DISEASES OF JOINTS
Definition of terms--Ankylosis. DISEASES: Errors of
development--Bacterial diseases: _Pyogenic_; _Gonorrhœal_;
_Tuberculous_; _Syphilitic_; _Acute rheumatism_--Diseases
associated with certain constitutional conditions: _Gout_; _Chronic
articular rheumatism_; _Arthritis deformans_;
_Hæmophilia_--Diseases associated with affections of the nervous
system: _Neuro-arthropathies_; _Charcot's disease_--Hysterical or
mimetic affections of joints--Tumours and cysts--Loose bodies.
#Definition of Terms.#--The term _synovitis_ is applied to any reaction
which affects the synovial membrane of a joint. It is usually associated
with effusion of fluid, and this may be serous, sero-fibrinous, or
purulent. As the term synovitis merely refers to the tissue involved, it
should always be used with an adjective--such as gouty, gonorrhœal, or
tuberculous--which indicates its pathological nature.
The terms _hydrops_, _hydrarthrosis_, and _chronic serous synovitis_ are
synonymous, and are employed when a serous effusion into the joint is
the prominent clinical feature. Hydrops may occur apart from
disease--for example, in the knee-joint from repeated sprains, or when
there is a loose body in the joint--but is met with chiefly in the
chronic forms of synovitis which result from gonorrhœa, tuberculosis,
syphilis, arthritis deformans, or arthropathies of nerve origin.
_Arthritis_ is the term applied when not only the synovial membrane but
the articular surfaces, and it may be also the ends of the bones, are
involved, and it is necessary to prefix a qualifying adjective which
indicates its nature. When effusion is present, it may be serous, as in
arthritis deformans, or sero-fibrinous or purulent, as in certain forms
of pyogenic and tuberculous arthritis. Wasting of the muscles,
especially the extensors, in the vicinity of the joint is a constant
accompaniment of arthritis. On account of the involvement of the
articular surfaces, arthritis is apt to be followed by ankylosis.
The term _empyema_ is sometimes employed to indicate that the cavity of
the joint contains pus. This is observed chiefly in chronic disease of
pyogenic or tuberculous origin, and is usually attended with the
formation of abscesses outside the joint.
_Ulceration of cartilage_ and _caries of the articular surfaces_ are
common accompaniments of the more serious and progressive forms of joint
disease, especially those of bacterial origin. The destruction of
cartilage may be secondary to disease of the synovial membrane or of the
subjacent bone. When the disease begins as a synovitis, the synovial
membrane spreads over the articular surface, fuses with the cartilage
and eats into it, causing defects or holes which are spoken of as
ulcers. When the disease begins in the bone, the marrow is converted
into granulation tissue, which eats into the cartilage and separates it
from the bone. Following on the destruction of the cartilage, the
articular surface of the bone undergoes disintegration, a condition
spoken of as _caries of the articular surface_. The occurrence of
ulceration of cartilage and of articular caries is attended with the
clinical signs of fixation of the joint from involuntary muscular
contraction, wasting of muscles, and starting pains. These _starting
pains_ are the result of sudden involuntary movements of the joint. They
occur most frequently as the patient is dropping off to sleep; the
muscles becoming relaxed, the sensitive ulcerated surfaces jar on one
another, which causes sudden reflex contraction of the muscles, and the
resulting movement being attended with severe pain, wakens the patient
with a start. Advanced articular caries is usually associated with some
abnormal attitude and with shortening of the limb. It may be possible to
feel the bony surfaces grate upon one another. When all its constituent
elements are damaged or destroyed, a joint is said to be _disorganised_.
Should recovery take place, repair is usually attended with union of the
opposing articular surfaces either by fibrous tissue or by bone.
#Conditions of Impaired Mobility of Joints.#--There are four conditions
of impaired mobility in joints: rigidity, contracture, ankylosis, and
locking. _Rigidity_ is the fixation of a joint by involuntary
contraction of muscles, and is of value as a sign of disease in
deep-seated joints, such as the hip. It disappears under anæsthesia.
_Contracture_ is the term applied when the fixation is due to permanent
shortening of the soft parts around a joint--muscles, tendons,
ligaments, fasciæ, or skin. As the structures on the flexor aspect are
more liable to undergo such shortening, contracture is nearly always
associated with flexion. Contracture may result from disease of the
joint, or from conditions outside it--for example, disease in one of
the adjacent bones, or lesions of the nerves.
_Ankylosis_ is the term applied when impaired mobility results from
changes involving the articular surfaces. It is frequently combined with
contracture. Three anatomical varieties of ankylosis are
recognised--(a) The _fibrous_, in which there are adhesions between
the opposing surfaces, which may be in the form of loose isolated bands
of fibrous tissue, or may bind the bones so closely together as to
obliterate the cavity of the joint. The resulting stiffness, therefore,
varies from a mere restriction of the normal range of movement, up to a
close union of the bones which prevents movement. Fibrous ankylosis may
follow upon injury, especially dislocation or fracture implicating a
joint, or it may result from any form of arthritis. (b) _Cartilaginous
ankylosis_ implies the fusion of two apposed cartilaginous surfaces. It
is often found between the patella and the trochlear surface of the
femur in tuberculous disease of the knee. The fusion of the
cartilaginous surfaces is preceded by the spreading of a vascular
connective tissue, derived from the synovial membrane, over the
articular cartilage. Clinically, it is associated with absolute
immobility, (c) _Bony ankylosis_ or _synostosis_ is an osseous union
between articulating surfaces (Figs. 154 and 155). It may follow upon
fibrous or cartilaginous ankylosis, or may result from the fusion of two
articular surfaces which have lost their cartilage and become covered
with granulations. In the majority of cases it is to be regarded as a
reparative process, presenting analogies with the union of fracture.
[Illustration: FIG. 154.--Osseous Ankylosis of Femur and Tibia in
position of flexion.]
The term _arthritis ossificans_ has been applied by Joseph Griffiths to
a condition in which the articular surfaces become fused without evident
cause.
The occurrence of ankylosis in a joint before the skeleton has attained
maturity does not appear to impair the growth in length of the bones
affected; ankylosis of the temporo-maxillary joints, however, greatly
impairs the growth of the mandible. When there is arrest of growth
accompanying ankylosis, it usually depends on changes in the ossifying
junctions caused by the original disease.
To differentiate by manipulation between muscular fixation and
ankylosis, it may be necessary to anæsthetise the patient. The nature
and extent of ankylosis may be learned by skiagraphy; in osseous
ankylosis the shadow of the two bones is a continuous one. In fibrous as
contrasted with osseous ankylosis mobility may be elicited, although
only to a limited extent; while in osseous ankylosis the joint is
rigidly fixed, and attempts to move it are painless.
[Illustration: FIG. 155.--Osseous Ankylosis of Knee in the flexed
position following upon Tuberculous Arthritis.
(Anatomical Museum, University of Edinburgh.)]
The _treatment_ is influenced by the nature of the original lesion, the
variety of the ankylosis, and the attitude of the joint. When there is
restriction of movement due to fibrous adhesions, these may be elongated
or ruptured. Elongation of the adhesions may be effected by
manipulations, exercises, and the use of special forms of
apparatus--such as the application of weights to the limb. It may be
necessary to administer an anæsthetic before rupturing strong fibrous
adhesions, and this procedure must be carried out with caution, in view
of such risks as fracture of the bone--which is often rarefied--or
separation of an epiphysis. There is also the risk of fat embolism, and
of re-starting the original disease. The giving way of adhesions may be
attended with an audible crack; and the procedure is often followed by
considerable pain and effusion into the joint, which necessitate rest
for some days before exercises and manipulations can be resumed.
_Operative treatment_ may be called for in cases in which the bones are
closely bound to one another by fibrous or by osseous tissue.
_Arthrolysis_, which consists in opening the joint and dividing the
fibrous adhesions, is almost inevitably followed by their reunion.
_Arthroplasty._--Murphy of Chicago devised this operation for restoring
movement to an ankylosed joint. It consists in transplanting between the
bones a flap of fat-bearing tissue, from which a bursal cavity lined
with endothelium and containing a fluid rich in mucin is ultimately
formed.
Arthroplasty is most successful in ankylosis following upon injury; when
the ankylosis results from some infective condition such as tuberculosis
or gonorrhœa, it is liable to result in failure either because of a
fresh outbreak of the infection or because the ankylosis recurs.
When arthroplasty is impracticable, and a movable joint is desired--for
example at the elbow--a considerable amount of bone, and it may be also
of periosteum and capsular ligament, is resected to allow of the
formation of a false joint.
When bony ankylosis has occurred with the joint in an undesirable
attitude--for example flexion at the hip or knee--it can sometimes be
remedied by osteotomy or by a wedge-shaped resection of the bone, with
or without such additional division of the contracted soft parts as will
permit of the limb being placed in the attitude desired.
Bony ankylosis of the joints of a finger, whether the result of injury
or disease, is difficult to remedy by any operative procedure, for while
it is possible to restore mobility, the new joint is apt to be
flail-like.
_Locking._--A joint is said to lock when its movements are abruptly
arrested by the coming together of bony outgrowths around the joint. It
is best illustrated in arthritis deformans of the hip in which new bone
formed round the rim of the acetabulum mechanically arrests the
excursions of the head of the femur. The new bone, which limits the
movements, is readily demonstrated in skiagrams; it may be removed by
operative means. Locking of joints is more often met with as a result of
injuries, especially in fractures occurring in the region of the elbow.
