Manual of Surgery Volume I Part 54

The _terminations_ vary with the gravity of the infection and with the stage at which treatment is inst.i.tuted. In the milder forms recovery is the rule, with more or less complete restoration of function. In more severe forms the joint may be permanently damaged as a result of fibrous or bony ankylosis, or from displacement or dislocation. From changes in the peri-articular structures there may be contracture in an undesirable position, and in young subjects the growth of the limb may be interfered with. The persistence of sinuses is usually due to disease in one or other of the adjacent bones. In the most severe forms, and especially when several joints are involved, death may result from toxaemia.

The _treatment_ is carried out on the same principles as in other pyogenic infections. The limb is immobilised in such an att.i.tude that should stiffness occur there will be the least interference with function. Extension by weight and pulley is the most valuable means of allaying muscular spasm and relieving intra-articular tension and of counteracting the tendency to flexion; as much as 15 or 20 pounds may be required to relieve the pain.

The induction of hyperaemia is sometimes remarkably efficacious in relieving pain and in arresting the progress of the infection. If the fluid in the joint is in sufficient quant.i.ty to cause tension, if it persists, or if there is reason to suspect that it is purulent, it should be withdrawn without delay; an exploring syringe usually suffices, the skin being punctured with a tenotomy knife, and, as practised by Murphy, 5 to 15 c.c. of a 2 per cent. solution of formalin in glycerin are injected and the wound is closed. In virulent infections the injection may be repeated in twenty-four hours. Drainage by tube or otherwise is to be condemned (Murphy). A vaccine may be prepared from the fluid in the joint and injected into the subcutaneous cellular tissue.

Suppuration in the peri-articular soft parts or in one of the adjacent bones must be looked for and dealt with.

When convalescence is established, attention is directed to the restoration of the functions of the limb, and to the prevention of stiffness and deformity by movements and ma.s.sage, and the use of hot-air and other baths.

At a later stage, and especially in neglected cases, operative and other measures may be required for deformity or ankylosis.

#Metastatic Forms of Pyogenic Infection#

In #pyaemia#, one or more joints may fill with pus without marked symptoms or signs, and if the pus is aspirated without delay the joint often recovers without impairment of function.

In #typhoid fever#, joint lesions result from infection with the typhoid bacillus alone or along with pyogenic organisms, and run their course with or without suppuration; there is again a remarkable absence of symptoms, and attention may only be called to the condition by the occurrence of dislocation.

Joint lesions are comparatively common in #scarlet fever#, and were formerly described as scarlatinal rheumatism. The most frequent clinical type is that of a serous synovitis, occurring within a week or ten days from the onset of the fever. Its favourite seat is in the hand and wrist, the sheaths of the extensor tendons as well as the synovial membrane of the joints being involved. It does not tend to migrate to other joints, and rarely lasts longer than a few days. It is probably due to the specific virus of scarlet fever.

At a later stage, especially in children and in cases in which the throat lesion is severe, an arthritis is sometimes observed that is believed to be a metastasis from the throat; it may be acute and suppurative, affect several joints, and exhibit a septicaemic or pyaemic character.

The joints of the lower extremity are especially apt to suffer; the child is seriously ill, is delirious at night, develops bed-sores over the sacrum and, it may happen that, not being expected to recover, the legs are allowed to a.s.sume contracture deformities with ankylosis or dislocation at the hip and flexion ankylosis at the knees; should the child survive, the degree of crippling may be pitiable in the extreme; prolonged orthopaedic treatment and a series of operations--arthroplasty, osteotomies, and resections--may be required to restore even a limited capacity of locomotion.

#Pneumococcal affections of joints#, the result of infection with the pneumococcus of Fraenkel, are being met with in increasing numbers. The local lesion varies from a _synovitis_ with infiltration of the synovial membrane and effusion of serum or pus, to an _acute arthritis_ with erosion of cartilage, caries of the articular surfaces, and disorganisation of the joint. The knee is most frequently affected, but several joints may suffer at the same time. In most cases the joint affection makes its appearance a few days after the commencement of a pneumonia, but in a number of instances, especially among children, the lung is not specially involved, and the condition is an indication of a generalised pneumococcal infection, which may manifest itself by endocarditis, empyema, meningitis, or peritonitis, and frequently has a fatal termination. The differential diagnosis from other forms of pyogenic infection is established by bacteriological examination of the fluid withdrawn from the joint. The treatment is carried out on the same lines as in other pyogenic infections, considerable reliance being placed on the use of autogenous vaccines.

