from that of lymphangitis, which generally accompanies it. The first
essential is physiological rest for the part involved, such as
confinement in bed, and the least possible disturbance of the inflamed
area, which should be placed in the most restful position and handled
as little as possible. Local soothing and evaporating lotions may be
used, or, as seems to the writer preferable in most cases, applications
of a 10 per cent. ichthyol-mercurial ointment, or of the Credé silver
ointment, neither of which should be rubbed in, but spread upon the
skin and covered with an impermeable material. These will, after a few
days, prove irritating, and a substitution of something milder may be
required; but in the acute stage they will render greater service than
anything else. _A phlebitis which has been provoked and is perpetuated
by the presence of septic material cannot be successfully treated so
long as its provoking cause remain._ Puerperal sepsis which results in
pelvic phlebitis calls for thorough curetting of the uterus, while an
abscess in the jaw or about the mouth, resulting from diseased teeth,
necessitates the extirpation of the latter, providing the jaws can be
separated sufficiently to permit of it. What may be needed in cases of
thrombophlebitis of the cranial sinuses has just been mentioned.
In any part of the body a vein which is filled with a breaking-down
clot can be promptly and judiciously treated by exposure and removal
of the involved part, or by free and open incision, with suitable
after-treatment.
A chronic phlebitis that produces such lesions as varices will be dealt
with under its proper head.
INJURIES OF VEINS.
=Rupture of Veins.=--Rupture of small veins is the inevitable
consequence of every injury sufficiently serious to be in any sense
disabling, its visible expression taking the form at least of
ecchymosis, sometimes of distinct hematoma. Again, after long-continued
pressure by which return of venous blood is prevented, certain
degenerations take place in the vein walls which lead to their yielding
on apparently trivial provocation; thus veins situated distally to
large aneurysms sometimes give way, while the frequency with which they
rupture in large varices of the limbs and in hemorrhoids is everywhere
recognized. In the days when venesection was so frequently practised,
usually at the bend of the elbow, a traumatic communication between
the artery and the vein was frequently produced, with consequent
anastomosis. When this was direct, the vessels being in contact with
each other, it was an _aneurysmal varix_. When there was more or
less of an intervening sac, through which the blood flowed from one
to the other, it was spoken of as a _varicose aneurysm_. Save in
rare cases produced by puncture or gunshot wounds such lesions are
curiosities. Should operation be required the sac, if there be one,
may be extirpated, or the vein may be ligated above and below the
communication. (See above.)
=Air Embolism.=--Air embolism may follow injury to the large venous
trunks, especially about the head and neck. This term implies the
entrance, by aspiration, of air into the veins, its bubbles being
carried along to the right side of the heart, where they are supposed
to more or less interfere with its action. Sometimes at the instant
of the accident a sucking or gasping sound may be heard. Formerly the
condition was considered alarming, but now it is almost a bugbear. It
is probable that minor degrees of the accident often occur without
perceptible alteration in heart action. Serious disturbance, however,
is possible, especially if the longitudinal sinus or the common jugular
be extensively opened, and the patient’s head is above the level of
the body at the time. Such an accident might call for artificial
respiration, and it has been suggested to aspirate the right side of
the heart. When its danger can be foreseen precautions should be taken
by pressure on the proximal side of the injury. Air embolism is said
also to have followed parturition, and even exposure of veins in the
stomach by the ulcerative process. (See p. 38.)
=Treatment.=--Most injured veins can be tied _in situ_ and their
function left to the collateral circulation. Fear is sometimes felt
about the axillary and the femoral veins, and serious discussions
have arisen as to whether amputation might be called for should these
large channels be so injured as to be made useless. Experience has
shown that either of them may be ligated, with nothing worse than
temporary edema of the limb beyond. Should there then occur, by
accident or during an operation, an opening of these venous trunks
one may apply the ligature, if necessary. Before resorting to this,
however, one may consider the advisability of the application of a
fine _suture_ to the margins of the wound in the vein, which has
become a standard procedure, or, if the opening be small, and it can
be seized with a hemostat, it may be left _in situ_ for two or three
days, closing the wound around it, and so supporting and protecting the
part with dressings that it shall not be disturbed. A small forceps
or its equivalent may thus be left upon a cranial sinus, a jugular,
subclavian, axillary, femoral, or other vein without jeopardizing the
result.
