The moist glistening membrane lining the abdomen (peritoneum) and that lining the chest (pleura) are similar to the synovial sac between the bone ends at joints or the synovial sheaths of tendons.

Bursae. A bursa, which is a sac lined with serous membrane, placed over a joint or other prominent part for protection, is also quite similar. All of these membranes are smooth and moist, giving lubrication to movable parts, thus: the peritoneum covering the intestines, permits of their easy worm-like action within the abdomen; the pleura makes for the free rise and fall of the lungs; the synovial sacs of joints allow the bones to ride smoothly one upon the other; the synovial sheath of a tendon acts like a silken sleeve in which the tendon slides up and down and, lastly, pressure over a bony point causes the member to move aside because of the slipping of the walls of the bursa, one upon the other, when compressed.

INJURIES AND DISEASES OF BURSAE.

Synovial bursae exist normally in connection with tendons or with certain joints, and may be developed by continued friction or pressure at certain parts of the body. Deep bursae are sometimes connected with the joints, or are in very close relation with them.

Injuries of Bursae. Wounds of bursae may be either contused, incised, lacerated, or punctured, and, if they become infected, may prove most serious injuries. Wounds of bursae should be thoroughly disinfected and drained; they usually heal with obliteration of the sac.

Acute Bursitis. This affection usually results from an injury or from continuous irritation of a bursa, and is characterized by tenderness, pain, redness of the skin, and swelling or distension of the bursa. If suppuration occurs, the inflammation is apt to extend to the surrounding cellular tissue, or, if in close proximity to a joint, the latter may be involved. Bursitis can usually be diagnosed from other affections by the rapidity of development of the inflammatory symptoms, the location of the swelling in relation to certain tendons or joints, and its globular shape.

Treatment. This consists in elevating the part and putting it at rest on a splint, and in the application of cold or pressure. If, however, the pain and swelling due to effusion continue, and there is evidence of suppuration, the bursa should be freely opened and irrigated, and subsequently packed with sterilized or iodoform gauze. Under this treatment the cavity soon becomes obliterated as healing occurs. The bursae most commonly involved are the prepatellar and that over the metatarsal joint of the great toe.

Chronic Bursitis. This affection may result from acute bursitis which does not terminate in suppuration, or may develop slowly from long continued irritation or pressure, or from tubercular infection of the bursae and is accompanied by little pain.

The most marked feature in chronic bursitis is the distension of the sac with fluid, and in some cases the walls of the sac become so thickened that the bursa is converted into a solid tumor. Chronic bursitis of the prepatellar bursae is not infrequent, and is commonly known us Housemaid’s knee, resulting from long continued pressure upon the knee occurring in those whose occupation causes them to constantly bear pressure upon this part.

Gumma of the prepatellar bursa is very common, and should be suspected in every case of suppuration of this bursa without assignable cause. It often results in extensive sloughing.

Hernial protrusion of a portion of a bursa is sometimes seen after injuries of bursae.

Treatment. The treatment of chronic bursitis, if the sac is distended with fluid, consists in removal of the fluid by aspiration, or by making an incision and introducing a drain. The greatest care should be observed to keep the wound aseptic. The bursae may be removed by dissection. This is the only treatment which is likely to be of use in cases where the bursa is very thick or is converted into a solid tumor. In removing these growths by dissection, great care should be exercised to avoid opening the neighboring joints.

Bunion. This is a bursal enlargement over the metatarsophalangeal articulation of the great toe, which is very frequently observed with hallux valgus, this being the most universal cause. The part is swollen and tender upon pressure, and if suppuration occurs the pain is severe, and cellulitis is apt to develop, involving the surrounding parts, or the joint may be involved, caries of the bones of the articulation resulting.

Treatment. If suppuration has not occurred, the part should be protected from pressure by a circular shield of felt or plaster; if suppuration has taken place, the part should be incised and drained, and if the joint is found diseased it should be curreted and dressed with an antiseptic dressing; if malposition of the toe exists, its position should be corrected by amputation of the head of the metatarsal.

Inflammation of Synovial and Serous Membranes. When the serous and synovial membranes are attacked by inflammation, the stage of congestion is accompanied by exudation of serum and fibrin from the surface, and the endothelial cells become swollen and detached in large numbers. The serous exudation may be sufficient to fill the entire cavity involved. There is a form of dry or fibrinous inflammation, without fluid exudate, in which the surface of the membrane loses its polish, becoming dry and red, and adhesions readily form wherever the surfaces are in contact.