In certain injuries of the semilunar menisci of the knee, also, the
joint is liable to a variety of locking, which differs, however, in many
respects from that described above.
#Errors of Development.#--These include congenital dislocations and
other deformities of intra-uterine origin, such as abnormal laxity of
joints, absence, displacement, or defective growth of one or other of
the essential constituents of a joint. The more important of these are
described along with the surgery of the Extremities.
DISEASES OF JOINTS
#Bacterial Diseases.#--In most bacterial diseases the organisms are
carried to the joint in the blood-stream, and they lodge either in the
synovial membrane or in one of the bones, whence the disease
subsequently spreads to the other structures of the joint. Organisms may
also be introduced through accidental wounds. It has been shown
experimentally that joints are among the most susceptible parts of the
body to infection, and this would appear to be due to the viscid
character of the synovial fluid, which protects organisms from
bactericidal agents in the tissues and fluids.
PYOGENIC DISEASES
The commoner pyogenic diseases are the result of infection of one or
other of the joint structures with _staphylococci_ or _streptococci_,
which may be demonstrated in the exudate in the joint and in the
substance of the synovial membrane. The mode of infection is the same as
in the pyogenic diseases of bone, the metastasis occurring most
frequently from the mucous membrane of the pharynx (J. B. Murphy). The
localisation of the infection in a particular joint is determined by
injury, exposure to cold, antecedent disease of the joint, or other
factors, the nature of which is not always apparent.
The effects on the joint vary in severity. In the milder forms, there is
engorgement and infiltration of the synovial membrane, and an effusion
into the cavity of the joint of serous fluid mixed with flakes of
fibrin--_serous synovitis_. In more severe infections the exudate
consists of pus mixed with fibrin, and, it may be, red blood
corpuscles--_purulent_ or _suppurative synovitis_; the synovial membrane
and the ligaments are softened, and the surface of the membrane presents
granulations resembling those on an ulcer; foci of suppuration may
develop in the peri-articular cellular tissue and result in abscesses.
In _acute arthritis_, all the structures of the joint are involved; the
articular cartilage is invaded by granulation tissue derived from the
synovial membrane, and from the marrow of the subjacent bone; it
presents a worm-eaten or ulcerated appearance, or it may undergo
necrosis and separate, exposing the subjacent bone and leading to
disintegration of the osseous trabeculæ--_caries_. With the destruction
of the ligaments, the stability of the joint is lost, and it becomes
disorganised.
The _clinical features_ vary with the extent of the infection. When
this is confined to the synovial and peri-synovial tissues--_acute
serous_ and _purulent synovitis_--there is the usual general reaction,
associated with pyrexia and great pain in the joint. The part is hot and
swollen, the swelling assuming the shape of the distended synovial sac,
fluctuation can usually be elicited, and the joint is held in the flexed
position.
When the joint is infected by extension from the surrounding cellular
tissue, the joint lesion may not be recognised at an early stage because
of the swollen condition of the limb, and because there are already
symptoms of toxæmia. We have observed a case in which both the hip and
knee joints were infected from the cellular tissue.
If the infection involves all the joint structures--_acute
arthritis_--the general and local phenomena are intensified, the
temperature rises quickly, often with a rigor, and remains high; the
patient looks ill, and is either unable to sleep or the sleep is
disturbed by starting pains. The joint is held rigid in the flexed
position, and the least attempt at movement causes severe pain; the
slightest jar--even the shaking of the bed--may cause agony. The joint
is hot, tensely distended, and there may be œdema of the peri-articular
tissues or of the limb as a whole. If the pus perforates the joint
capsule, there are signs of abscess or of diffuse suppuration in the
cellular tissue. The final disorganisation of the joint is indicated by
abnormal mobility and grating of the articular surfaces, or by
spontaneous displacement of the bones, and this may amount to
dislocation. In the acute arthritis of infants, the epiphysis concerned
may be separated and displaced.
When the _joint is infected through an external wound_, the anatomical
features are similar to those observed when the infection has reached
the joint by the blood-stream, but the destructive changes tend to be
more severe and are more likely to result in disorganisation.
The _terminations_ vary with the gravity of the infection and with the
stage at which treatment is instituted. 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 toxæmia.
The _treatment_ is carried out on the same principles as in other
pyogenic infections. The limb is immobilised in such an attitude 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 hyperæmia is sometimes remarkably efficacious in
relieving pain and in arresting the progress of the infection. If the
fluid in the joint is in sufficient quantity 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 massage, 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 #pyæmia#, 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 septicæmic or pyæmic
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 assume 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 orthopædic 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 pass 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 association with gonorrhœal urethritis,
vulvo-vaginitis, or gonorrhœal 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 gonorrhœa and the incidence of joint disease. In women,
the gonorrhœal 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 gonorrhœal 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 gonorrhœa 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 gonorrhœal 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 gonorrhœal 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 hyperæmia 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 massaged 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 anæsthesia 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 König 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).
[Illustration: 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 circumscribes 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 masses 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 masses; under the influence of movement it may
assume 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 accumulation
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
bursæ, 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 œdematous, and the peri-articular fat
becomes swollen and gelatinous, constituting 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 Sequelæ._--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.
#Clinical Features.#--These vary with the different anatomical forms of
the disease, and with the joint affected.
Sometimes the disease is ushered in by a febrile attack attended with
pains in several joints--described by John Duncan as _tuberculous
arthritic fever_. This is liable to be mistaken for rheumatic fever,
from which, however, it differs in that there is no real migration from
joint to joint; there is an absence of sweating and of cardiac
complications; and no benefit follows the administration of salicylates.
In exceptional cases, tuberculous joint disease follows an acute course
resembling that of the pyogenic arthritis of infants. This has been
observed in children, especially in the knee, the lesion being in the
synovial membrane, and attended with an accumulation of pus in the
joint. If promptly treated by incision and drainage, recovery is rapid,
and free movement of the joint, may be preserved.
The onset and early stages of tuberculous disease, however, are more
often insidious, and are attended with so few symptoms that the disease
may have obtained a considerable hold before it attracts notice. It is
not uncommon for patients or their friends to attribute the condition to
injury, as it often first attracts attention after some slight trauma or
excessive use of the limb. The symptoms usually subside under rest, only
to relapse again with use of the limb.
The initial local symptoms may be due to the presence of a focus in the
neighbouring bone, perhaps causing neuralgic pains in the joint, or
weakness, tiredness, stiffness, and inability to use the limb, these
symptoms improving with rest and being aggravated by exertion.
It is rarely possible by external examination to recognise deep-seated
osseous foci in the vicinity of joints; but if they are near the surface
in a superficial bone--such as the head of the tibia--there may be local
thickening of the periosteum, œdema, pain, and tenderness on pressure
and on percussion.
_X-ray Appearances of Tuberculous Joints._--Gross lesions such as
caseous foci in the marrow of the adjacent bone show as clear areas with
an ill-defined margin; a sclerosed focus gives a denser shadow than the
surrounding bone, and a sequestrum presents a dark shadow of irregular
contour, and a clear interval between it and the surrounding bone.
Caries of the articular surface imparts a woolly appearance or irregular
contour in place of the well-defined outline of the articular end of the
bone. In bony ankylosis the shadow of the two bones is a continuous one,
the joint interval having been filled up. The minor changes are best
appreciated on comparison with the normal joint of the other limb.
_Wasting of muscles_ is a constant accompaniment of tuberculous joint
disease. It is to be attributed partly to want of use, but chiefly to
reflex interference with the trophic innervation of the muscles. It is
specially well seen in the extensor and adductor muscles of the thigh in
disease of the knee, and in the deltoid in disease of the shoulder. The
muscles become soft and flaccid, they exhibit tremors on attempted
movement, and their excitability to the faradic current is diminished.
The muscular tissue may be largely replaced by fat.
_Impairment of the normal movements_ is one of the most valuable
diagnostic signs, particularly in deeply seated joints such as the
shoulder, hip, and spine. It is due to a protective contraction of the
muscles around the joint, designed to prevent movement. This muscular
fixation disappears under anæsthesia.
_Abnormal attitudes of the limb_ occur earlier, and are more pronounced
in cases in which pain and other irritative symptoms of articular
disease are well marked, and are best illustrated by the attitudes
assumed in disease of the hip. They are due to reflex or involuntary
contraction of the muscles acting on the joint, with the object of
placing it in the attitude of greatest ease; they also disappear under
anæsthesia. With the lapse of time they not only become exaggerated, but
may become permanent from ankylosis or from contracture of the soft
parts round the joint.
_Startings at night_ are to be regarded as an indication that there is
progressive disease involving the articular surfaces.
_The formation of extra-articular abscess_ may take place early, or it
may not occur till long after the disease has subsided. The abscess may
develop so insidiously that it does not attract attention until it has
attained considerable size, especially when associated with disease of
the spine, pelvis, or hip. The position of the abscess in relation to
different joints is fairly constant and is determined by the anatomical
relationships of the capsule and synovial membrane to the surrounding
tissues. The bursæ and tendon sheaths in the vicinity may influence the
direction of spread of the abscess and the situation of resulting
sinuses. When the abscess is allowed to burst, or is opened and becomes
infected with pyogenic bacteria, there is not only the risk of
aggravation of the disease and persistent suppuration, but there is a
greater liability to general tuberculosis.