VARICES AND PHLEBECTASES.
The term _phlebectasia_ implies an extensive affection of a portion of
the venous system, characterized by more or less uniform enlargement
of all its veins. A similar involvement of isolated veins is usually
spoken of as _varix_. These conditions may be congenital or acquired.
Fig. 182 illustrates a congenital varicose condition occurring in a
lad aged sixteen years. Such a lesion may be explained by congenital
defect in some of the deeper veins, thus compelling the venous blood
to return through the more superficial channels. These congenital
lesions are more common in the lower extremities, but may be seen in
all parts of the body. Varices, also, by virtue of their exciting and
contributing causes, are most common in the lower extremities and
in the lower venous terminals, as in the scrotum, the rectum, etc.
Acquired varices usually imply previous lesion in the vein walls,
sometimes inflammatory, sometimes toxic. The walls of the veins thus
become at first atrophied, this condition being often followed by
irritative hyperplasia, by which finally the veins become thickened and
strengthened, and sometimes calcified. The enlargements are irregular
and sacculations frequently form. In such sacculi thrombi may occur and
be followed by calcification, the resulting concretions being known
as _phleboliths_. These can often be recognized through the skin in
old and chronic cases. Sometimes adjoining sacculi become confluent
and there forms what is called an _anastomotic varix_. By such
communications cavernous conditions are produced which, when placed
subcutaneously, lead to peculiar and distinctive tumor formations.
[Illustration: FIG. 182
Congenital varices. (Park.)]
As already stated, the tendency to varices is indirectly the result
of man’s assumption of the upright position, by which greater stress
is placed upon the valves and the lower veins than they are prepared
to bear. Naturally these conditions occur often in those who are
constantly engaged in hard work upon the feet. Varices, then, are
lesions, not so much of the leisurely and sedentary as of the active
and working classes. Anything which predisposes to venous stasis may be
regarded as a contributing cause--thus their relations with weakened
hearts and obstructed lungs are indirect, but positive. Many women
suffer in this way as the consequence of their first pregnancy, with
its pressure upon the pelvic veins; while tight garters, corsets, and
belts also predispose to overloading of the lower veins. Slight but
almost permanent causes of this kind, through the influence of gravity,
thus produce varices in the course of time.
To varices in certain locations have been given special names. To such
a dilatation of the spermatic and pampiniform plexus has been given
the name _varicocele_. When the hemorrhoidal veins are involved the
condition is known as _hemorrhoids_ or _piles_. The former is often
credited with being due to the anatomical arrangement of the left
spermatic vein, through which blood is not as directly poured into
the vena cava as on the right side, while the relation of chronic
constipation, with its obstruction to the circulation in the rectal
walls, will account for many cases of hemorrhoids, and the disturbance
implied by the term cirrhosis of the liver will furnish an explanation
for many others. A similar condition in the esophageal veins has
given rise to the term _esophageal hemorrhoids_. Most indicative and
extraordinary expressions of closing of deep circulation may be seen in
some instances of intrathoracic and intra-abdominal diseases, _i. e._,
cases in which the superficial veins of the chest and thorax become
remarkably enlarged. Such expressions as these are to be regarded as
natural efforts to obviate a difficulty, and no attempt should be made
to eradicate such varices.