In suppurative inflammation, pus is produced by emigration, and also by the detached endothelial cells. If fibrin is present, false membranes form on the surface and the membrane itself appears to be greatly thickened. At a later stage the proliferating cells invade these layers of fibrin and they become organized into connective tissue, and new vessels develop on them. Their tendency, however, is to disappear after a time, and the membrane returns to its original condition, unless the inflammation has been very intense, in which case the new connective tissue becomes permanent. Chronic inflammation of these membranes is marked by general thickening of all the layers, the formation of dense connective tissue in the fibrinous membranes, strong adhesions, and sometimes complete obliteration of the cavities, their endothelial lining disappearing entirely.

SYNOVITIS

Like other structures of the body the joints are subject to injury and disease and because of the nature and course of pathologic processes in them, one should bear in mind their anatomic construction.

The expanded ends of the bones in the joints are covered with a thin layer of cartilage and are bound to each other by a dense capsule which is firmly attached to the bones at their necks, where it is closely connected with the periosteum. The joint cavity is lined (excepting where additional fibrocartilages are present) with a synovial sac which sometimes communicates with a bursa.

Inflammations of varying intensity are of frequent occurrence; they maybe due to rheumatism or gout, to traumatism, to the action of microorganisms, or, to disturbances of innervation. They may be slight or severe, acute or chronic. They may terminate in resolution, in permanent new formations, more or less deforming and disabling, or in the destruction of the articulation.

Inflammations may arise in the joint structures proper or may extend to it from contiguous structures, such as the cancellous bone ends, the overlying tendons or the periarticular connective tissue. They may be largely confined to a single structure, the synovial membrane being ordinarily affected, or they may involve the whole joint.

Acute synovitis. Synovitis may occur as a result of a simple injury, such as a subcutaneous wound, a contusion, or a sprain. Exposure to cold and the presence of a movable cartilage are also common causes. Aseptic conditions in the synovial membrane seldom extend to the other joint structures (see “Arthritis”) and heal with or without impairment of the joint, depending on the degree of inflammation.

Symptoms. The joint is painful, especially upon motion, and particularly so at night. It is swollen and tense and may be fluctuating. At the knee, the patella is floated up from the condyles and can be depressed upon slight pressure. The joint is held in a position of partial flexion which permits of the greatest ease, because of the diminished tension in this position.

Local heat and tenderness are not necessarily great, and constitutional symptoms, if present, are moderate in degree.

In the suppurative affections of joints, all of the above symptoms are intense and there is a general arthritis.

After a few hours or days the intensity of the symptoms subsides, the pain lessens, the swelling diminishes, as the effusion and extravasated blood are absorbed, the limb takes its natural position, and recovery promptly takes place. If there has been much hemorrhage into the joint, adhesions due to the organization of the clot may cause some restriction of motion.

Treatment. The joint must be placed at rest and an ice bag kept in constant contact. Even pressure with cotton and broad bandages often hastens absorption, but cannot at first be borne with comfort.

In rare instances aspiration of the effusion must be resorted to, but the certainty should exist that absorption is impossible, before a joint is punctured. The greatest care must be exercised in introducing a needle into a joint to avoid infection.

Chronic Synovitis. While it is true that an inflammation of a synovial membrane cannot long remain without extending to the other joint structures, the fact remains that symptoms peculiar to synovitis often persist for months. These are properly viewed as constituting a condition of chronicity. The active swelling and abundant effusion, belonging to the acute stage, subside, but an undue amount of fluid remains, with some pain and weakness.

If, with proper treatment and rest, these symptoms persist, there is an extension of the process to the bone ends and an exacerbation of symptoms.

The subsidence of a chronic synovitis generally leaves a weak and impaired joint, though pain may be absent. Movements, especially in extension, are restricted, and grating or cracking remain as evidences of the roughened membrane.

Treatment. The mere presence of a superabundance of fluid in a joint does not in itself constitute a diseased state, but may be the evidence of impaired circulation of the part. Absorption may occur with rest and tight bandaging, or with massage, friction, and baking, results may often be obtained. Certain cases resisting such procedures are best treated with a plaster of Paris cast to immobilize the part for several months. When the affection is of long standing and the joint is much distended it may be termed hydrops articuli or hydrarthrosis.

