for absorption afforded by a large synovial surface are great, and the
lymphatics are sure to carry toxins in abundance. The signs, then, of
septicemia, sometimes even of pyemia, are often pronounced. In the
presence of a joint full of pus the prognosis may be regarded as
exceedingly grave. Pain and tenderness seem to bear but little
relation to the swelling. Usually pain is an expression of distention,
yet some of the non-inflammatory forms of apparently milder type
are extremely painful. Pain is influenced by the position of the joint,
and the patient instinctively seeks that position in which suffering is
minimized. In a joint disorganized by the presence of pus there is
less sensitiveness, except on rough handling, unless the trouble have
extended far beyond the joint limits, and cellulitis be present, with
suppuration threatening. In metastatic joint abscess tenderness
rather than pain is the common rule.
In the presence of an acute inflammation in the joint end of a long
bone the other joint structures will participate to an extent
proportionate to its acuteness. With an acute osteomyelitis—e. g.,
near the articular surface—the synovial membrane will participate,
just as does the pleura in many cases of pneumonia, and we may
look for fluid in the joint in one case as we do for fluid in the chest
cavity in the other. Moreover, pictures of acute or chronic
tuberculous affections of the synovia correspond very closely to
those of the pleura. Tuberculous disease is liable to spread in every
direction in both diseases. The reverse of this, however, is not true in
all diseases of the chest, and there are many synovial as well as
pleural affections which are confined to their respective sacs.
The same statement, almost, can be made concerning the bursæ
and tendon sheaths in proximity to infected joints. Particularly is this
true when any of these connect with joint cavities.
The metastatic forms of pyarthrosis, as a collection of pus within
the joint capsule is called, are more insidious, though sometimes
equally destructive. They are by no means confined to one joint, and
in pyemia especially many of the joints will become involved. (See
Pyemia.) These secondary affections seem to be purulent from the
outset. In gonorrhea the effused fluids will often be found nearly
pure cultures of the gonococcus; after typhoid they contain typhoid
bacilli, etc. Such expressions are less frequent after pneumonia,
influenza, and the acute exanthemas, but may be seen even after
smallpox. It is often in these severely destructive joint lesions that
spontaneous dislocation occurs (Fig. 193).
—In the presence of a single joint lesion indications for treatment
are quite clear. When we have multiple and pyemic or gonorrheal
pyarthrosis it is often exceedingly difficult to determine what is for
the best interest of the patient. In general it may be said that
pyemia progressed to this extent will almost certainly be fatal, and
 Treatment.we may
Fig. 193
rest content with
aspirating the
affected joints, or
perhaps in leaving
them alone; because
we may feel that they
constitute but a small
proportion of the
metastatic foci which
eventually determine
death. On the other
hand, in other
infections with
pyarthrosis it would
be better to aspirate
or to open and drain,
because these cases
are slow and chronic,
and the exudate is
sometimes so rich in
fibrin as to lead to
quite firm spurious
ankylosis.
Thus gonorrheal
synovitis is usually
monarticular,
Pneumococcus infection of ankle; rapid destruction of
all joint structures. Child aged nine months. (Lexer.) although several
joints may be
involved. It is readily recognized in the presence of the active
disease, but there are times when recognition is made difficult by
the latency of urethral symptoms or the concealment of their
existence. The knee is usually the joint most often involved; next the
joints about the foot, and sometimes the tendon sheaths and bursæ
adjoining them.
 Syphilitic arthritis is a chronic and mildly but steadily progressive
affection. It rarely assumes purulent form without some secondary
infection. It is frequently combined with gumma along the
epiphyseal border. In hereditary syphilis numerous joints may be
involved in changes of the rachitic type.
Gout or some of its allied rheumatoid manifestations may lead to a
dry form of synovitis, with deposit of urates or of lymph, and the
formation of tophi in the neighborhood, or it may assume the form
of a chronic and intractable hydrarthrosis. The acute forms are
accompanied by great pain, with redness and swelling, peri-articular
and intra-articular. The tendency of these cases is to chronicity and
recurrence.
General Treatment.—Upon the nature of the condition will
depend the treatment of joint diseases. The questions of when to
operate and when to abstain, when to enforce rest and when to
begin passive and when active motion, call for discriminating
judgment. An acute or even mild traumatic synovitis should, first of
all, be protected from becoming purulent. Should injury be
accompanied by a bruise, the greatest care should be given to
antisepsis, and the part sterilized and dressed with every precaution.
Should there be no external injury we may rely ordinarily upon cold,
wet compresses, with suitable elastic compression and physiological
rest. Should two or three days of this treatment fail to bring about
nearly complete resorption the aspirator may be employed to
withdraw the fluid. If this should be found to be bloody or too thick
to run through the needle, it will be advisable to make small
incisions on either side, under the strictest precautions, and to
practise thorough irrigation, by which the joint cavity will be
completely cleared of foreign material. As soon, however, as the
presence of pus is indicated, or even suspected, the whole character
of the treatment should change. The surgeon should now endeavor
to be as radical as possible. The more purulent the collection the
more are free incision, irrigation, and drainage indicated and the
more complicated the condition the more he should make
counteropenings here and there, wherever joint pockets may be
emptied.
 When muscle spasm not only seriously disturbs the patient but