=Symptoms.=--In cases requiring surgical intervention, varicose veins
present the following features, which are particularly indicative; they
not only enlarge in diameter but elongate, and consequently have to
assume a tortuous arrangement to accommodate their increased length;
they cause a constant sense of fulness and discomfort, which often
amounts to actual pain, especially after laborious effort. This pain is
due to the distention of the venous trunks, to pressure upon cutaneous
nerves, and often to disturbances of nutrition. In fact, nutrition
is so often disturbed as to be accompanied by _skin lesions_, which
begin as eczema and terminate in extensive ulcerations. So frequent is
this association, and so distinctive its type, that such ulcers are
frequently referred to as varicose. If the term be used to imply the
association it perhaps may stand; if intended to typify a peculiar type
of ulcer it is objectionable, as the ulcer itself is simply such as may
happen on any surface whose nutrition is more or less perverted.
The most common causes of varicosities in the lower extremities are
previous lesions, such as phlebitis following typhoid, injuries of the
limbs or trunk, the pressure of tumors, fecal accumulations, garters
or belts, laborious work in the upright position, and the possible
complications of all cases from variation in the original anatomical
arrangement of veins and their valves; pregnancy also should be added
to this list.
The condition is rare in early life. Liability to it increases with
age. Varices rarely occur in the upper limbs in connection with certain
occupations or athletic sports, _e. g._, baseball and tennis.
The measure of the distention of veins can often be taken by the
sensation of fulness and muscle cramp. In few surgical lesions do
appearances give as much aid in diagnosis. This is particularly true of
superficial varices. Varicosities of the deeper veins maybe suspected
when patients complain of discomfort, pain, cramp, and swelling of the
feet after hard work.
Varices would rarely lead to ulceration were it not for the superficial
infections incurred in many obvious ways--sometimes by the finger-nails
of the individual, who is constantly tempted to scratch or rub the area
in which he feels such incessant discomfort.
=Treatment.=--Suitable treatment of varices of the internal veins,
varicocele, hemorrhoids, etc., will be indicated in its proper place.
In this chapter only _varices of the extremities_ will be considered.
When a tendency to the varicose condition is noted early, and a cause
can be discovered, removal of the cause may be all that is needed. When
the condition is well established, and yet not sufficiently prominent
to justify radical treatment, it should consist largely in support
by bandages or elastic stockings, applied discriminatingly, with
sufficient pressure to prevent undue distention and not sufficient to
cause edema. It frequently affords much relief and prevents aggravation
of the condition; on the other hand, once the veins become accustomed
to this support they yield more readily upon its withdrawal, and the
treatment by gentle constriction once begun, which is sufficient for
many cases, can rarely be discontinued, even after a lapse of time.
A maximum of rest and elevation of the limb are requisite in the
non-operative treatment of varicose veins. The compression exercised
by elastic stockings is of only temporary benefit, and is simply
such an assistance as is a crutch to a cripple. The less the patient
remains upon the foot and the less he takes hot baths or indulges in
other relaxing measures the better. Cold shower or tub baths are far
preferable, with massage of the deeper muscles, the large veins being
avoided. Such a patient should never walk slowly, but always rapidly,
and rest as soon as fatigued. All diathetic conditions should receive
attention.