When, in spite of all the methods of treatment here described, the condition does not yield, very good results may be obtained by the aspiration of the fluid, and the injection of a few drams of a three per cent. or five per cent. solution of carbolic acid. This operation, though simple, requires every aseptic precaution, and should never be performed in the presence of any acute symptoms.

For other phases of Synovitis see Arthritis.

ARTHRITIS

The structures of a joint are: bone, cartilage, ligaments, synovial membrane and, in some cases, fibrocartilage. Hence, a joint inflammation is an inflammation of all of these structures, and is designated, arthritis.

The inflammation may begin in any one of these structures, but sooner or later, all are involved. The synovial membrane, however, when inflamed, seems to prove an exception to the rule in that inflammation may or may not extend from it to the rest of the joint. If such an extension does take place we have an arthritis.

We may therefore have two distinct classes of joint inflammation: (1) the varieties of synovitis, and (2) the varieties of arthritis. These inflammations may be acute or chronic.

In synovitis there is only the inflammation of the synovial membrane, while in arthritis there is inflammation of the synovial membrane plus inflammation of the bone covering (periostitis); of the bone (osteitis); of cartilage (chondritis); of bone marrow (osteomyelitis); and also a cellulitis of the ligaments attached to the joint involved.

Symptoms. The symptoms of arthritis are obviously more severe than those of a simple articular synovitis and are both local and general. The general symptoms arise from the absorption into the circulation of either bacteria or their toxins, and vary greatly in severity. There is either a toxemia or a septicemia, with the usual symptoms of a general sepsis.

The local symptoms are those common to synovitis and arthritis: pain, tenderness, swelling, heat, redness and loss of function. From these alone a differential diagnosis between synovitis and arthritis cannot be made. If, however, there is a sensation of crepitus conveyed to the examiner’s hand upon passive motion, there is an arthritis present beyond doubt. This symptom is due to the destruction of the synovial covering of the bone ends involved, permitting contact of bone with bone. It is more common to chronic joint disease, but may also accompany acute conditions, especially if they are severe.

Symptoms peculiar to the variety of infection and the history as to duration, causation, course and number of joints involved, must be considered in making a diagnosis or prognosis.

Varieties. Besides simple traumatic arthritis, there are many constitutional disorders which affect the joints conspicuously; these are: tuberculosis, syphilis, gonorrhea, gout and rheumatism.

A prominent cause of many instances of arthritis heretofore regarded as rheumatic in origin, is now known to exist in any area of infection. Such “foci of infection” discharge a certain amount of infective material into the circulation, which may find lodgment in a joint and set up an acute process.

It has been proven in numerous cases that a so-called rheumatism will yield promptly to drainage of a chronic abscess, no matter how remote the location. Oral conditions especially have been found responsible for this form of arthritis. Abscesses at the apexes of teeth and pyorrhoea alveolaris, when properly operated, yield nothing short of miracles, in the way of relieved symptoms.

In addition to the varieties of arthritis already mentioned, those due to certain infectious diseases, such as measles, scarlet fever, typhoid fever, smallpox or erysipelas, should be included, as well as cases of neuropathic origin.

TRAUMATIC ARTHRITIS

Nonpenetrating and Penetrating

Nonpenetrating. Ordinary contusions or twisting at a joint, may result in the establishment of an inflammatory process within the joint, evidenced by much swelling and giving the sensation of fluctuation to the examining hands, indicating the presence of fluid within the synovial membrane. This occurs also when there is a detached fibrocartilage in the joint. The synovial membrane is thickened and there is an exudation of serum.

Sprains belong in this classification. These are simple, clean, inflammatory conditions.

Symptoms. These are generally limited to those enumerated as belonging to synovitis, except that the disability is more pronounced.

Treatment. Rest and wet dressings generally suffice to effect restitution in a few weeks.

Penetrating. Should the joint be injured by violence so that there is a loss of continuity of the tissues leading into the joint proper, there is every probability of infective material gaining entrance. These are serious accidents, though restoration of an efficient joint is possible, but when improperly treated or neglected, local destruction, or even loss of life may occur.

Penetrating wounds of joints usually occur in consequence of accidents with firearms, sharp tools, or falling upon sharp objects. Frequently, penetration of a joint follows suppuration in the immediate neighborhood.