threatens to draw the limb into an undesirable position it should be
overcome, either by employment of traction with weight and pulley,
or by forcible reposition and fixation in suitable splints, such as
plaster of Paris. Some of the most extensive operations that are
called for are necessitated by neglect to observe these precautions
early. Often nothing will afford so much relief as the use of traction,
with sufficient weight, tiring out contracted muscles, and thus not
actually separating joint surfaces, but overcoming that muscle spasm
which brings them tightly together and thus gives pain.
In the more chronic form of cases absorption may be promoted by
elastic compression, by massage, by wet compresses, and
sometimes by blistering. Ordinarily, and especially in those cases
characterized by pain, more can be accomplished with the actual
cautery drawn lightly and rapidly over the surface of the joint than
by blistering. This application is referred to as the flying cautery, and
it is one of the most effective agents known for the relief of deep-
seated pain, as well as of cutaneous hyperesthesia. Its use causes
little if any unpleasant sensation, and should be repeated at daily
intervals until the primary object is attained.
Should aspiration of a distended joint be practised at any time,
one should atone for the loss of intra-articular pressure thereby
produced by external compression, preferably with an elastic
medium.
In the writer’s opinion it is not advisable to use a small aspirating
trocar in those cases which are likely to call for irrigation. The
aspirating needle should be confined to the non-purulent collections
of fluid, although some surgeons advise and practise throwing into a
mildly infected joint, through such a needle, some reasonably strong
antiseptic fluid or emulsion, hoping thus to gain its bactericidal effect
without external incision.
The active manifestations of disease being mastered, one
addresses himself naturally to the greatest possible prevention of
deformity and restoration of function. Indeed, these should be kept
in view from the outset, although we have, for a time, to disregard
them in favor of more imperative indications. If ankylosis appear
inevitable the joint should be kept in that position in which, when
stiff, it will be most useful. This position will be, at the elbow, at a
right angle; at the hip or knee, nearly complete extension. When, on
the other hand, restoration of function is hoped for it will be
obtained through a combination of massage, active and passive
movements, with the use perhaps of some sorbefacient ointment,
such as the compound ichthyol-mercurial, or by the nearly constant
use of cold, wet compresses, combined with the other measures.
The greatest care should be exercised in determining the time when
absolute rest given to an inflamed joint should be changed to the
gentle or more forcible movements required for restoring use to
previously inflamed joint surfaces.
Chronic Synovitis and Arthritis.—A chronic serous effusion into
a joint is given the term hydrarthrosis. This condition is never
primary; it is always the residue of some previous acute lesion, or
else it is the result of neuropathic or rheumatoid changes going on in
and about the joint, accompanied by relaxation of membranes
permitting passive distention with fluid. The contained fluid is
ordinarily pure serum. It may contain a little blood or numerous
particles or shreds of fibrin, while in rare instances there will be
found in it drops of oil or even fat crystals. The degree of distention
of a joint capsule is the measure of the gravity of the case, as this
membrane, like any other, will yield to gradual distention, although it
at the same time undergoes thickening as a protective measure.
Thus the synovia may, under certain circumstances, become as thick
as the pleura. The result is a tough, leathery condition of this
membrane, which makes it exceedingly difficult to manage. The joint
thus involved will appear more prominent than it should, because of
the atrophy of the surrounding structures. Accurate comparisons can
only be made by measuring corresponding joints. Neighboring
bursæ and tendon sheaths often participate in the distention. These
collections are ordinarily painless, or nearly so, but interfere, to
varying extent, with the function of the joint. Anatomical outlines
disappear or are concealed by the bag of fluid. It is rare that there
are any constitutional symptoms except perhaps those of the disease
which causes the disturbance. The amount of fluid which may be
contained in a long-distended knee-joint, for instance, is relatively
very large. The prognosis in these cases will depend much upon the
underlying cause, as well as upon the age, vitality, and docility of the
patient.
Treatment.—Removal of the fluid is always the indication. After
reasonable effort has shown that this is not possible by the
employment of massage, the actual cautery and elastic compression,
combined with functional rest, it should be withdrawn by the
aspirating needle or trocar. The more experience, however, we have
with affections of this class the more we will realize that the interior
of the synovial membrane is frequently studded with deposits,
fringes, etc., which are not affected by mere aspiration, and the
more cogent argument will be gained for sufficiently free incision to
permit inspection of the interior of the joint, removal of tags of
tissue, thorough washing out and sponging, by which a change in
circulation and nutrition is certainly affected; and this may be
combined with excision of a liberal portion of the thickened
membrane, by which the dimensions of the joint may be materially
reduced when the opening is sutured. For long-standing cases of
well-marked hydrarthrosis, especially in the knee, the writer would
urge this method of treatment. Drainage, if called for at all, can be
made with strands of silkworm, or some temporary material which
will quickly disappear or be promptly removed. This is particularly
applicable for the milder forms of tuberculous synovitis, in which the
joint is thus treated on the same principle that is applied in washing
out a tuberculous peritoneal cavity.