When it is not possible to early and speedily remove the existing cause
there is but one cure for varices, and that is by _radical surgical
treatment_. A generation ago this was effected by the injection
into the veins of perhaps one of the iron salts, in order to produce
artificial and instantaneous thrombosis, by which later occlusion of
the vein could be induced. The coagulating effects were decided, and
so also were the effects of the germs introduced at the same time, in
the absence of ordinary antiseptic precautions. Thus it resulted that
the mortality, even after this trifling procedure, was tremendous and
led to its abandonment. When it had been demonstrated, through Lister’s
achievements, that the surgeon could be clean about such work, it was
learned also that veins could be more radically treated than had been
previously realized. With the advent of the antiseptic era came more
effective and extensive operations upon veins. Now we know that with
strict asepsis they can be handled with absolute impunity, and open
methods of treatment have replaced the subcutaneous. No hesitation is
at present felt in exposing the veins at one point, or numerous points,
and applying ligatures; these, however, have been found to be less
effective than a long incision made over a vein, with its complete
_extirpation_. Thus the long internal saphenous should nearly always
be excised, though it take an incision twenty inches in length, in
order to take off the weight of its column of blood. It is ordinarily a
simple matter to clamp and tie each branch as it is divided, and, after
removal of the principal trunk, to bring together the entire incision
with subcutaneous or continuous sutures. In the same way numerous
incisions may be made in the leg. It is possible, however, to meet with
so many enlarged veins that the surgeon may feel that he cannot thus
eradicate each one. In such cases it is my custom to extirpate the
principal trunk or trunks involved above, and then to combine this with
_Schede’s suggestion to completely or partly circumcise the leg_, below
the knee, down to the deep fascia, cutting across every vein and tying
on each side those which bleed to any extent. After all these veins are
ligated the incision is usually brought together again, as above. By
this means all communication between the subcutaneous veins above and
below the line of incision is cut off. Wound healing is accompanied
by a temporary edema of the foot and leg, especially when these are
held down, and by more or less numbness of the skin due to division of
the cutaneous nerves; but circulation and nerve supply both rearrange
themselves in time, and the result is usually satisfactory.[28]
[28] _Extirpation of the Internal Saphenous._--Keller has quite
recently suggested a new method of extirpating these varicose veins
without extensive scarring. He exposes the vein at two points
a considerable distance apart, and ties above and below after
separating it from its surroundings. The vein is then cut below
the proximal end, the upper end of the section to be removed split
and a strong ligature tied to it, care being taken to include no
more tissue in the ligature than will pass through the lumen of
the vessel. Then from the lower end a wire loop or probe is passed
upward, a ligature is threaded into its eye and the probe is then
withdrawn, carrying the ligature, after which traction is made upon
the latter, the edges of the vein being inverted into its own lumen,
it being thus extirpated by being turned inside out and withdrawn
from its sheath. With the internal saphenous, when a slight puckering
is seen about midway between the incisions, indicating that the
anterior branch of the vessel has been reached, a third incision
is made, the branch is ligated and divided, and then the traction
renewed until the vein is entirely pulled through the lower opening.
Several cases thus treated have been very successful.
Should ulcer, _i. e._, the so-called _varicose ulcer_, be present, it
may also be attacked radically, and at the same time completely, by
_excising_ the affected area, _with its indurated border_, down to the
level of the deep fascia, and covering the surface thus denuded with
Thiersch skin grafts from some other portion of the body. Should such
an ulcer require treatment after this fashion it is best to attend
to excision of the infected area first, in order to clear away all
material which might harbor germs. The usual procedure, then, should
be excision of the ulcer, extirpation of the veins, to be concluded
by skin grafting. A limb thus radically treated should be included in
a comfortable dressing, and then be affixed to some splint or other
device by which absolute rest and repose may be maintained.
In milder cases, where no single large dilated vein seems to call for
extirpation, it may suffice to practise Schede’s operation alone.
Experience has taught this fact, that in dealing with extensive varices
the surgeon is more likely to err on the side of leniency than on that
of thoroughness.
VENOUS ANGIOMAS.
These have already been mentioned in the chapter on Tumors as
constituting one variety of the angiomas. Many of them are of
congenital origin. In many instances they produce erectile tumors.
They frequently occur in the liver, in the thyroid, and other internal
organs, as well as on the body surface.
A venous tumor, composed of good-sized veins, distended perhaps far
beyond their normal capacity, constitutes a _compound varix_, of which
the best expression is a hemorrhoid or a varicocele. Another form is
composed almost entirely of capillary veins, which are increased not
only in size but also in number. These constitute the growths called
“_mothers’ marks_,” “_strawberry growths_,” etc. Technically they are
_venous nevi_, which vary in size from trifling lesions to large tumors
of varying shapes. These growths are always most conspicuous about
the hands and face, because these are the visible parts of the body.