Symptoms. The extent of the injury, the particular joint involved, and the nature of the vulnerating body will affect the train of symptoms. An escape of synovial fluid, pain and some swelling will occur even with a very small penetration. Should the joint escape infection, the synovitis quickly subsides and recovery takes place with little or no impairment of the functional value of the part. The opening in the capsule closes, the extravasated blood is absorbed and the synovial surface is again smooth. If, however, the wound has been inflicted with an unclean instrument, or if at any time before healing it becomes septic, a very different and graver condition obtains.

Septic Arthritis. Infection with bacteria of suppuration, chiefly the staphylococcus albus or the streptococcus pyogenes, produces an acute arthritis which frequently, despite the most careful treatment, will result in the destruction of the joint, and not seldom in the loss of life.

The infection may occur in one of several ways: (1) directly through a dirty instrument, or the lodgment of infective material in the tract leading to the joint cavity; (2) by the extension of a suppurative process, either of the bones or soft tissue adjacent; or, by (3) the deposition into the joint of infective organisms circulating in the blood stream.

Symptoms. However produced, large numbers of organisms are present and a high grade of inflammation ensues. An abundant amount of pus is soon formed; the synovial membrane, the bone ends and the joint capsule are actively inflamed, and soon become disorganized. Perforation of the capsule is followed by infection and suppuration of the tendons and other structures about the joint, which soon affects the superficial structures and forms an opening through the skin. The pain is intense, generally worse at night; the swelling is great and fluctuation is distinct; the skin is red and hot, and the parts above and below are edematous. Any attempt at motion increases the suffering.

With these local symptoms there is an accompanying train of constitutional symptoms which may eventuate fatally. At first there is a chill, or a sensation of chilliness after which the temperature quickly runs up several degrees, and either remains so, or goes down and up several times in twenty-four hours, as in other septic conditions. The pulse may be strong and full at first, but soon becomes rapid and weak. In very acute cases, death from septicemia may occur in a few days.

In ordinary cases, drainage of the pus, either naturally or artificially, will result in a remission of the symptoms both locally and generally.

Treatment. In this, as in other suppurative processes, safety lies in the prompt opening of the abscesses and the evacuation of the pus, thus accomplishing free drainage, with subsequent disinfection by means of applications or irrigations. Immobilization of the parts and rigid antisepsis will generally yield good results as to life, though recovery with ankylosis is the rule. In the most severe cases, constitutional symptoms are so grave as to warrant immediate amputation above the infected joint.

Tubercular Arthritis. The great majority of chronic joint diseases are tubercular in origin, the tubercle bacilli being deposited in any of the joint structures, or in structures contiguous to a joint; with children, very frequently in the bone substance.

Whether the tubercular process originates in the joint cavity itself or outside of it in the surrounding tissues, destruction of the articular ends of the bones is usual.

The parts become thickened and edematous; there is a gelatinous or cheesy appearance, in which the membrane, cartilaginous bone ends, capsule, and ligamentous structures all share. Frequently the synovial membrane is studded with miliary tubercles and its cavity is filled with an abundant serous secretion. The contour of the joint becomes globular or spindle shaped, because of the atrophy of the parts above and below it and the swelling of the periarticular structures. The skin becomes white and thick because of the obliteration of the superficial vessels and because of its edematous infiltration.

Symptoms. Pain is, as a rule, but slight in the strictly synovial stage of tubercular arthritis, but when the bones are involved, it is severe, though acute symptoms, such as heat and redness, are lacking.

Deformity is a constant accompaniment of the disease; its degree is greater or less according to the joint affected, the extent of the disease, and the treatment pursued. It is due to the natural tendency to assume the position of greatest ease; to the softening and destruction of the ligaments, and to the effort on the part of nature to immobilize an injured member by means of tonic contraction of the muscles. These causes often result in the creation and persistence of a malformation and malposition of the part.

Cheesy degeneration and liquefaction take place in more or less degree, and though their occurrence is often not evidenced by any aggravation of the symptoms, sinus formation with persisting discharge occurs.

When these sinuses occur, they generally become infected with other pus producing organisms, and aggravate the condition considerably. In the course of months or years, many such openings may occur through which masses of soft tissue or bone, either carious or necrosed (sequestra), may be discharged.