ARTHRITIS DEFORMANS AND OSTEO-ARTHRITIS.

Under this general name have been grouped a number of
conditions, including the so-called rheumatoid arthritis, and referring
to a variety of chronic progressive lesions of joints which involve the
articular cartilages and synovial membranes, later the bones, and
which produce more or less loss of function and deformity. Although
often spoken of as “rheumatoid,” the condition has nothing to do
with rheumatism as such, whatever that may be. It moreover
 Fig. 194
presents no analogies to the
forms of acute synovitis already
described. These lesions are
more common in women than in
men, occurring oftener in those
who have been sterile, and
during or after the menopause.
So far as their etiology and
pathology are concerned, it is
true, though it seem trite to say
it, that they are the result of
disturbed nutrition, which itself
may be referred back to
perverted trophic influences.
Exposure, bad hygienic
surroundings, improper food,
mental perturbation, and
depression are more or less
potent factors in most of the
cases. In some instances
occurring in advanced age they
seem to be due to changes
ordinarily regarded as senile.
When joint lesions are multiple
and symmetrical, and
accompanied by other nutritive
changes, we may refer the cause
back to the central nervous
system. When monarticular they
are more likely to be the residue
of some previous infection or
injury, such as gonorrhea,
Arthritis deformans, knee. (Ransohoff.) influenza, or an acute exanthem.
If in connection with the joint
manifestations we find the spleen and lymphatics enlarged, then the
case may be regarded as doubtless infectious in nature.
 The pathological changes within these joints include almost every
imaginable alteration. Bones soften and atrophy at one point, or at
another become enlarged and thickened, and throw out osteophytic
projections by which the whole shape of the joint is materially
changed. Cartilages atrophy here and thicken there, and disappear,
at times, to an extent by which bone is exposed, the exposed
surfaces frequently becoming polished or eburnated. The position of
the joint and its general contour may be materially altered by these
changes, and marked deformity or notable enlargement result.
Subluxations are not infrequent, while the ligamentous structures
are sufficiently strong to perform their function, and the joint yields
or “wabbles.” Meanwhile the synovial membrane undergoes
corresponding changes, and becomes distended with fluid so that
hydrarthrosis is a frequent accompaniment.
On the other hand, there is another type of analogous changes
where the tendency is atrophic throughout and little if any extra fluid
accumulates. Such a joint may become smaller rather than larger,
especially if, as in some cases, some part of the bone practically
disappears.
At all events muscle atrophy, sometimes with pseudo-ankylosis,
sometimes with actual ankylosis, will characterize most of these
cases, and muscles naturally disappear as they functionate less and
less.
Pain is an irregular feature, some of the lesions being quite
painful, others almost free from it. The lesions are essentially
progressive in their character, unless the whole body condition and
environment can be changed for the better. Consequently individuals
become more and more crippled. Muscle spasm is rarely present, but
when such changes occur in the intervertebral joints the individual
becomes gradually bent over or deformed, partly because the
muscles no longer have strength to maintain the erect posture, and
partly from actual changes in the bones and joints. Most of the
instances, however, are characterized by tenderness, while a general
myalgia or malaise is a frequent complaint. There are sometimes
exacerbations, during which both severe neuralgic pains and mild
fever are quite pronounced. Not infrequently on handling the
affected joint pseudocrepitus or actual crepitus will be obtained.
Sometimes the joint surfaces are roughened, and then this sensation
is most pronounced. When the synovial membrane is proliferated, in
pannus form, over the cartilages, its enlarged fringes will give a soft
crepitus which is quite distinctive. Fragments of these fringes, as
well as of cartilage, may become detached, and loose objects of this
kind in the joint may be recognized by the sense of touch.
While this is going on within the joint, adjoining tendon sheaths
and bursæ become more or less involved, and even the periosteum
will undergo considerable thickening.
The monarticular type is more frequent in men than in women,
and occurs more often in a large joint or in the spine, in which latter
case it is hardly to be considered monarticular. The changes that
may occur in the spine are distinctive, varying from trifling stiffness
and limitation of motion to pronounced deformity, by which, for
instance, not only the kyphosis of acute spondylitis may be imitated,
but the body flexed to an angle with the axis of the pelvis and fixed
there, so that the individual is bent to nearly a right angle. Some of
the other deformities of this condition are more or less characteristic.
In the hands the fingers are bent toward the ulnar side, and often