They may, however, occur at any point, but mainly about the face and
the orbit. A diffuse form, whose area may be almost unlimited, but
usually circumscribed, is that called “port-wine mark,” which occurs
more frequently about the face. It has been attributed to mental
impressions during pregnancy, but there seems little to justify this
view. The affected surface is sometimes pigmented and generally more
hairy. Surface markings of this kind may accompany that form of neuroma
described as plexiform neuroma. Fig. 183, from Holloway, illustrates
another form of congenital growth of this kind. These growths rarely
occur in the nasopharynx, where they not only obstruct but are sources
of actual danger from hemorrhage.
[Illustration: FIG. 183
Congenital venous nevus. (Holloway).]
=Treatment.=--The most satisfactory treatment of a limited growth of
this kind is _excision_, especially if this can be made at an early
age. The resulting scar will be smaller, the healing more prompt, and
the result in every way better. When excision seems impracticable
_electrolysis_ should be employed, one or both poles of a galvanic
battery of six to ten cells being connected with needles, which are
inserted directly into the growth, and whose position is constantly
changed, so that the coagulating effect of the electric current may be
equably distributed throughout the growth. Occasionally the growth may
be so shaped as to permit of _ligature_, and it is best employed either
with or without the use of a needle, after which it may be excised or
will slough off. This is essentially one method of treating external
hemorrhoids. Methods by injection of coagulants are all open to serious
objection, are hazardous, and should be abandoned. A port-wine mark may
be sometimes treated by a tattooing process, which should, however, be
practised with strict antiseptic precautions. Electrolysis may also be
practised over a small area at a time. The more destructive method, by
use of the cautery, is likely to leave scars almost as conspicuous as
the original condition. Occasionally a lesion of this kind will be so
shaped and placed as to justify excision with an autoplastic operation.
CHAPTER XXX.
INJURIES AND DISEASES OF THE LYMPH VESSELS AND NODES.
An appreciation of the pathology of the lymphatic system requires
a brief allusion here to the latest investigations and conclusions
regarding the purpose of the lymph as a fluid and the channels by
which it is distributed. Under the term lymph, Hall has included four
different types: (1) Tissue lymph, which fills the intercellular spaces
throughout the body; (2) circulating lymph, which passes through
the lymphatic capillaries into the circulatory system by way of the
thoracic duct; (3) chyle, or the peculiar circulating lymph of the
intestinal tract, which carries into the general circulation its load
of nutritive material; (4) serous lymph, _i. e._, the contents of the
serous cavities. Closely related to the latter are the aqueous humor,
the cerebrospinal and the synovial fluids. All these fluids, except
chyle, contain at least 95 per cent. of water and nearly 4 per cent. of
proteids.
The lymph is the only fluid which comes into contact with all the
living cells of the body; it pervades every part of its substance
to such an extent that it has been said that the higher animals are
essentially aquatic because they practically live in a watery medium.
Blood normally comes into contact only with the endothelial cells
of the vessels and with those cells in the splenic pulp and perhaps
other localities which have to do with its elaboration, and these are
but a minute proportion of the total cells of the body. All the rest
receive their nutrition and even their oxygen through the lymph, which
receives them from the blood. Moreover, nearly all the waste materials
of the body are emptied into the lymphatic system, and thus directly
or indirectly find their way into the blood to be further extruded.
Thus, with the exception of the endothelium, the lymph is the medium of
exchange between blood and tissue. In this the lymph and the lymphatics
play a role which even for the surgeon must be of the greatest
importance.
The amount of lymph which empties into the vena cava from the thoracic
duct represents only that which comes from the viscera, bearing its
special load of nutritive material. When we consider the communication
between the blood-vascular and the lymph-vascular systems, the
promptitude with which material injected into the tissues (_e. g._,
salt solution) is taken up by the lymphatics and its effects made known
through the bloodvessels, we will better appreciate how deleterious
material also can be quickly distributed through the system. The lymph
then must be regarded as a fluid derived from the blood by combined
filtration and osmosis, which makes its way back into the blood again
with equal ease.