Diagnosis. This may be easy, difficult, or impossible, depending on the duration, the joint involved, and the character of the disease in any individual case.

At times it is impossible to differentiate from syphilis, which, however, is quite uncommon, but with which tuberculosis has many symptoms in common. The history of the individual, and a blood examination will generally suffice. If the disease is advanced to the stage of abscess and sinus formation, there can be no doubt as the nature of the trouble.

Very often the disease in the articular ends of the bones advances slowly, giving very little pain and no appreciable swelling or atrophy. There may be only an unwillingness to use the part very much, and the disease may very well be overlooked. In such insidious cases a diagnosis can be reached by aspiration and subsequent examination of the serous fluid for tubercle bacilli. An X-ray will show the rarifaction of the bony structures and the thickened periosteum.

The course of tubercular joint disease is entirely dependent upon its extent at the time it is recognized, and the treatment pursued. It is of paramount importance that attention be given any persisting pain or discomfort in or near a joint, and that rest and every diagnostic aid be employed before pronouncing a case hysteria, neuralgia or “growing pains.” In a few cases the process can be arrested and little or no diminution of function remains. This, however, is the exception; there is usually destruction of the intra-articular cartilages, and of the synovial membrane, and the formation of bands of great density, which impair the motion of the part even to rigidity (fibrous ankylosis). The restriction of motion may be absolute if ossification of the granulation tissue lying between the epiphyses unites their eroded ends (bony ankylosis).

At times, though recovery seems to have been secured, a sinus may persist because of some slight area of remaining caries, or because the tract itself is tubercular. In other instances a recurrence may follow after months or years of quiescence. This may be due to the setting free of encapsulated organisms, or because of a new infection at a point of least resistance.

Treatment is that of tubercular disease in general. The most essential features in the conduct of these cases are rest and the establishment of ideal hygienic conditions. Forced feeding, sunlight and air, play as important a part here as in pulmonary tuberculosis. Absolute rest of the part can be secured only with the aid of plaster of Paris braces, or splints of other materials. Such immobilization should include the joints immediately above and below the one affected. Hyperemia, by the use of a rubber bandage above the joint, or by baking of the joint, is of great value.

In the majority of instances these methods will yield good results in from six months to a year. Operative interference will be necessary in addition to the above, where caseation and secondary infection have occurred. Thorough drainage of the infected joint, either by widening already existing sinuses, or by free incision followed by irrigation, will frequently be necessary.

Joints Generally Involved are the larger ones of the extremities, but this does not preclude the possibility of any joint being the seat of a tubercular inflammation. The vertebral articulations and the digital articulations of the feet and hands are commonly affected. In children, the hip joint is the one most attacked; frequently the knee, ankle and elbow are affected in the order given.

In nearly all cases of arthritis of tubercular origin the original focus of infection is located in the bone, though the synovial membrane, or an adjacent osteomyelitis, may be the first point attacked.

Syphilitic Arthritis. This is rather a rare condition, but must be differentiated from tuberculosis, because of its slow onset and progress, and because of the mildness of the symptoms and the spindlelike shape of the joint. There is usually but one joint involved and eventually a dark fluid will escape should sinus formation occur.

Diagnosis will generally be known in advance from the history, through a Wassermann test of the blood, or an X-ray picture will often be of value.

In syphilis, the original focus of infection in a joint will be found in the soft tissues, while in tuberculosis, the articular ends of the bone are first involved. An examination of the discharged fragments of tissue in syphilis will show a round cell infiltration; in tuberculosis, possibly typical tubercle tissue.

Treatment by anti-syphilitic remedies, if successful, will also indicate the nature of an obscure case, a pronounced response to such treatment being a positive diagnostic aid.

Gonorrhoeal Arthritis. This affection is nearly always very acute, beginning as an acute synovitis and extending to the articular fibrocartilages at an early date.

Constitutional symptoms nearly always accompany this variety of arthritis, a chill and high temperature being the rule.

This condition is often called gonorrhoeal rheumatism. It is due to the lodgment of the gonococcus of Neisser in the joint, from the blood stream.

Gonorrhoeal arthritis is a form of septic arthritis, its pathology and symptomatology being in many respects the same. It may, in favorable cases, limit itself to the synovial membrane, in which event the symptoms will yield more readily to treatment, though the affection in any event is an acute one, and a diagnosis as to extent is difficult to make owing to the extreme pain of even slight motion.