strongly flexed, perhaps even overlapped, thus giving the hand a
peculiar claw-like appearance. The feet are extended completely, the
joints rigid, the toes turned outward, and also overlapping. By such
changes in the hip and knee the legs and thighs may be flexed and
the hips perhaps so ankylosed as to prevent separation of the knees.
While these changes are, as stated, most common in the later years
of life, children are not exempt, girls being more frequently affected
than boys, the condition coming on at first with more or less acute
symptoms. These children will often be found to have enlarged
spleens and lymph nodes, to show malnutrition, while some of them
will display certain symptoms of exophthalmic goitre. In other words,
they are in that condition included under the term status
lymphaticus, to which subject the reader is referred. (See p. 163.)
It would appear, then, that we can expunge the term chronic
articular rheumatism, since by it is not meant the ultimate result of
an acute rheumatic Fig. 195
affection, but rather
one of the vague
conditions described
above.
Fig. 195, taken
from a skeleton in the
author’s possession,
illustrates an extreme
condition of this kind,
characterized by
multiple synostoses,
nearly all of the
principal joints being
involved.
As between the
terms osteo-arthritis
and arthritis
deformans it is not
practicable to make
such accurate
distinctions as shall
be acceptable to all.
In a general way the
more the bone
participates the more
we may use the
former designation,
whereas when other
joint structures are
chiefly involved we
may resort to the
latter.
In general, then, all
these conditions are
evidenced by joint
deformity, especially
by irregularities, by
more or less effusion,
by considerable
tenderness, by
creaking of the joints
when used, by pain
which is a variable
feature and may be
referred to nerve
disturbances,
occasionally by
muscle spasm, but
always, in cases of
long standing, by
muscle atrophy. A
view of the interior of
joints thus affected
will give a complex
picture of atrophy
here and hypertrophy
there of each or all of
the component
structures of the
joint, sometimes with
a gradual overgrowth
of articular bone
surfaces, sometimes
with more or less
complete
disappearance of the
same, e. g., in the
acetabulum.
Treatment.—So
far as treatment of
these conditions is
concerned, it should General osteo-arthritis, with multiple synostoses
be recalled, first of (“ossified man”).
all, that the disease
itself is exceedingly chronic in its tendency, and due to conditions
which have probably been of long standing. Constitutional treatment
is as essential as local, and must consist in restoring the
environment and the nutrition of the patient to normal standards.
Elimination is deficient in such cases, and should be stimulated by
hot-air baths, massage, and such exercise as may be possible, as
well as by the use of diuretics and laxatives to the degree indicated.
The local treatment may consist also of massage, elastic
compression, aspiration in rare instances, the use of wet packs, and,
in many cases, the use of hot, dry air. Various forms of apparatus
are now upon the market by which almost any of the joints may be
subjected to the influence of dry, hot air at a temperature of 280° F.
When properly used, great relief and improvement may be expected.
Their use, however, calls for the best of judgment and a combination
of the measures already mentioned.[31]
[31] The following types of arthritis bear little, if any, relation to true
rheumatic disease, though often spoken of as rheumatoid:
The chronic villous form, most common in the knee, purely local, without
effusion, and giving dry crepitus or creaking. The joint fringes are
numerous, and sometimes vascular. If the crepitus be marked and the
fringes too extensive the latter may be relieved by operation. Otherwise this
form is to be treated by early local stimulation, with some support, at least
with a bandage.
The atrophic form, of unknown etiology, causing progressive and finally
crippling swelling, with later atrophy. There is little if any fluid present. Here
the changes occur in both bone and cartilage, with a tendency to abnormal
calcification. In this form rest and hypernutrition, especially with normal
proteids, are called for, and every possible stimulus to elimination through
all the emunctories.
The hypertrophic arthritis, by which cartilages are first thickened and
then ossified, interfering with motion and with contour. This form causes
great limitation of motion and sometimes pressure on nerves, with referred
pains. It seems to have some relation to cold, exposure, and injury.
Detachment of pieces of cartilage is not uncommon, so that there are loose
bodies in the joint cavity. Treatment here consists of fixation, with
 improvement of nutrition and elimination. This form may subside under
proper treatment.
The chronic, gouty arthritis, with deposits of sodium urate in and around
the joint tissues, with perhaps some bone absorption beneath them, which
are not connected with the bone. In the digits entire phalanges may
disappear by absorption. The treatment here is essentially constitutional
and directed toward the gouty diathesis.