Lymph vessels which are sufficiently large to be recognized have thin
walls and are provided with valves like the veins, the lymph stream
being propelled by a _vis a tergo_ from the heart. Any injury which
permits blood to escape will also injure numerous minute lymph vessels;
in fact, in such little maneuvers as vaccination the attempt is made to
draw lymph alone and not blood. If a large lymph trunk be divided there
may be an outpour of lymph, and if this happen to be the _thoracic
duct_ the external escape of its lymph stream may seriously interfere
with nutrition. Injuries which divide it within the thorax are usually
fatal, but it may be divided in the neck by a puncture or stab wound,
or during a deep operation. Escape of lymph into the abdominal cavity
under similar circumstances gives rise to _chylous ascites_, and when
into the thorax to _chylous hydrothorax_. In the former case repeated
tapping may tide over the emergency and lead to eventual recovery; in
the latter, aspiration or even open incision may be necessary. When
the thoracic duct has been injured in the neck it may be possible to
close the opening with sutures or to suture tissues over it. In a few
instances final recovery has followed the formation of a _chylous
fistula_. Injury to this duct is to be recognized by the flow of milky
(_i. e._, chylous) fluid from the wound or from the duct itself. When
poured into the abdomen or the thorax the retained fluid has the same
milky appearance. It has been suggested to withhold all food in order
to favor the spontaneous closure of such an opening, supporting the
patient meanwhile by rectal nourishment and by the introduction of milk
into the veins. The right lymphatic duct is less liable to injury, and
such lesions on the right side would be of less importance.
[Illustration: PLATE XXXI
Diagram of the Nodes and Vessels of the Head and Neck, showing the
Regions that are Drained into Each Group of Nodes. Deep structures in
red, superficial in black. (Gerrish.)]
[Illustration: PLATE XXXII
Diagram of the Nodes of the Right Upper Limb and their Superficial
Tributaries, showing the Areas Drained by Each Group. Deep structures
in red, superficial in black.
Diagram of the Superficial Inguinal and the Popliteal Nodes of the
Right Side and their Superficial Tributaries, showing Areas Drained by
Each Subgroup. Deep structures in red, superficial in black. Frequent
variations in dotted lines. (Gerrish.)]
[Illustration: PLATE XXXIII.
Diagram of the nodes of the trunk and their tributary vessels. (F. H.
G.)]
THE ARRANGEMENT OF THE LYMPH VESSELS AND NODES.
Inasmuch as most of the surgical infections, including cancer, are
disseminated by means of the lymph vessels it is necessary that the
surgeon should know the relation of vessels and nodes to the other
parts of the body. The surgical anatomy of the lymphatics can be
appreciated by reference to Gerrish’s admirable diagrams. (See Plates
XXXI, XXXII, and XXXIII.) They will indicate at a glance what it would
take pages to describe. The reader should also make frequent reference
to these diagrams in connection with studies of septic infection,
tuberculosis, and especially of cancer.
OCCLUSION OF LYMPH VESSELS.
Occlusion of lymph vessel; may be either _congenital_ or _acquired_.
The congenital type is of extreme interest pathologically, but perhaps
of less interest to the surgeon, since it rarely permits of a surgical
remedy. The reader interested in this subject should consult the
writings of Busey, who has contributed memorable monographs on the
general subject of occlusion of the lymphatics. The acquired forms have
to do with various conditions, such as thickening of vascular walls,
the pressure of exudates or of tumors, or even of callus, and with
the specific infections, of which syphilis and cancer are perhaps the
most illustrative. The result which is brought about by these various
causes is not so much the dilatation of the vessels as the saturation
or water-logging of the tissues on the distal side of the obstructive
lesion. The former is indicated by the formation of vesicles or bullæ
which will frequently ooze or weep continuously. Should the pressure
be localized and circumstances favor it, a truly cystic collection of
fluid may result. The more common type is the so-called _lymphedema_,
which, when chronic, is always accompanied by hyperplasia of the
affected tissues, their overgrowth resulting from a superabundance of
nutrition, the connective tissue apparently appropriating the larger
amount of this material for itself. Therefore with the dimensions
of a member enormously increased it will be found that almost every
other tissue except the connective has been starved out. Lymphedema
differs from that produced by venous obstruction by its obstinacy
and the density of the infiltration; in fact, it has been sometimes
spoken of as solid edema. If it continues for some time there are
permanent changes which do not admit of later dispersion, and permanent
enlargement is the result. The most unmistakable expressions of this
kind occur in the legs and the external genitals of both sexes (Fig.