In #measles#, #diphtheria#, #smallpox#, #influenza#, and #dysentery#, similar joint lesions may occur.

The joint lesions which accompany #acute rheumatism# or "rheumatic fever" are believed to be due to a diplococcus. In the course of a general illness in which there is moderate pyrexia and profuse sweating, some of the larger joints, and not infrequently the smaller ones also, become swollen and extremely sensitive, so that the sufferer lies in bed helpless, dreading the slightest movement. From day to day fresh joints are attacked, while those first affected subside, often with great rapidity. Affections of the heart-valves and of the pericardium are commonly present. On recovery from the acute illness, it may be found that the joints have entirely recovered, but in a small proportion of cases certain of them remain stiff and pa.s.s into the crippled condition described under chronic rheumatism. There is no call for operative interference.

#Gonococcal Affections of Joints.#--These include all forms of joint lesion occurring in a.s.sociation with gonorrhal urethritis, vulvo-vaginitis, or gonorrhal ophthalmia. They may develop at any stage of the urethritis, but are most frequently met with from the eighteenth to the twenty-second day after the primary infection, when the organisms have reached the posterior urethra; they have been observed, however, after the discharge has ceased. There is no connection between the severity of the gonorrha and the incidence of joint disease. In women, the gonorrhal nature of the discharge must be established by bacteriological examination.

As a complication of ophthalmia, the joint lesions are met with in infants, and occur more commonly towards the end of the second or during the third week.

The gonococcus is carried to the joint in the blood-stream and is first deposited in the synovial membrane, in the tissues of which it can usually be found; it may be impossible to find it in the exudate within the joint. The joint lesions may be the only evidence of metastasis, or they may be part of a general infection involving the endocardium, pleura, and tendon sheaths.

The joints most frequently affected are the knee, elbow, ankle, wrist, and fingers. Usually two or more joints are affected.

Several clinical types are differentiated. (1) A _dry poly-arthritis_ met with in the joints and tendon sheaths of the wrist and hand, formerly described as gonorrhal rheumatism, which in some cases is trifling and evanescent, and in others is persistent and progressive, and results in stiffness of the affected joints and permanent crippling of the hand and fingers.

(2) The commonest type is a _chronic synovitis_ or _hydrops_, in which the joint--very often the knee--becomes filled with a serous or sero-fibrinous exudate. There are no reactive changes in the synovial membrane, cellular tissue, or skin, nor is there any fever or disturbance of health. The movements are free except in so far as they are restricted by the amount of fluid in the joint. It usually subsides in two or three weeks under rest, but tends to relapse.

(3) An _acute synovitis_ with peri-articular phlegmon is most often met with in the elbow, but it occurs also in the knee and ankle. There is a sudden onset of severe pain and swelling in and around the joint, with considerable fever and disturbance of health. The slightest movement causes pain, and the part is sensitive to touch. The skin is hot and tense, and in the case of the elbow may be red and fiery as in erysipelas.

The deposit of fibrin on the synovial membrane and on the articular surfaces may lead to the formation of adhesions, sometimes in the form of isolated bands, sometimes in the form of a close fibrous union between the bones.

(4) A _suppurative arthritis_, like that caused by ordinary pus microbes, may be the result of gonococcal infection alone or of a mixed infection. Usually only one joint is affected, but the condition may be multiple. The articular cartilages are destroyed, the ends of the bones are covered with granulations, extra-articular abscesses form, and complete osseous ankylosis results.

The _diagnosis_ is often missed because the possibility of gonorrha is not suspected.

The denial of the disease by the patient is not always to be relied upon, especially in the case of women, as they may be ignorant of its presence. The chief points in the differential diagnosis from acute articular rheumatism are, that the gonorrhal affection is more often confined to one or two joints, has little tendency to wander from joint to joint, and its progress is not appreciably influenced by salicylates, although these drugs may relieve pain. The conclusive point is the recognition of a gonorrhal discharge or of threads in the urine.