NEUROPATHIC JOINT DISEASE.

This received its first full and classical description from Charcot in
1868. The term refers to joint lesions which follow and are
apparently connected with certain injuries and diseases of the spinal
cord, or the peripheral nervous system. The non-traumatic forms are
mostly associated with locomotor ataxia and syringomyelia. Some of
them have an abrupt onset, while others come on very insidiously.
Pain is usually notable by its absence, and the involved joints show
few, if any, evidences of hyperemia or inflammation. They become
unnaturally mobile and relaxed and usually much, sometimes
enormously, distended with fluid. The morbid changes within the
joints comprise imaginary combinations of atrophy and hypertrophy,
with proliferative formations in bone cartilages. Osteophytes and
exostoses are met with, and ossification may occur in the
neighboring tendons and ligaments. Surprising alterations take place
in certain joints; thus, as shown in Fig. 197, the head of the
humerus may disappear and corresponding changes may occur in
other joints. While it is the knee which suffers most frequently, no
joints, not even those of the spine or jaw, are exempt.
 Fig. 196 Fig. 197

Charcot’s disease of elbow. Atrophic disappearance of bone after

chronic joint disease.
 Fig. 198 Fig. 199

Tabetic arthropathy. (Case of E. A. Neuropathic arthritis (tabetic joints).