The sinuses may be so tortuous that a probe cannot be passed to the
primary focus of disease, and their course and disposition can only be
demonstrated by injecting the sinuses with an emulsion of bismuth and
taking X-ray photographs.
Tuberculous infection of the lymph glands of the limb is exceptional,
but may follow upon infection of the skin around the orifice of a sinus.
A slight rise of temperature in the evening may be induced in quiescent
joint lesions by injury or by movement of the joint under anæsthesia, or
by the fatigue of a railway journey. When sinuses have formed and become
infected with pyogenic bacteria, there may be a diurnal variation in the
temperature of the type known as hectic fever (Fig. 11).
_Relative Frequency of Tuberculous Disease in Different
Joints._--Hospital statistics show that joints are affected in the
following order of frequency: Spine, knee, hip, ankle and tarsus, elbow,
wrist, shoulder. The hip and spine are most often affected in childhood
and youth, the shoulder and wrist in adults; the knee, ankle, and elbow
show little age preference.
_Clinical Variations of Tuberculous Joint Disease._--The above
description applies to tuberculous joint disease in general; it must be
modified to include special manifestations or varieties.
When the main incidence of the infection affects the synovial membrane,
the clinical picture may assume the form of a _hydrops_, or of an
_empyema_ in which the joint is filled with pus. More common than either
of these is the well-known _white swelling_ or _tumor albus_ (Wiseman,
1676) which is the clinical manifestation of diffuse thickening of the
synovial membrane along with mucoid degeneration of the peri-synovial
cellular tissue. It is well seen in joints which are superficial--such
as the knee, ankle, elbow, and wrist. The swelling, which is the first
and most prominent clinical feature, develops gradually and painlessly,
obliterating the bony prominences by filling up the natural hollows. It
appears greater to the eye than is borne out by measurement, being
thrown into relief by the wasting of the muscles above and below the
joint. In the early stage the swelling is elastic, doughy, and
non-sensitive, and corresponds to the superficial area of the synovial
membrane involved, and there is comparatively little complaint on the
part of the patient, because the articular surfaces and ligaments are
still intact. There may be a feeling of weight in the limb, and in the
case of the knee and ankle the patient tires on walking and drags the
leg with more or less of a limp. Movements of the joint are permitted,
but are limited in range. The disability is increased by use and
exertion, but, for a time at least, it improves under rest.
If the disease is not arrested, there follow the symptoms and signs of
involvement of the articular surfaces.
_Influence of Tuberculous Joint Disease on the General
Health._--Experience shows that the early stages of tuberculous joint
disease are compatible with the appearance of good health. As a rule,
however, and especially if there is mixed infection, the health suffers,
the appetite is impaired, the patient is easily tired, and there may be
some loss of weight.
#Treatment.#--In addition to the general treatment of tuberculosis,
local measures are employed. These may be described under two heads--the
conservative and the operative.
_Conservative treatment_ is almost always to be employed in the first
instance, as by it a larger proportion of cures is obtained with a
smaller mortality and with better functional results than by operation.
_Treatment by rest_ implies the immobilisation of the diseased limb
until pain and tenderness have disappeared. The attitude in which the
limb is immobilised should be that in which, in the event of subsequent
stiffness, it will be most serviceable to the patient. Immobilisation
may be secured by bandages, splints, extension, or other apparatus.
_Extension_ with weight and pulley is of value in securing rest,
especially in disease of the hip or knee; it eliminates muscular spasm,
relieves pain and startings at night, and prevents abnormal attitudes of
the limb. If, when the patient first comes under observation, the limb
is in a deformed attitude which does not readily yield to extension, the
deformity should be corrected under an anæsthetic.
_The induction of hyperæmia_ is often helpful, the rubber bandage or the
hot-air chamber being employed for an hour or so morning and evening.
_Injection of Iodoform._--This is carried out on the same lines as have
been described for tuberculous abscess. After the fluid contents of the
joint are withdrawn, the iodoform is injected; and this may require to
be repeated in a month or six weeks.
After the injection of iodoform there is usually considerable reaction,
attended with fever (101° F.), headache, and malaise, and considerable
pain and swelling of the joint. In some cases there is sickness, and
there may be blood pigment in the urine. The severity of these phenomena
diminishes with each subsequent injection.
The use of Scott's dressing and of blisters and of the actual cautery
has largely gone out of fashion, but the cautery may still be employed
with benefit for the relief of pain in cases in which ulceration of
cartilage is a prominent feature.
The application of the X-rays has proved beneficial in synovial lesions
in superficial joints such as the wrist or elbow; prolonged exposures
are made at fortnightly intervals, and on account of the cicatricial
contraction which attends upon recovery, the joint must be kept in good
position.
Conservative treatment is only abandoned if improvement does not show
itself after a thorough trial, or if the disease relapses after apparent
cure.
_Operative Treatment._--Other things being equal, operation is more
often indicated in adults than in children, because after the age of
twenty there is less prospect of recovery under conservative treatment,
there is more tendency for the disease to relapse and to invade the
internal organs, and there is no fear of interfering with the growth of
the bones. The state of the general health may necessitate operation as
the most rapid method of removing the disease. The social status of the
patient must also be taken into account; the bread-winner, under
existing social conditions, may be unable to give up his work for a
sufficient time to give conservative measures a fair trial.
The _local conditions_ which decide for or against operation are
differently regarded by different surgeons, but it may be said in
general terms that operative interference is indicated in cases in which
the disease continues to progress in spite of a fair trial of
conservative measures; in cases unsuited for conservative
treatment--that is to say, where there are severe bone lesions.
Operative interference is indicated also when the functional result will
be better than that likely to be obtained by conservative measures, as
is often the case in the knee and elbow. Cold abscesses should, if
possible, be dealt with before operating on the joint.
In many cases the extent of the operation can only be decided after
exploration. The aim is to remove all the disease with the least
impairment of function and the minimum sacrifice of healthy tissue. The
more open the method of operating the better, so that all parts of the
joint may be available for inspection. The methods of Kocher, which
permit of dislocating the joint, are specially to be recommended, as
this procedure affords the freest possible access. Diseased synovial
membrane is removed with the scissors or knife. If the cartilages are
sound, and if a movable joint is aimed at, they may be left; but if
ankylosis is desired, they must be removed. Localised disease of the
cartilage should be removed with the spoon or gouge, and the bone
beneath investigated. If the articular surface is extensively diseased,
a thin slice of bone should be removed, and if foci in the marrow are
then revealed, it is better to gouge them out than to remove further
slices of bone, as this involves sacrifice of the cortex and periosteum.
Operative treatment of deformities resulting from tuberculous joint
disease has almost entirely replaced reduction by force; the contracted
soft parts are divided, and the bone is resected.
_Amputation_ for tuberculous joint disease has become one of the rare
operations of surgery, and is only justified when less radical measures
have failed and the condition of the limb is affecting the general
health. Amputation is more frequently called for in persons past middle
life who are the subjects of pulmonary tuberculosis.
SYPHILITIC DISEASE
Syphilitic affections of joints are comparatively rare. As in
tuberculosis, the disease may be first located in the synovial membrane,
or it may spread to the joint from one of the bones.
In #acquired syphilis#, at an early stage and before the skin eruptions
appear, one of the large joints, such as the shoulder or knee, may be
the seat of pain--_arthralgia_--which is worse at night. In the
secondary stage, a _synovitis_ with serous effusion is not uncommon, and
may affect several joints. Syphilitic _hydrops_ is met with almost
exclusively in the knee; it is frequently bilateral, and is insidious in
its onset and progress, the patient usually being able to go about.
In the _tertiary stage_ the joint lesions are persistent and
destructive, and result from the formation of gummata, either in the
deeper layers of the synovial membrane or in the adjacent bone or
periosteum.
_Peri-synovial_ and _peri-bursal gummata_ are met with in relation to
the knee-joint of middle-aged adults, especially women. They are usually
multiple, develop slowly, and are rarely sensitive or painful. One or
more of the gummata may break down and give rise to tertiary ulcers. The
co-existence of indolent swellings, ulcers, and depressed scars in the
vicinity of the knee is characteristic of tertiary syphilis.
The disease spreads throughout the capsule and synovial membrane, which
becomes diffusely thickened and infiltrated with granulation tissue
which eats into and replaces the articular cartilage. Clinically, the
condition resembles tuberculous disease of the synovial membrane, for
which it is probably frequently mistaken, but in the syphilitic
affection the swelling is nodular and uneven, and the subjective
symptoms are slight, mobility is little impaired, and yet the deformity
is considerable.
_Syphilitic osteo-arthritis_ results from a gumma in the periosteum or
marrow of one of the adjacent bones. There is gradual enlargement of one
of the bones, the patient complains of pains, which are worst at night.
The disease may extend to the synovial membrane and be attended with
effusion into the joint, or it may erupt on the periosteal surface and
invade the skin, forming one or more sinuses. The further progress is
complicated by the occurrence of pyogenic infection leading to necrosis
of bone, in the knee-joint, for example, the patella or one of the
condyles of the femur or tibia, may furnish a sequestrum. In such cases,
anti-syphilitic treatment must be supplemented by operation for the
removal of the diseased tissues. In the knee, excision is rarely
necessary; but in the elbow it may be called for to obtain a movable
joint.