The disease may persist or may relapse, and the patient may be laid up for weeks or months, and may finally be crippled in one or in several joints.

The _treatment_--besides that of the urethral disease or of the ophthalmia--consists in rest until all pain and sensitiveness have disappeared. The pain is relieved by salicylates, but most benefit follows weight extension, the induction of hyperaemia by the rubber bandage and hot-air baths; if the joint is greatly distended, the fluid may be withdrawn by a needle and syringe. Detoxicated vaccines should be given from the first, and in afebrile cases the injection of a foreign protein, such as anti-typhoid vaccine, is beneficial (Harrison).

Murphy has found benefit from the introduction into the joint, in the early stages, of from 5 to 15 c.c. of a 2 per cent. solution of formalin in glycerin. This may be repeated within a week, the patient being kept in bed with light weight extension. In the chronic hydrops the fluid is withdrawn, and about an ounce of a 1 per cent. solution of protargol injected; the patient should be warned of the marked reaction which follows.

After all symptoms have settled down, but not till then, for fear of exciting relapse or metastasis, the joint is ma.s.saged and exercised.

Stiffness from adhesions is most intractable, and may, in spite of every attention, terminate in ankylosis even in cases where there has been no suppuration. Forcible breaking down of adhesions under anaesthesia is not recommended, as it is followed by great suffering and the adhesions re-form. Operation for ankylosis--arthroplasty--should not be undertaken, as the ankylosis recurs.

TUBERCULOUS DISEASE

Tuberculous disease of joints results from bacillary infection through the arteries. The disease may commence in the synovial membrane or in the marrow of one of the adjacent bones, and the relative frequency of these two seats of infection has been the subject of considerable difference of opinion. The traditional view of Konig is that in the knee and most of the larger joints the disease arises in the bone and in the synovial membrane in about equal proportion, and that in the hip the number of cases beginning in the bones is about five times greater than that originating in the membrane. This estimate, so far as the actual frequency of bone lesions is concerned, has been generally accepted, but recent observers, notably John Fraser, do not accept the presence of bone lesions as necessarily proving that the disease commenced in the bones; he maintains, and we think with good grounds, that in many cases the disease having commenced in the synovial membrane, slowly spreads to the bone by way of the blood vessels and lymphatics, and gives rise to lesions in the marrow.

#Morbid Anatomy.#--Tuberculous disease in the articular end of a long bone may give rise to _reactive changes_ in the adjacent joint, characterised by effusion and by the extension of the synovial membrane over the articular surfaces. This may result in the formation of adhesions which obliterate the cavity of the joint or divide it into compartments. These lesions are comparatively common, and are not necessarily due to actual tuberculous infection of the joint.

The _infection of the joint_ by tubercle originating in the adjacent bone may take place at the periphery, the osseous focus reaching the surface of the bone at the site of reflection of the synovial membrane, and the infection which begins at this point then spreads to the rest of the membrane. Or it may take place in the central area, by the projection of tuberculous granulation tissue into the joint following upon erosion of the cartilage (Fig. 156).

[Ill.u.s.tration: FIG. 156.--Section of Upper End of Fibula, showing caseating focus in marrow, erupting on articular surface and infecting joint.]

_Changes in the Synovial Membrane._--In the majority of cases there is a _diffuse thickening of the synovial membrane_, due to the formation of granulation tissue, or of young connective tissue, in its substance.

This new tissue is arranged in two layers--the outer composed of fully formed connective or fibrous tissue, the inner of embryonic tissue, usually permeated with miliary tubercles. On opening the joint, these tubercles may be seen on the surface of the membrane, or the surface may be covered with a layer of fibrinous or caseating tissue. Where there is greater resistance on the part of the tissues, there is active formation of young connective tissue which circ.u.mscribes or encapsulates the tubercles, so that they remain embedded in the substance of the membrane, and are only seen on cutting into it.

The thickened synovial membrane is projected into the cavity of the joint, filling up its pouches and recesses, and spreading over the surface of the articular cartilage "like ivy growing on a wall."

Wherever the synovial tissue covers the cartilage it becomes adherent to and fused with it. The morbid process may be arrested at this stage, and fibrous adhesions form between the opposing articular surfaces, or it may progress, in which case further changes occur, resulting in destruction of the articular cartilage and exposure of the subjacent bone.