Smith.) (Lexer.)

Locomotor ataxia is a common disease, but syringomyelia has

been regarded as exceedingly rare. Nevertheless, Schlesinger has
collected 130 cases of it, in one-fourth of which bone and joint
symptoms were present. That the nervous system is primarily at
fault is made clear, among other things, by the rapidity of
involvement occasionally seen, where, for instance, an entire limb
becomes edematous, with every indication of severe disturbance. In
tabes the lower extremities suffer more often than the others; the
reverse is true in cases of syringomyelia. While floating bodies in the
joints and ossification of the muscles and soft parts are common in
arthritis deformans, they seldom occur in the neuropathic lesions.
Suppuration and necrosis are rare in any of these forms, occurring
more frequently in the finger than elsewhere, and are probably due
to infection of those areas where sensibility is lost and trifling
injuries less guarded against. The neuropathic lesions are more
commonly symmetrical, and are often accompanied by a cretinic
general appearance (Figs. 196, 197, 198, 199, 200 and 201).
 Fig. 200

Skiagram of joints shown in Fig. 199. (Lexer.)

 Fig. 201

Arthropathy of syringomyelia. Left elbow, illustrating disintegration, etc., without

ulceration or suppuration. (Quenu.)

The joint complications of syringomyelia are frequently

characterized by skin lesions which tend to suppurate, by sudden
edema, occasionally followed by phlegmon and even necrosis, also
by other disturbances of innervation.
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.

GONORRHEAL OR POSTGONORRHEAL ARTHRITIS.