In #inherited syphilis# the earliest joint affections are those in which
there is an effusion into the joint, especially the knee or elbow; and
in exceptional cases pyogenic infection may be superadded, and pus form
in the joint.
In older children, a gummatous synovitis is met with of which the most
striking features are: its insidious development, its chronic course,
symmetrical distribution, freedom from pain, the free mobility of the
joint, its tendency to relapse, and its association with other
syphilitic stigmata, especially in the eyes. The knees are the joints
most frequently affected, and the condition usually yields readily to
anti-syphilitic treatment without impairment of function.
JOINT DISEASES ACCOMPANYING CERTAIN CONSTITUTIONAL CONDITIONS
#Gout.#--_Arthritis Urica._--One of the manifestations of gout is that
certain joints are liable to attacks of inflammation associated with the
deposit of a chalk-like material composed of sodium biurate, chiefly in
the matrix of the articular cartilage, it may be in streaks or patches
towards the central area of the joint, or throughout the entire extent
of the cartilage, which appears as if it had been painted over with
plaster of Paris. As a result of this uratic infiltration, the cartilage
loses its vitality and crumbles away, leading to the formation of what
are known as gouty ulcers, and these may extend through the cartilage
and invade the bone. The deposit of urates in the synovial membrane is
attended with effusion into the joint and the formation of adhesions,
while in the ligaments and peri-articular structures it leads to the
formation of scar tissue. The metatarso-phalangeal joint of the great
toe, on one or on both sides, is that most frequently affected. The
disease is met with in men after middle life, and while common enough in
England and Ireland, is almost unknown in hospital practice in Scotland.
The _clinical features_ are characteristic. There is a sudden onset of
excruciating pain, usually during the early hours of the morning, the
joint becomes swollen, red, and glistening, with engorgement of the
veins and some fever and disturbance of health and temper. In the course
of a week or ten days there is a gradual return to the normal. Such
attacks may recur only once a year or they may be more frequent; the
successive attacks tend to become less acute but last longer, and the
local phenomena persist, the joint remaining permanently swollen and
stiff. Masses of chalk form in and around the joint, and those in the
subcutaneous tissue may break through the skin, forming indolent ulcers
with exposure of the chalky masses (_tophi_). The hands may become
seriously crippled, especially when the tendon sheaths and bursæ also
are affected; the crippling resembles that resulting from arthritis
deformans but it differs in not being symmetrical.
The local _treatment_ consists in employing soothing applications and a
Bier's bandage for two or three hours twice daily while the symptoms are
acute; later, hot-air baths, massage, and exercises are indicated. It is
remarkable how completely even the most deformed joints may recover
their function. Dietetic and medicinal treatment must also be employed.
#Chronic Rheumatism.#--This term is applied to a condition which
sometimes follows upon acute articular rheumatism in persons presenting
a family tendency to acute rheumatism or to inflammations of serous
membranes, and manifesting other evidence of the rheumatic taint, such
as chorea or rheumatic nodules.
The changes in the joints involve almost exclusively the synovial
membrane and the ligaments; they consist in cellular infiltration and
exudation, resulting in the formation of new connective tissue which
encroaches on the cavity of the joint and gives rise to adhesions, and
by contracting causes stiffness and deformity. The articular cartilages
may subsequently be transformed into connective tissue, with consequent
fibrous ankylosis and obliteration of the joint. The bones are affected
only in so far as they undergo fatty atrophy from disuse of the limb, or
alteration in their configuration as a result of partial dislocation.
Osseous ankylosis may occur, especially in the small joints of the hand
and foot.
The disease is generally poly-articular and may be met with in childhood
and youth as well as in adult life. In some cases pain is so severe that
the patient resists the least attempt at movement. In others, the
joints, although stiff, can be moved but exhibit pronounced crackings.
When there is much connective tissue formed in relation to the synovial
membrane, the joint is swollen, and as the muscles waste above and
below, the swelling is spindle-shaped. Subacute exacerbations occur from
time to time, with fever and aggravation of the local symptoms and
implication of other joints. After repeated recurrences, there is
ankylosis with deformity, the patient becoming a helpless cripple. On
account of the tendency to visceral complications, the tenure of life is
uncertain.
From the nature of the disease, _treatment_ is for the most part
palliative. Salicylates are only of service during the exacerbations
attended with pyrexia. The application of soda fomentations, turpentine
cloths, or electric or hot-air baths may be useful. Improvement may
result from the general and local therapeutics available at such places
as Bath, Buxton, Harrogate, Strathpeffer, Wiesbaden, or Aix. In selected
cases, a certain measure of success has followed operative interference,
which consists in a modified excision. The deformities resulting from
chronic rheumatism are but little amenable to surgical treatment, and
forcible attempts to remedy stiffness or deformity are to be avoided.
#Arthritis Deformans# (_Osteo-arthritis, Rheumatoid Arthritis, Rheumatic
Gout, Malum Senile, Traumatic or Mechanical Arthritis_).--Under the term
arthritis deformans, which was first employed by Virchow, it is
convenient to include a number of joint affections which have many
anatomical and clinical features in common.
The disease is widely distributed in the animal kingdom, both in
domestic species and in wild animals in the natural state such as the
larger carnivora and the gorilla; evidence of it has also been found in
the bones of animals buried with prehistoric man.
The morbid changes in the joints present a remarkable combination of
atrophy and degeneration on the one hand and overgrowth on the other,
indicating a profound disturbance of nutrition in the joint structures.
The nature of this disturbance and its etiology are imperfectly known.
By many writers it is believed to depend upon some form of
auto-intoxication, the toxins being absorbed from the gastro-intestinal
tract, and those who suffer are supposed to possess what has been called
an "arthritic diathesis."
The localisation of the disease in a particular joint may be determined
by several factors, of which trauma appears to be the most important.
The condition is frequently observed to follow, either directly or after
an interval, upon a lesion which involves gross injury of the joint or
of one of the neighbouring bones. It occurs with greater frequency after
repeated minor injuries affecting the joint and its vicinity, such as
sprains and contusions, and particularly those sustained in laborious
occupations. This connection between trauma and arthritis deformans led
Arbuthnot Lane to apply to it the term _traumatic_ or _trade arthritis_.
The traumatic or strain factor in the production of the disease may be
manifested in a less obvious fashion. In the lower extremity, for
example, _any condition which disturbs the static equilibrium of the
limb as a whole_ would appear to predispose to the disease in one or
other of the joints. The static equilibrium may be disturbed by such
deformities as flat-foot or knock-knee, and badly united fractures of
the lower extremity. In hallux valgus, the metatarso-phalangeal joint of
the great toe undergoes changes characteristic of arthritis deformans.
A number of cases have been recorded in which arthritis deformans has
followed upon antecedent disease of the joint, such as pyogenic or
gonorrhœal synovitis, upon repeated hæmorrhages into the knee-joint in
bleeders, and in unreduced dislocations in which a new joint has been
established.
[Illustration: FIG. 157.--Arthritis Deformans of Elbow, showing
destruction of articular surfaces and masses of new bone around the
articular margins.
(Anatomical Museum, University of Edinburgh.)]
Lastly, Poncet and other members of the Lyons school regard arthritis
deformans as due to an attenuated form of tuberculous infection, and
draw attention to the fact that a tuberculous family history is often
met with in the subjects of the disease.
[Illustration: FIG. 158.--Arthritis Deformans of Knee, showing
eburnation and grooving of articular surfaces.
(Anatomical Museum, University of Edinburgh.)]
_Morbid Anatomy._--The commonest type is that in which the articular
surfaces undergo degenerative changes. The primary change involves the
articular cartilage, which becomes softened and fibrillated and is worn
away until the subjacent bone is exposed. If the bone is rarefied, the
enlarged cancellous spaces are opened into and an eroded and worm-eaten
appearance is brought about; with further use of the joint, the bone is
worn away, so that in a ball-and-socket joint like the hip, the head of
the femur and the acetabulum are markedly altered in size and shape.
More commonly, the bone exposed as a result of disappearance of the
cartilage is denser than normal, and under the influence of the
movements of the joint, becomes smooth and polished--a change described
as _eburnation_ of the articular surfaces (Fig. 158). In hinge-joints
such as the knee and elbow, the influence of movement is shown by a
series of parallel grooves corresponding to the lines of friction
(Fig. 158).
[Illustration: FIG. 159.--Hypertrophied Fringes of Synovial Membrane in
Arthritis Deformans of Knee.
(Museum of Royal College of Surgeons, Edinburgh.)]
While these degenerative changes are gradually causing destruction of
the articular surfaces, reparative and hypertrophic changes are taking
place at the periphery. Along the line of the junction between the
cartilage and synovial membrane, the proliferation of tissue leads to
the formation of nodules or masses of cartilage--_ecchondroses_--which
are subsequently converted into bone (Fig. 157). Gross alterations in
the ends of the bone are thus brought about which can be recognised
clinically and in skiagrams, and which tend to restrict the normal range
of movement. The extension of the ossification into the synovial
reflection and capsular ligament adds a collar or "lip" of new bone,
known as "lipping" of the articular margins, and also into other
ligaments, insertions of tendons and intermuscular septa giving rise to
bony outgrowths or osteophytes not unlike those met with in the
neuro-arthropathies.