In rare instances the synovial membrane presents nodular ma.s.ses or lumps, resembling the tuberculous tumours met with in the brain; they project into the cavity of the joint, are often pedunculated, and may give rise to the symptoms of loose body. The fringes of synovial membrane may also undergo a remarkable development, like that observed in arthritis deformans, and described as arborescent lipoma. Both these types are almost exclusively met with in the knee.

_The Contents of Tuberculous Joints._--In a large proportion of cases of synovial tuberculosis the joint is entirely filled up by the diffuse thickening of the synovial membrane. In a small number there is an abundant serous exudate, and with this there may be a considerable formation of fibrin, covering the surface of the membrane and floating in the fluid as flakes or ma.s.ses; under the influence of movement it may a.s.sume the shape of melon-seed bodies. More rarely the joint contains pus, and the surface of the synovial membrane resembles the wall of a cold abscess.

_Ulceration and Necrosis of Cartilage._--The synovial tissue covering the cartilage causes pitting and perforation of the cartilage and makes its way through it, and often spreads widely between it and the subjacent bone; the cartilage may be detached in portions of considerable size. It may be similarly ulcerated or detached as a result of disease in the bone.

_Caries of Articular Surfaces._--Tuberculous infiltration of the marrow in the surface cancelli breaks up the spongy framework of the bone into minute irregular fragments, so that it disintegrates or crumbles away--caries. When there is an absence of caseation and suppuration, the condition is called _caries sicca_.

The pressure of the articular surfaces against one another favours the progress of ulceration of cartilage and of articular caries. These processes are usually more advanced in the areas most exposed to pressure--for example, in the hip-joint, on the superior aspect of the head of the femur, and on the posterior and upper segment of the acetabulum.

The occurrence of _pathological dislocation_ is due to softening and stretching of the ligaments which normally retain the bones in position, and to some factor causing displacement, which may be the acc.u.mulation of fluid or of granulations in the joint, the involuntary contraction of muscles, or some movement or twist of the limb. The occurrence of dislocation is also favoured by destructive changes in the bones.

_Peri-articular tubercle and abscess_ may result from the spread of disease from the bone or joint into the surrounding tissues, either directly or by way of the lymphatics. A peri-articular abscess may spread in several directions, sometimes invading tendon sheaths or bursae, and finally reaching the skin surface by tortuous sinuses.

Reactive changes in the vicinity of tuberculous joints are of common occurrence, and play a considerable part in the production of what is clinically known as _white swelling_. New connective tissue forms in the peri-articular fat and between muscles and tendons. It may be tough and fibrous, or soft, vascular, and dematous, and the peri-articular fat becomes swollen and gelatinous, const.i.tuting a layer of considerable thickness. The fat disappears and is replaced by a mucoid effusion between the fibrous bundles of connective tissue. This is what was formerly known as _gelatinous degeneration_ of the synovial membrane. In the case of the wrist the newly formed connective tissue may fix the tendons in their sheaths, interfering with the movements of the fingers.

In relation to the bones also there may be reactive changes, resulting in the formation of spicules of new bone on the periosteal surfaces and at the attachment of the capsular and other ligaments; these are only met with where pyogenic infection has been superadded.

_Terminations and Sequelae._--A natural process of cure may occur at any stage, the tuberculous tissue being replaced by scar tissue. Recovery is apt to be attended with impairment of movement due to adhesions, ankylosis, or contracture of the peri-articular structures. Caseous foci in the interior of the bones may become encapsulated, and a cure be thus effected, or they may be the cause of a relapse of the disease at a later date. Interference with growth is comparatively common, and may involve only the epiphysial junctions in the immediate vicinity of the joint affected, or those of all the bones of the limb. This is well seen in adults who have suffered from severe disease of the hip in childhood--the entire limb, including the foot, being shorter and smaller than the corresponding parts of the opposite side.

Atrophic conditions are also met with, the bones undergoing fatty atrophy, so that in extreme cases they may be cut with a knife or be easily fractured. These atrophic conditions are most marked in bedridden patients, and are largely due to disuse of the limb; they are recovered from if it is able to resume its functions.