This condition may occur during the active stage of gonorrhea or
after its apparent subsidence. It was probably the discovery of the
pathogenic gonococcus by Neisser, in 1879, which gave to this lesion
an identity of its own, and induced the profession to abandon the
name gonorrheal rheumatism, by which it had been known. It has
nothing to do with rheumatism, and should not be linked with it in
name any more than in idea. In well-marked cases the gonococcus
will nearly always be found, usually in pure culture, in the joint fluid.
It appears in different degrees of severity, from a mere hydrops,
which is mild, accompanied by slight tissue changes, to a
phlegmonous condition, with widespread destruction of joint
structures and serious constitutional disturbances. As between these
extremes there may be a pyarthrosis or empyema, which is usually
the result of a mixed infection.
As a complication of urethritis it occurs in 4 or 5 per cent. of
cases, the percentage being larger in children than in adults, the
knee being affected in about one-third of these cases. It is not
necessarily monarticular, however, and sometimes several joints will
be involved. Along with the joint condition there will frequently occur
cardiac lesions (endocarditis) and eye complications. In fact, some of
these cases terminate fatally through the mechanism of a seriously
involved heart, i. e., septic endocarditis or myocarditis. When it
occurs in the ankle or in the tarsal joints the ligaments and
surrounding bursæ are often involved. This involvement, unless
recognized and properly treated, may lead to serious deformity,
e. g., flat-foot of the most painful kind. Many of these lesions at the
heel are accompanied by true exostoses, which are often painful and
more or less disabling (“painful heel”). Thus, Jaeger has recently
reported a group of ten such cases. These may require excision. In
general this form of arthritis is characterized by severe pain, often
worse at night, and a peculiar distortion of the swollen joint,
because it is usually complicated by a distention of the adjoining
tendon sheaths and bursæ, which is rare in other forms of arthritis.
It has been aptly stated that if in these cases the same zeal were
displayed in seeking for gonococci that has often been shown in
looking for uric acid it would be less often neglected. So far as
treatment is concerned, I desire in this place only to call attention to
the absolute inutility of all the so-called antirheumatic remedies and
diet. However, if the urine be hyperacid it should be corrected by
ordinary means. At first absolute rest, with the local use of the
ichthyol-mercurial or Credé ointment, should be given. Such
antiseptics as one has most confidence in may also be administered
internally for their general beneficial effect. An overdistended joint
should be tapped and irrigated. As soon as the presence of pus can
be determined, either with or without exploration, the joint should
be opened, thoroughly irrigated, and drained. If this were always
done in time the more severe phlegmonous and destructive cases
would rarely occur.
 TUBERCULOUS ARTHRITIS.
Tuberculous disease of the joints is one of the most frequent of
surgical lesions. It has produced characteristic appearances which
have been known under the name of “scrofula of joints,” until a
clearer recognition of the pathology of the condition led to the
abandonment of the term scrofula. Tumor albus, or white swelling,
was another term commonly applied to these lesions, because of the
anemic appearance of the surface of the swollen joint.
Tuberculous arthritis assumes different phases in proportion to the
involvement of the different component structures of the joint. Some
cases begin purely as a tuberculous synovitis, and may for a long
time be limited to the synovial structures. Others begin within the
spongy texture of the expanded joint ends of the long bones, the
disease spreading from such foci and involving everything in the
path which its products take in the effort to secure spontaneous
evacuation, products of softening and infection travelling in the
direction of least resistance.
It has been the writer’s custom to always follow Savory, in his
suggestion to students to let their mental pictures of consumption of
the lungs and pleuræ serve for illustration in similar disease of joints.
Thus the cancellous bone structure much resembles the lung tissue
in its spongy character. In both a capsule surrounds the mass of
tubercle, and in each, by breaking down of its contents, a cavity is
formed. Moreover, the pleura bears practically the same resemblance
and relation to the lung and the chest wall that the synovialis does
to the bone end and the joint cavity; as we may have pleuritis with
phthisis, so we may have synovitis with tuberculous ostitis; and as
adhesions tend to form in the pleural cavity, so also do they in the
synovial cavity. Furthermore, in each case obliteration of deeper
veins causes the more prominent appearance of the subcutaneous
veins, and as tuberculous pleurisy often terminates in empyema, so
does tuberculous hydrarthrosis often terminate in pyarthrosis,
perhaps with fungous ulceration. In almost every feature, then, the
progress and effect of tuberculosis in the lung and bone end may be
likened to each other.
 In some clinics bone and joint tuberculosis constitute nearly one-
third of the total of cases treated. Joints of the lower limb are the
ones most frequently involved in children, while in the adult those of
the upper extremity are generally attacked. It is not often that more
than one joint is involved at one time. The relation of traumatism to
this disease has been frequently discussed, and is variously
regarded. The disease is more common in those who are
predisposed to it by environment or by heredity, in the latter case
hereditary evidences usually being well marked. In such predisposed
individuals, especially in the early years of life, severe injuries are
usually promptly repaired, while the milder traumatisms, which are
often frequent and to which too little attention is paid, seem often to
so far lower tissue resistance as to favor an infection to which the
individual is already favorably predisposed. The true position to take,
then, would appear to be this, that traumatisms rarely lead directly
to joint tuberculosis, but only indirectly by affecting tissue
susceptibility.
Thus lesions which begin in the epiphyses lead to what is known
as osteopathic joint disease, while those which have their origin in
the synovia give rise to the arthropathic forms. The former are more
common in children and the latter in adults (Fig. 202).
Pathology.—In regard to the pathology of these conditions it
does not vary from that mentioned in the earlier portion of this work
in connection with the general subject of Surgical Tuberculosis. The
deposit of tubercle in the tissue whose resistance has been
weakened is followed by the formation of granulation tissue, which,
so long as the germs survive, tends to increase and to make room
for itself at the expense of surrounding tissue. At the same time
there occurs a tissue struggle by which the attempt is made to throw
around an active focus a protecting barrier, which in soft tissues
consists of condensed fibrous and connective tissue, and, in bone, of
a sclerotic capsule, as though the intent were to imprison the
disturbing cause, and, by completely enclosing it, effect protection.
When this attempt at encapsulation is successful spontaneous
recovery follows. It will be made successful, to some extent at least,
by treatment whose most important local feature is physiological
rest. On the other hand, when the attempt is unsuccessful and the
barrier is transgressed by granulation tissue, the lesion will advance
in the direction of least resistance, while its progress will be made
known, especially as it approaches the surface, by very significant
signs: adhesion of the overlying structures and finally of the skin,
with purplish discoloration of the latter. Finally softening occurs with
escape of granulation tissue, which, so soon as it is freed from
pressure, will grow more luxuriantly and with more color,
constituting the fungous granulation tissue, to which German
pathologists so often allude, or so-called “proud flesh.” When this
appears upon the surface it is soon infected with pyogenic
organisms, breaks down, and an abscess cavity results, connecting
with the original focus and its extensions. This may be so placed as
to lie outside the joint capsule, which, in some respects, is fortunate
for the patient. The joint function may then be compromised to only
a minor degree.
 Fig. 202