Proliferative changes in the synovial membrane are attended with
increased vascularity and thickening of the membrane and an enlargement
of its villi and fringes. When the fatty fringes are developed to an
exaggerated degree, the condition is described as an _arborescent
lipoma_ (Fig. 159). Individual fringes may attain the size of a hazel
nut, and the fibro-fatty tissue of which they are composed may be
converted into cartilage and bone; such a body may remain attached by a
narrow pedicle or stalk, or this may be torn across and the body becomes
loose and, unless confined in a recess of the joint, it wanders about
and may become impacted between the articular surfaces. These changes in
the synovial membrane are often associated with an abundant exudate or
hydrops. These degenerative and hypertrophic changes, while usually
attended with marked restriction of movement and sometimes by "locking"
of the joint, practically never result in ankylosis.
The _ankylosing type_ of chronic arthritis is fortunately much rarer
than those described above, and is chiefly met with in the joints of the
fingers and toes and in those of the vertebral column. The synovial
membrane proliferates, grows over the cartilage, and replaces it, and
when two such articular surfaces are in contact they tend to adhere,
thus obliterating the joint, cavity, and resulting in fibrous or bony
ankylosis. The changes progress slowly and, before they result in
ankylosis, various sub-luxations and dislocations may occur with
distortion and deformity which, in the case of the fingers, is extremely
disabling and unsightly (Fig. 160).
_Clinical Features._--It is usually observed that in patients who are
still young the tendency is for the disease to advance with considerable
rapidity, so that in the course of months it may cause crippling of
several joints. The course of the disease as met with in persons past
middle life is more chronic; it begins insidiously, and many years may
pass before there is pronounced disability. The earliest symptom is
stiffness, especially in the morning after rest, which passes off
temporarily with use of the limb. As time goes on, the range of movement
becomes restricted, and crackings occur. This stage of the disease may
be prolonged indefinitely; if it progresses, stiffness becomes more
pronounced, certain movements are lost, others develop in abnormal
directions, and deformed attitudes add to the disablement. The disease
is compatible with long life, but not with any active occupation, hence
those of the hospital class who suffer from it tend to accumulate in
workhouse infirmaries.
_Hydrops_ is most marked in the knee, and may affect also the adjacent
bursæ. As the joint becomes distended with fluid, the ligaments are
stretched, the limb becomes weak and unstable, and the patient complains
of a feeling of weight, of insecurity, and of tiredness. Pain is
occasional and evanescent, and is usually the result of some extra
exertion, or exposure to cold and wet. This form of the disease is
extremely chronic, and may last for an indefinite number of years. It is
to be diagnosed from the other forms of hydrops already considered--the
purely traumatic, the pyogenic, gonorrhœal, tuberculous, and
syphilitic--and from that associated with Charcot's disease.
_Hypertrophied fringes and pedunculated or loose bodies_ often co-exist
with hydrops, and give rise to characteristic clinical features,
particularly in the knee. The fringes, especially when they assume the
type of the arborescent lipoma, project into the cavity of the joint,
filling up its recesses and distending its capsule so that the joint is
swollen and slightly flexed. Pain is not a prominent feature, and the
patient may walk fairly well. On grasping the joint while it is being
actively flexed and extended, the fringes may be felt moving under the
fingers. Symptoms from impaction of a loose body are exceptional.
[Illustration: FIG. 160.--Arthritis Deformans of Hands, showing
symmetry of lesions, ulnar deviation of fingers, and nodular thickening
at inter-phalangeal joints.]
_The dry form of arthritis deformans_, although specially common in the
knee, is met with in other joints, either as a mon-articular or
poly-articular disease; and it is also met with in the joints of the
spine and of the fingers as well as in the temporo-mandibular joint. In
the joints of the fingers the disease is remarkably symmetrical, and
tends to assume a nodular type (Heberden's nodes) (Fig. 160); in younger
subjects it assumes a more painful and progressive fusiform type
(Fig. 161). In the larger joints the subjective symptoms usually precede
any palpable evidence of disease, the patient complaining of stiffness,
crackings, and aching, aggravated by changes in the weather. The
roughness due to fibrillation of the articular cartilages causes coarse
friction on moving the joint, or, in the knee, on moving the patella on
the condyles of the femur. It may be months or even years before the
lipping and other hypertrophic changes in the ends of the bones are
recognisable, and before the joint assumes the deformed features which
the name of the disease suggests.
The capsular ligament, except in hydrops, is the seat of
connective-tissue overgrowth, and tends to become contracted and rigid.
Intra-articular ligaments, such as the ligamentum teres in the hip, are
usually worn away and disappear. The surrounding muscles undergo
atrophy, tendons become adherent to their sheaths and may be ossified,
and the sheaths of nerves may be involved by the cicatricial changes in
the surrounding tissues.
_The X-ray appearances of arthritis deformans_ necessarily vary with the
type of the disease and the joint affected; in the joints of the fingers
there is a narrowing of the spaces between the articular ends of the
bones as a result of absorption of the articular cartilage, and
rarefaction of the cancellous tissue in the vicinity of the joints; in
the larger joints there is "lipping" of the articular margins,
osteophytes, and other evidence of abnormal ossification in and around
the joint. Eburnation of the articular surfaces is shown by increase in
the density of the shadow of the bone in the areas affected.
[Illustration: FIG. 161.--Arthritis Deformans affecting several
Joints, in a boy æt. 10.
(Dr. Dickson's case.)]
_Treatment._--Treatment is for the most part limited to the relief of
symptoms. On no account should the affected joints be kept at rest by
means of splints or other apparatus. Active movements and exercises of
all kinds are to be persevered with. When pain is a prominent feature,
it may be relieved either by douches of iodine and hot water (tincture
of iodine 1 oz. to the quart), or by the application of lint saturated
with a lotion made up of chloral hydrate, gr. v, glycerin Ʒj, water ℥j,
and covered with oil-silk. Strain and over-use of the joint and sudden
changes of temperature are to be avoided. The induction of hyperæmia by
means of massage, the elastic bandage, and hot-air baths is often of
service. Operative interference is indicated when the disease is of a
severe type, when it is mon-articular, and when the general condition of
the patient is otherwise favourable. Excision has been practised with
success in the hip, knee, elbow, and temporo-mandibular joints.
Limitation of movement and locking at the hip-joint when due to new bone
round the edge of the acetabulum may be greatly relieved by removal of
the bone--a procedure known as _cheilotomy_. Loose bodies and
hypertrophied fringes if causing symptoms may also be removed by
operation.
When stiffness and grating on movement are prominent features we have
found the injection of from half to one ounce of sterilised white
vaseline afford decided relief.
The patient should be nourished well, and there need be no restriction
in the diet such as is required in gouty patients, so long as the
digestion is not impaired. Benefit is also derived from the
administration of cod-liver oil, and of tonics, such as strychnin,
arsenic, and iron, and in some cases of iodide of potassium. Luff
recommends the administration over long periods of guaiacol carbonate,
in cachets beginning with doses of 5–10 grs. and increased to 15–20 grs.
thrice daily. A course of treatment at one of the reputed spas--Aix,
Bath, Buxton, Gastein, Harrogate, Strathpeffer, Wiesbaden, Wildbad--is
often beneficial.
In some cases benefit has followed the prolonged internal administration
of liquid paraffin.
On the assumption that the condition is the result of an
auto-intoxication from the intestinal tract, saline purges and
irrigation of the colon are indicated, and Arbuthnot Lane claims to have
brought about improvement by short-circuiting or by resecting the colon.
Residence in a warm and dry climate, with an open-air life, has been
known to arrest the disease when other measures have failed to give
relief.
The application of radium and the ingestion of radio-active waters have
also been recommended.
#Hæmophilic# or #Bleeder's Joint#.--This is a rare but characteristic
affection met with chiefly in the knee-joint of boys who are the
subjects of hæmophilia. After some trivial injury, or even without
apparent cause, a hæmorrhage takes place into the joint. The joint is
tensely swollen, cannot be completely extended, and is so painful that
the patient is obliged to lie up. The temperature is often raised (101°
to 102° F.), especially if there are also hæmorrhages elsewhere. The
blood in the joint is slowly re-absorbed, and by the end of a fortnight
or so, the symptoms completely disappear. As a rule these attacks are
repeated; the pain attending them diminishes, but the joint becomes the
seat of permanent changes: the synovial membrane is thickened,
abnormally vascular, and coloured brown from the deposit of blood
pigment; on its surface, and in parts of the articular cartilage, there
is a deposit of rust-coloured fibrin; there may be extensive adhesions,
and in some cases changes occur like those observed in arthritis
deformans with erosion and ulceration of the cartilage and a form of dry
caries of the articular surfaces, which may terminate in ankylosis.
As the swelling of the joint is associated with wasting of the muscles,
with stiffness, and with flexion, the condition closely resembles
tuberculous disease of the synovial membrane. From errors in diagnosis
such joints have been operated upon, with disastrous results due to
hæmorrhage.
The treatment of a recent hæmorrhage consists in securing absolute rest
and applying elastic compression. The introduction of blood-serum (10–15
c.c.) into a vein may assist in arresting the hæmorrhage;
anti-diphtheritic serum is that most readily obtainable.
After an interval, measures should be adopted to promote the absorption
of blood and to prevent stiffness and flexion; these include massage,
movements, and extension with weight and pulley.