Symptoms. These are similar to those of septic arthritis, except that usually only one joint is affected and the existence of a gonorrhoeal infection can always be determined. Both knees, or both ankles, but more commonly, only one joint, are affected, accompanied by severe constitutional symptoms. There rarely occurs any indication of sinus formation or of spontaneous drainage in this variety of arthritis, and it is held by many, that in cases where this tendency exists, there is a mixed infection, other pus producing organisms being present.

Treatment. The original infection of the urologic tract must receive the utmost care, in order to eradicate the supply of germs to the circulation. The injection of anti-gonococcic sera or vaccines finds its best application in these cases. The local treatment consists of rest and immobilization of the extremity affected.

The application of either extreme heat or cold to the joint is agreeable and efficacious.

There are many reasons in justification of either of these treatments over the other, but in general it may be said that, in the acute stage, cold is better, while in the latter stages, heat will accomplish more to establish easy motion of the part and to lessen the danger of ankylosis.

Active or arterial hyperemia by baking, is especially valuable in the subacute stage.

Prognosis. In those cases in which the pain and swelling is severe and the constitutional symptoms alarming, we may always expect a true arthritis to exist. In these cases much exudate is formed in the joint, which upon organization, leads to fibrous bands and limitation of the joint function (fibrous ankylosis).

In the milder cases, ankylosis is the exception, if proper remedial measures are carried out.

Rheumatic Arthritis. Rheumatic articular affections are common, and are both acute or chronic. In the light of recent investigations it is believed that many of these cases are due to foci of infection in various parts of the body which pollute the blood stream with organisms which subsequently find lodgment in either the organs or joints. Infections existing in the tonsils and teeth roots have been shown to act in this way. There may, however, be cases directly attributable to rheumatism, though these are not so well understood.

Acute Rheumatism. One or several joints may be attacked simultaneously. Subsidence of the inflammation may occur, while others are becoming inflamed.

Symptoms are those of acute synovitis; suppuration never occurs unless there has been a mixed infection, and limitation of motion is a rare sequela. The pain, swelling and tenderness is extreme, and the constitutional symptoms, while being severe are not usually grave. In the chronic variety, on the other hand, there may be limitation of motion due to the formation of bands and adhesions after months or years of inflammation. This variety may start as such or may begin as an acute condition.

Treatment. The treatment, besides local rest and heat, consists of the administration of antirheumatic remedies and hygienic precautions.

Diagnosis will rest largely on the blood examination for circulating organisms, the general examination for foci of infection, and the family history.

Gouty Arthritis. Whatever may be the essential nature of gout, its manifestations are common in the smaller joints, such as the fingers and the metatarsophalanges of the great toe. Deposits of urates, chiefly sodium urate, take place in the connective tissue of the joint and also in the cartilage. Consequent upon the irritation of these salts, there is an increase in the connective tissue followed by contraction, impairment of motion, and alteration in the shape of the joint. Repeated attacks of acute inflammation occur, of greater or lesser intensity, and the uratic deposits attain a considerable size, occasionally forming abscesses or ulcerations in the overlying skin.

Like rheumatism, gout is a manifestation of a constitutional state, and requires medical care.

Infective Arthritis. These are the arthritic manifestations of diseases as smallpox, scarlet fever, typhoid fever, measles and erysipelas. They are due to infective material deposited from the circulation, and are in every way similar to septic arthritis, which see. There are always suppurative synovitis and osteomyelitis, with a consequent ankylosis of bony structure. The constitutional symptoms are very intense, and free incision and drainage is indicated.

Neuropathic Arthritis. (Charcot’s Disease). This is a peculiar osteoarthritis observed in patients with locomotor ataxia. The disease is an acute one, so far as objective conditions are concerned, there being no pain or constitutional derangements of consequence. Without any injury having been received, the joint, particularly the knee, suddenly swells, the intra-articular effusion becoming abundant. This may soon be absorbed and with it the articular ends of the bones wear away and break down into small fragments. The limb becomes atrophied and shrunken, and the joint itself becomes weak, often flail.

This disease seems to be due to nutritive changes in consequence of changes in the spinal cord nerve centres. There is no satisfactory treatment and the patients must be kept in bed.