Central sequestrum. (Ransohoff.)

Often the direction of least resistance is toward the joint cavity,

this fungous tissue loosening and perforating cartilage or periosteum
before it enters the joint. Having penetrated it again it grows
extensively until the cavity is distended, its rapidity of growth
diminishing with the degree of pressure produced by its
surroundings. This pressure will also make it less vascular, and when
such a joint is opened it at first appears pale and anemic. In
proportion as the joint distends it loses in motility, while should
recovery occur spontaneously or as the result of treatment this
tissue will to some extent disappear, to be replaced by adhesions by
which pseudo-ankylosis is produced. The extent of the intra-articular
involvement will cause obstruction to the deeper return circulation,
and thus is brought about the prominence with which the
subcutaneous veins appear. The degree of hydrarthrosis is
apparently not limited except by the distensibility of the joint. In the
articular or arthropathic forms there is always more or less synovial
outpour.
Fig. 203
 Tuberculous panarthritis. (Ransohoff.)

To the condition already described may be added the destruction

produced by suppuration, infection occurring either through the
circulation, as is quite possible, or through some trifling surface
abrasion. In more chronic cases caseation may occur, especially in
bone foci. Finally, as the result of a combination of morbid
processes, there is produced more or less complete disorganization,
all of which is summed up in the term tuberculous panarthritis. To
that condition in which the articular surfaces are more or less
studded with fungous patches the term pannus of the joint is often
applied. To reiterate, then, as between a chronic hydrarthrosis and a
destructive panarthritis, perhaps even with necrosis of epiphyses, it
is but a difference of degree and of combination of infectious
processes (Figs. 203, 204, 205 and 206).
Among the other consequences of panarthritis may be the
formation of sequestra in or near the epiphyses, and such
destruction as shall lead to pathological dislocation, the latter being
well illustrated in Figs. 204 and 207. This dislocation is always the
result of the pull of muscles thrown into that condition of reflex
spasm which is a characteristic feature of this disease. It appears
conspicuously at the knee, usually as a backward subluxation (Fig.
207), and at the hip as an upward dislocation, sometimes with more
or less apparent migration of the acetabulum. Another consequence
of tuberculous hydrarthrosis, which frequently persists even long
after the subsidence of the acute stage of the disease, is the
occurrence within the joint cavity of rice-grain or melon-seed bodies,
for whose presence it is not easy to account. The generally received
explanation is that they are the result of fibrinous outpour, whose
fluid portions have been absorbed, while the remaining nearly pure
fibrin is broken up into particles and rounded off by attrition during
the movements of the joint. They may accumulate in astonishing
amount, thus stamping the disease as having a chronic rather than
an acute character. After a time they provoke a fresh outpour of
fluid, as a result of the irritation which they produce. This fluid is at
first usually clear serum, but becomes turbid or seropyoid, and, if