JOINT DISEASES ASSOCIATED WITH LESIONS OF THE NERVOUS SYSTEM:
NEURO-ARTHROPATHIES
_In Lesions of Peripheral Nerves._--In the hand, and more rarely in the
foot, when one or other of the main nerve-trunks has been divided or
compressed, the joints may become swollen and painful and afterwards
become stiff and deformed. Bony ankylosis has been observed.
_In Affections of the Spinal Medulla._--In myelitis, progressive
muscular atrophy, poliomyelitis, insular sclerosis, and in traumatic
lesions, joint affections are occasionally met with.
The occurrence of joint lesions in _locomotor ataxia_ (tabes dorsalis)
was first described by Charcot in 1868--hence the term "Charcot's
disease" applied to them. Although they usually develop in the ataxic
stage, one or more years after the initial spinal symptoms, they may
appear before there is any evidence of tabes. The onset is frequently
determined by some injury. The joints of the lower extremity are most
commonly affected, and the disease is bilateral in a considerable
proportion of cases--both knees or both hips, for instance, being
implicated.
Among the theories suggested in explanation of these arthropathies the
most recent is that by Babinski and Barré, which traces the condition to
vascular lesions of a syphilitic type in the articular arteries.
The first symptom is usually a swelling of the joint and its vicinity.
There is no redness or heat and no pain on movement. The peri-articular
swelling, unlike ordinary œdema, scarcely pits even on firm pressure.
[Illustration: FIG. 162.--Bones of Knee-joint in advanced stage of
Charcot's Disease. The medial part of the head of the tibia has
disappeared.
(Anatomical Museum, University of Edinburgh).]
In mild cases this condition of affairs may persist for months; in
severe cases destructive changes ensue with remarkable rapidity. The
joint becomes enormously swollen, loses its normal contour, and the ends
of the bones become irregularly deformed (Fig. 162). Sometimes, and
especially in the knee, the clinical features are those of an enormous
hydrops with fibrinous and other loose bodies and hypertrophied
fringes--and great œdema of the peri-articular tissues (Fig. 163). The
joint is wobbly or flail-like from stretching and destruction of the
controlling ligaments, and is devoid of sensation. In other cases,
wearing down and total disappearance of the ends of the bones is the
prominent feature, attended with flail-like movements and with coarse
grating. Dislocation is observed chiefly at the hip, and is rather a
gross displacement with unnatural mobility than a typical dislocation,
and it is usually possible to move the bones freely upon one another and
to reduce the displacement. A striking feature is the extensive
formation of new bone in the capsular ligament and surrounding muscles.
The enormous swelling and its rapid development may suggest the growth
of a malignant tumour. The most useful factor in diagnosis is the entire
absence of pain, of tenderness, and of common sensibility. The freedom
with which a tabetic patient will allow his disorganised joint to be
handled requires to be seen to be appreciated.
[Illustration: FIG. 163.--Charcot's Disease of Left Knee. The joint is
distended with fluid and the whole limb is œdematous.]
The rapidity of the destructive changes in certain cases of tabes, and
the entire absence of joint lesions in others, would favour the view
that special parts of the spinal medulla must be implicated in the
former group.
In _syringomyelia_, joint affections (gliomatous arthropathies) are more
frequent than in tabes, and they usually involve the upper extremity in
correspondence with the seat of the spinal lesion, which usually affects
the lower cervical and upper thoracic segments. Except that the joint
disease is seldom symmetrical, it closely resembles the arthropathy of
tabes. The completeness of the analgesia of the articular structures
and of the overlying soft parts is illustrated by the fact that in one
case the patient himself was in the habit of letting out the fluid from
his elbow with the aid of a pair of scissors, and that in another the
joint was painlessly excised without an anæsthetic.
[Illustration: FIG. 164.--Charcot's Disease of both Ankles: front view.
Man, æt. 32.]
The disease may become arrested or may go on to complete
disorganisation; suppuration may ensue from infection through a breach
of the surface, and in rare cases the joint has become the seat of
tuberculosis.
[Illustration: FIG. 165.--Charcot's Disease of both Ankles: back view.
Man, æt. 32.]
_Treatment_, in addition to that of the nerve lesion underlying the
arthropathy, consists in supporting and protecting the joint by means of
bandages, splints, and other apparatus. In the lower extremity, the use
of crutches is helpful in taking the strain off the affected limb. When
there is much distension of the joint, considerable relief follows upon
withdrawal of fluid. The best possible result being rigid ankylosis in a
good position, it may be advisable to bring this about artificially by
arthrodesis or resection. Operation is indicated when only one joint is
affected and when the cord lesion is such as will permit of the patient
using the limb. The wounds heal well, but the victims of tabes are
unfavourable subjects for operative interference, on account of their
liability to intercurrent complications. When the limb is quite useless,
amputation may be the best course.
_In cerebral lesions_ attended with hemiplegia, joint affections,
characterised by evanescent pain, redness, and swelling, are
occasionally met with. The secondary changes in joints which are the
seat of paralytic contracture are considered with the surgery of the
Extremities.
In cases of _hysteria_ and other _functional affections of the
nervous system_, an intermittent neuropathic hydrops has been
observed--especially in the knee. Without apparent cause, the joint
fills with fluid and its movements become restricted, and after from two
to eight days the swelling subsides and the joint returns to normal. A
remarkable feature of the condition is that the effusion into the joint
recurs at regular intervals, it may be over a period of years. Psychic
conditions have been known to induce attacks, and sometimes to abort
them or even to cause their disappearance. Hence it has been recommended
that treatment by suggestion should be employed along with tonic doses
of quinine and arsenic.
HYSTERICAL OR MIMETIC JOINT AFFECTIONS
Under this heading, Sir Benjamin Brodie, in 1822, described an affection
of joints, characterised by the prominence of subjective symptoms and
the absence of pathological changes. Although most frequently met with
in young women with an impressionable nervous system, and especially
among those in good social circumstances, it occurs occasionally in men.
The onset may be referred to injury or exposure to cold, or may be
associated with some disturbance of the emotions or of the generative
organs; or the condition may be an involuntary imitation of the symptoms
of organic joint disease presented by a relative or friend.
It is characteristic that the symptoms develop abruptly without
satisfactory cause, that they are exaggerated and wanting in harmony
with one another, and that they do not correspond with the features of
any of the known forms of organic disease. In some cases the only
complaint is of severe pain; more often this is associated with
excessive tenderness and with impairment of the functions of the joint.
On examination the joint presents a normal appearance, but the skin
over it is remarkably sensitive. A light touch is more likely to excite
pain than deep and firm pressure. Stiffness is a variable feature--in
some cases amounting to absolute rigidity, so that no ordinary force
will elicit movement. It is characteristic of this, as of other
neuroses, that the symptoms come and go without sufficient cause. When
the patient's attention is diverted, the pain and stiffness may
disappear. There is no actual swelling of the joint, although there may
be an appearance of this from wasting of the muscles above and below. If
the joint is kept rigid for long periods, secondary contracture may
occur--in the knee with flexion, in the hip with flexion and adduction.
The _diagnosis_ is often a matter of considerable difficulty, and the
condition is liable to be mistaken for such organic lesions as a
tuberculous or pyogenic focus in the bone close to the joint.
The greatest difficulty is met with in the knee and hip, where the
condition may closely simulate tuberculous disease. The use of the
Röntgen rays, or examination of the joint under anæsthesia, is helpful.
The _local treatment_ consists chiefly in improving the nutrition of the
affected limb by means of massage, exercises, baths, and electricity.
Splints are to be avoided. In refractory cases, benefit may follow the
application of blisters or of Corrigan's button. The general condition
of the patient must be treated on the same lines as in other neuroses.
The Weir-Mitchell treatment may have to be employed in obstinate cases,
the patient being secluded from her friends and placed in charge of a
nurse. Complete recovery is the rule, but when the muscles are weak and
wasted from prolonged disuse, a considerable time may elapse before the
limb returns to normal.
TUMOURS AND CYSTS
New growths taking origin in the synovial membrane are rare, and are not
usually diagnosed before operation. They are attended with exudation
into the joint, and in the case of _sarcoma_ the fluid is usually
blood-stained. If the tumour projects in a polypoidal manner into the
joint, it may cause symptoms of loose body. One or two cases have been
recorded in which a _cartilaginous tumour_ growing from the synovial
membrane has erupted through the joint capsule and infiltrated the
adjoining muscles. _Multiple cartilaginous tumours_ forming loose bodies
are described on p. 544.
_Cysts of joints_ constitute an ill-defined group which includes ganglia
formed in relation to the capsular ligament. Cystic distension of bursæ
which communicate with the joint is most often met with in the region of
the knee in cases of long-standing hydrops. It was suggested by Morrant
Baker that cystic swellings may result from the hernial protrusion of
the synovial membrane between the stretched fibres of the capsular
ligament, and the name "Baker's cysts" has been applied to these.
In the majority of cases, cysts in relation to joints give rise to
little inconvenience and may be left alone. If interfered with at all,
they should be excised.
LOOSE BODIES
It is convenient to describe the varieties of loose bodies under two
heads: those composed of fibrin, and those composed of organised
connective tissue.
#Fibrinous Loose Bodies# (Corpora oryzoidea).--These are homogeneous or
concentrically laminated masses of fibrin, sometimes resembling rice
grains, melon seeds, or adhesive wafers, sometimes quite irregular in
shape. Usually they are present in large numbers, but sometimes there is
only one, and it may attain considerable dimensions. They are not
peculiar to joints, for they are met with in tendon sheaths and bursæ,
and their origin from synovial membrane may be accepted as proved. They
occur in tuberculosis, arthritis deformans, and in Charcot's disease,
and their presence is almost invariably associated with an effusion of
fluid into the joint. While they may result from the coagulation of
fibrin-forming elements in the exudate, their occurrence in tuberculous
hydrops would appear to be the result of coagulation necrosis, or of
fibrinous degeneration of the surface layer of the diseased synovial
membrane. However formed, their shape is the result of mechanical
influences, and especially of the movement of the joint.
_Clinically_, loose bodies composed of fibrin constitute an unimportant
addition to the features of the disease with which they are associated.
They never give rise to the classical symptoms associated with impaction
of a loose body between the articular surfaces. Their presence may be
recognised, especially in the knee, by the crepitating sensation
imparted to the fingers of the hand grasping the joint while it is
flexed and extended by the patient.
The _treatment_ is directed towards the disease underlying the hydrops.
If it is desired to empty the joint, this is best done by open
incision.
[Illustration: FIG. 166.--Radiogram of Multiple Loose Bodies in
Knee-joint and Semi-membranosus Bursa in a man æt. 38.
(Mr. J. W. Dowden's case.)]
#Bodies composed of Organised Connective Tissue.#--These are
comparatively common in joints that are already the seat of some chronic
disease, such as arthritis deformans, Charcot's arthropathy, or synovial
tuberculosis. They take origin almost exclusively from an erratic
overgrowth of the fringes of the synovial membrane, and may consist
entirely of fat, the arborescent lipoma (Fig. 159) being the most
pronounced example of this variety. Fibrous tissue or cartilage may
form in one or more of the fatty fringes and give rise to hard nodular
masses, which may attain a considerable size, and in course of time may
undergo ossification.
Like other hypertrophies on a free surface, they tend to become
pedunculated, and so acquire a limited range of movement. The pedicle
may give way and the body become free. In this condition it may wander
about the joint, or lie snugly in one of its recesses until disturbed by
some sudden movement. A loose body free in a joint is capable of growth,
deriving the necessary nutriment from the surrounding fluid. The size
and number of the bodies vary widely. Single specimens have been known
to attain the size of the patella. The smaller varieties may number
considerably over a hundred.
[Illustration: FIG. 167.--Loose Body from Knee-joint of man æt. 25.
Natural size.
a = Convex surface. b = Concave surface.]
In arthritis deformans a rarer type of loose body is met with, a portion
of the lipping of one of the articular margins being detached by injury.
In Charcot's disease, bodies composed of bone are formed in relation to
the capsular and other ligaments, and may be made to grate upon one
another.
The _clinical features_ in this group are mainly those of the disease
which has given rise to the loose bodies, and it is exceptional to meet
with symptoms from impaction of the body between the articular surfaces.
Treatment is to be directed towards the primary disease in the joint, as
well as to the removal of the loose bodies.
[Illustration: FIG. 168.--Multiple partially ossified Chondromas of
Synovial Membrane, from Shoulder-joint, the seat of arthritis deformans,
from a man æt. 35.]
_Loose Bodies in Joints which are otherwise healthy._--It is in joints
otherwise healthy that loose bodies causing the classical symptoms and
calling for operative treatment are most frequently met with. They occur
chiefly in the knee and elbow of healthy males under the age of thirty.
The complaint may be of vague pains, of occasional cracking on moving
the joint, or of impairment of function--usually an inability to extend
or flex the joint completely. In many cases a clear account is given of
the symptoms which arise when the body is impacted between the articular
surfaces, namely, sudden onset of intense sickening pain, loss of power
in the limb and locking of the joint, followed by effusion and other
accompaniments of a severe sprain. On some particular movement, the
body is disengaged, the locking disappears, and recovery takes place.
Attacks of this kind may recur at irregular intervals, during a period
of many years. On examining the joint, it is usually found to contain
fluid, and there may be points of special tenderness corresponding to
the ligaments that have been overstretched. In cases in which there has
been recurrent attacks of locking, the ligaments become slack, the joint
is wobbly, and the quadriceps is wasted. The patient himself, or the
surgeon, may discover the loose body and feel it roll beneath his
fingers, especially if it is lodged in the supra-patellar pouch in the
knee, or on one or other side of the olecranon in the elbow. In most
instances the patient has carefully observed his own symptoms, and is
aware not only of the existence of the loose body, but of its erratic
appearance at different parts of the joint. This feature serves to
differentiate the lesions from a torn medial meniscus in which the pain
and tenderness are always in the same spot. As the body usually contains
bone, it is recognisable in a skiagram.
[Illustration: FIG. 169.--Multiple Cartilaginous Loose Bodies from
Knee-joint.]
There are two methods of _removing the body_; the first and simpler
method is applicable when the body can be palpated, usually in the
supra-patellar pouch; it is preferably transfixed by a needle and can
then be removed through a small incision; otherwise, the joint must be
freely opened and explored, firstly to find the body and further to
remove it.
The characters of this type of loose body are remarkably constant. It is
usually solitary, about the size of a bean or almond, concavo-convex in
shape, the convex aspect being smooth like an articular surface, the
concave aspect uneven and nodulated and showing reparative changes,
healing over of the raw surface, and the new formation of fibrous
tissue, hyaline cartilage and bone, the necessary nutriment being
derived from the synovial fluid (Fig. 167). The body is sometimes found
to be lodged in a defect or excavation in one of the articular surfaces,
usually the medial condyle of the femur, from which it is readily
shelled out by means of an elevator. It presents on section a layer of
articular cartilage on the convex aspect and a variable thickness of
spongy bone beneath this.
The origin of these bodies is one of the most debated questions in
surgical pathology; they obviously consist of a portion of the articular
surface of one of the bones, but how this is detached still remains a
mystery; some maintain that it is purely traumatic; König regards them
as portions of the articular surface which have been detached by a
morbid process which he calls "osteochondritis dessicans."
_Multiple Chondromas and Osteomas of the Synovial Membrane._--In this
rare type of loose body, the surface of the synovial membrane is studded
with small sessile or pedunculated tumours composed of pure hyaline
cartilage, or of bone, or of transition stages between cartilage and
bone. They are pearly white in colour, pitted and nodular on the
surface, rarely larger than a pea, although when compressed they may
cake into masses of considerable size. With the movements of the joint
many of the tumours become detached and lie in the serous exudate
excited by their presence. They are found also in the diverticula of the
synovial membrane, in the shoulder in the downward prolongation along
the tendon of the biceps, in the hip in the bursal extension beneath the
psoas.
The patient complains of increasing disability of the limb, movements of
the joint becoming more and more restricted and painful. There is
swelling corresponding to the distended capsule of the joint, and on
palpation the bodies moving under the fingers yield a sensation as of
grains of rice shifting in a bag. If the bodies are so numerous as to be
tightly packed together, the impression is that of a plastic mass having
the shape of the synovial sac. The stiffness and the cracking on
movement may suggest arthritis deformans, but the X-ray appearances make
the diagnosis an easy one. We have observed two cases of this affection
in the knee-joint of adult women, one in the shoulder-joint of an adult
male (Fig. 168), and Caird has observed one in the hip. The treatment
consists in opening the joint by free incision and removing the bodies.
_Displacement of the menisci_ of the knee is referred to with injuries
of that joint.
INDEX
Abdominal aneurysm, 313
aorta, compression of, 269
embolus of, 93
Abscess, 46
acute circumscribed, 46
of bone, 448
Brodie's, 448
chronic, 139
cold, 139
embolic, 66
formation of, 47
Hilton's method of opening, 50
pointing of, 48
pyæmic, 287
residual, 141
of skin, multiple, 382
stitch, 51
treatment of, 49
tuberculous, 139, 141
peri-articular, 514, 517
Achillo-bursitis, 432
Achillo-dynia, 422
Acidosis, 251
Acromion bursa, 429
Actinomycosis, 126
Active hyperæmia, 39
Acupuncture in aneurysm, 308
Acute arthritis of infants, 440
necrosis of bone, 439
Adductor longus muscle, rupture of, 408
Adenoma, 202
malignant, 209
sebaceous, 393
of skin, 393
varieties of, 202
Adiposus dolorosa, 186
Aërobes, 19
Air embolism, 265
hunger, 276
Albumosuria, 195, 474, 492
Aleppo boil, 129
Alexins, 22
Ambrine, 13, 238
Amputation neuroma, 344
Anaërobes, 19
Anæsthesia, after nerve injuries, 347
Analgesia, 347
Anaphylaxis, 23
Anatomical tubercle, 134
Anatomy. _See_ Surgical Anatomy
Anel's operation for aneurysm, 307
Aneurysm, 300. _See also_ Individual Arteries
abdominal, 313
acupuncture in, 308
amputation in, 310
by anastomosis, 298
Anel's operation for, 307, 310
arterio-venous, 263
axillary, 318
of bone, 498
brachial, 318
Brasdor's operation for, 308
cirsoid, 299
Colt's method of wiring for, 309
compression for, 308
consolidated, 304, 305
differential diagnosis of, 305
diffused, 302
digital compression in, 308
excision of, 307
of forearm and hand, 318
fusiform, 301
gelatin injections in, 309
Hunter's operation for, 307
iliac, 318
of individual arteries, 312
inguinal, 318
innominate, 314
intracranial, 316
of leg and foot, 320
ligation of artery for, 307
Macewen's acupuncture for, 308
Matas' operation for, 307
Moore-Corradi method, 308
natural cure of, 305
old operation for, 307
of ophthalmic artery, 317
orbital, 317
pathological, 301
pulse in, 304
rupture of, 306
sacculated, 302
suppuration in, 306
thoracic, 312
traumatic, 263, 310
treatment of, 306
varicose, 311
Wardrop's operation for, 308
X-rays in diagnosis of, 304
Aneurysmal varix, 311, 316, 318, 319, 320
Angioma, 284
arterial, 299
capillary, 294
cavernous, 297
racemosum venosum, 287
venous, 294
Angio-neurotic œdema, 348
sarcoma, 199
Angler's elbow, 406
Ankle, cellulitis of, 58
Ankylosis of joints, 503. _See also_ Individual Joints
Anoci-association, 253
Anthracæmia, 121
Anthrax, 119
Anti-bacterial sera, 23
-diphtheritic serum, 111
-streptococcic serum, 23, 109
-tetanic serum, 117
Antibodies, 22
Antigens, 22
Antiseptics, 242
Antitoxic sera, 23
Antitoxins, 22
Antivenin, 132
Aorta, abdominal, compression of, 269
aneurysm of, 313
embolism of, 93
ligation of, 314
pulsating, 305, 314
Arborescent lipoma, 423
Arseno-billon, 163
Arteries, anatomy of, 258
compression of individual, 269
contusion of, 260
digital compression of, 269
gangrene following ligation of, 94
gunshot wounds of, 263
Arteries, ligation of, for aneurysm, 307
punctured wounds of, 262
repair of, 266, 268
rupture of, 260
wounds of, 261, 262
Arterio-sclerosis, 282
Arterio-venous aneurysm, 310
Arteritis, varieties of, 282
Arthritis, 501. _See also_ Individual Joints
acute, 506
of infants, 440
deformans, 524
gonococcal, 510
neuropathic, 532
ossificans, 503
pneumococcal, 509
pyogenic, 506
rheumatic, 523
rheumatoid, 524
septic, 506
scarlatinal, 508
trade, 525
traumatic, 524
tuberculous, 512
urica, 522
Arthrolysis, 505
Arthropathies, 532
gliomatous, 534
Arthroplasty, 505
Articular caries, 502, 514
Artificial hyperæmia, 39
Ascites, chylous, 325
Asepsis, 18
Asphyxia, local, 97
traumatic, 254
Atheroma, 283
Avulsion of nerves, 375
of tendons, 411
Axilla, cellulitis of, 58
hygroma of, 328
Axillary aneurysm, 318
artery, embolus of, 93
lymph glands, 336
nerve, injuries of, 363
Bacilli, 19
Bacillus aërogenes capsulatus, 99
anthracis, 119
coli communis, 27
diphtheriæ 109
drum-stick, 112
of Ducrey, 154
of glanders, 123
Klebs-Löffler, 109
of malignant œdema, 101
mallei, 123
pyocyaneus, 29
of soft sore, 154
of tetanus, 112
tubercle, 133
typhosus, 29, 452
Bacteria, death of, 21
general characters of, 18
pathogenic properties of, 19
pyogenic, 24, 29
Bacterial intoxication, 21
Bacteriology, surgical, 17
Baker's cysts, 539
Bazin's disease, 74, 169
Beck's paste in sinuses, 145
Bed-sores, 73, 103
Bence-Jones on albumosuria, 195, 474, 492
Biceps, bursa under, 430
dislocation of long tendon of, 409
rupture of, 407
Bier's artificial hyperæmia, 38
B.I.P.P., 143
Birth palsies, 362
Biskra button, 129
Bismuth gauze, 247
injections in sinuses, 145
Bites of animals, 223
Black eye, 219
Bleeder's joint, 531
Bleeders, 277
bruises in, 218
Blisters, 376
purulent, 55
Blocking of nerves for shock, 252
Blood, count, 30
cysts, 214, 220
transfusion of, 11, 253
Blood vessels. _See_ Arteries and Veins
Bloodless state, treatment of, 276
Blood letting, general, 42
Boil, 379
Aleppo, 129
Delhi, 129
Bone. _See also_ Individual Bones
abscess of, 448
aneurysm of, 498
angioma of, 491
atrophy of, 479
bacterial diseases of, 438
Brodie's abscess of, 448
cancer of, secondary, 499
caries of, 437, 438
changes in ulcers of leg, 79
chondroma of, 487
cysts of, 477, 500
diseases of, 434
due to staphylococcus aureus, 438
endothelioma of, 492
exostoses of, 191, 481
fibroma of, 491
fragility of, 479
grafting, 16, 436
gumma of, 464
hydatid disease of, 467
hyperostosis, 435, 464
hypertrophic pulmonary osteo-arthropathy, 480
hypertrophy of, 435
lipoma of, 491
lipping of, 527
malacia of, 473
marrow, function of, 434
myeloma of, 491
myxoma of, 491
necrosis of, 438
neuropathic atrophy of, 479
osteoma of, 481
osteomalacia of, 473
osteomyelitis of, 65, 437, 438, 451, 453, 473
fibrosa, 476
osteoporosis of, 437
osteopsathyrosis, 479
ostitis deformans, 474
Paget's disease of, 474
periosteum, function of, 435
periostitis, 437
pulsating hæmatoma of, 498
pyogenic diseases of, 438
regeneration of, 436
rickety affections of, 468
sarcoma of, 492
sclerosis of, 435
scurvy affecting, 473
secondary tumours of, 499
surgical anatomy of, 434
staphylococcal diseases of, 438
syphilitic diseases of, 461, 465
transplantation of, 436
tuberculous diseases of, 454
tumours of, 480
malignant, 492, 499
metastatic, 499
thyreoid, 500
typhoid, infection of, 452
X-ray appearances in diseases of, 445, 455, 485, 491, 496
Bovine tuberculosis, 136
Brachial aneurysm, 318
artery, embolus of, 93
compression of, 269
birth-paralysis, 362
fibrositis, 413
neuralgia, 371
plexus, lesions of, 360
Brain, joint affections in lesions of, 537
syphilitic lesions of, 161
Branchial dermoids, 211
Brasdor's operation for aneurysm, 308
Brodie's abscess, 448
Bruises, 218
Bubo, 329
bullet, 153
of soft sores, 155
Bullet bubo, 153
Bullets, embedded, 231
varieties of, 230
Burnol, 238
Burns, 233
classification, of, 234
electrical, 239
pathology of, 233
by X-rays, 239
Bursæ. _See also_ Individual Bursæ
adventitious, 426
affections of, 426
individual, 428
diseases of, 426, 428
hæmatoma of, 426
hydrops of, 427
hygroma of, 423
inflammation of, 426
injuries of, 426
loose bodies in, 427
syphilis of, 428
tuberculosis of, 428
tumours of, 427, 428
Cachexia, cancerous, 207
Calcanean bursa, 432
Calcification in arteries, 282
in muscles, 416
in tuberculosis, 136
Callosities, 376
Callous ulcers, 79, 84
Cancer, 202
arsenic, 395
of bone, 499
cachexia in, 207
chimney-sweep's, 395
colloid, 210
columnar epithelial, 209
contagiousness of, 205
cystic, 210
definition of, 202
degeneration of, 205
encephaloid, 210
_en cuirasse_, 204
glandular, 210
glandular infection in, 203
increase of, 207
of lymph glands, 340
medullary, 210
melanotic, 210, 341, 397
paraffin, 395
pigmented, 210
radium treatment of, 208
rodent, 210, 395
scirrhous, 210
of skin, 394
spread of, 204
squamous epithelial, 208
ulceration of, 205
varieties of, 208
X-ray, 208
Cancrum oris, 102
Cantharides plaster, 42
Capillaries, anatomy of, 258
Capillary angioma, 294
loops, 3
Carbolic gangrene, 95
Carbon-dioxide snow, 297
Carbuncle, 380
Carcinoma. _See_ Cancer
Caries, 437, 438
of articular surfaces, 502, 514
sicca, 438
syphilitic, 462
tuberculous, 455
Carotid aneurysm, 314
artery, compression of, 269
tubercle, 269
Carpal ganglion, 214
Carron oil, 238
Cartilage, grafting of, 16
repair of, 7
ulceration of, 502, 514
Cartilaginous exostosis, 191, 481
Caseation in tuberculosis, 136
Catalepsy, 116
Catgut, infection by, 51
preparation of, 245
Cautery in hæmorrhage, 271
Cavernous angioma, 298
lymphangioma, 327
Cellulitis, 52
in different situations, 58
diffuse, 52
Cephalic or Kopf tetanus, 116
Cerebro-spinal meningitis, 115
Cervical adenitis, 332
rib, 360
Chalk stones in gouty joints, 523
Chancre, concealed, 152, 153, 157
erratic, 153
extra-genital, 153
hard, 151
meatal, 152
multiple, 152
relapsing false indurated, 172
soft, 154
urethral, 152