184).
[Illustration: FIG. 184
Lymphedema.]
When compression, position, massage, and such measures fail the only
other resort is amputation.
LYMPHANGIECTASIS AND ELEPHANTIASIS.
These terms refer to dilatation of the lymphatics, with a minimum
of actual obstruction, often as a sequence of some previous lesion
which has disappeared. In some of its expressions the condition is a
manifestation of a widespread general disease or a parasitic infection.
This is particularly true in those forms due to the presence of filariæ
in the blood, in which it is not a question of the obstruction of one
of a series of vessels, but plugging of a number of them by the adult
worms, which reside especially in the larger lymph and chyle passages,
sometimes even causing the appearance of chyle in the urine.
_Elephantiasis_ is an expressive term given to any enormous enlargement
of a part of the body, due to a combination of causes, of which
lymphatic dilatation and obstruction together constitute the most
important feature. The so-called congenital forms may have to do
with congenital deviations from the normal standard, but should be
differentiated from instances of gigantism, which have already been
alluded to in Chapter I, into whose etiology different factors probably
enter.
[Illustration: FIG. 185
Elephantiasis of leg, scrotum, and penis.]
[Illustration: FIG. 186
Elephantiasis of hand, acquired.]
Of the acquired forms of elephantiasis, those seen in the tropics are
nearly all expressions of filariasis. Sporadic instances are met with
in colder climates, and a condition resembling it is occasionally
observed for which no existing cause can be detected. Such a case
is illustrated in Fig. 186, which occurred in a convict in the
penitentiary in Buffalo, who had never been outside the limits of the
county, and in whom no parasites could be detected. Figs. 185, 187, and
188 illustrate typical instances of elephantiasis, Fig. 188 being taken
from a Klamath Indian woman in the Northwest Territory, the condition
being similar to that met with in the tropics.
The worms belong to the nematoids, the adult being 0.03 or thereabouts
in length, thinner than the diameter of a red corpuscle, rarely
remaining long in the quiescent state. They can thus pass into the
capillaries, which they may plug. The mosquito is discovered to be
the medium of transportation, either directly or indirectly, through
exposed drinking water, where the insect deposits her infected eggs.
The adult worms outside the body may attain a length of 1 Cm. From
the intestinal canal they pass into the lymph current and are carried
until their progress is checked, where they establish a permanent home
and breed and act as local irritants. The embryos which they produce
are innocent; it is the adult and parent organisms that produce the
damage. Lymph flow being thus obstructed the area previously drained by
a given vessel will undergo various changes in the direction already
described. In proportion, then, to the number of adult worms, and in
accordance with their location, will be involvement of an entire member
or of a more limited area, _e. g._, lymph scrotum (Fig. 187) or chylous
hydrocele.
[Illustration: FIG. 187
Elephantiasis of scrotum.]
[Illustration: FIG. 188
Elephantiasis of vulva (Klamath Indian woman).
(Contributed by Dr. H. L. Raymond, U. S. A.)]
As yet there is no cure for filariasis; hence there is no relief for
elephantiasis produced by it, except, when localized, to remove the
part. In the tropical forms it is the lower part of the body which
is usually involved. It begins in a limb, usually in the toes. It
produces discomfort rather than actual pain, at least until such time
as distention of the parts becomes unbearable. Along with lymphatic
engorgement there is a peculiar liability to erysipelas, which becomes
an exceedingly serious malady in tissues so saturated with lymph,
and with such possibility for the propagation of germs. A milder
degree of cutaneous and subcutaneous infection than is implied by
the term erysipelas, as used in this work, may be called erysipeloid
or cellulitis; it is quite common and frequently recurs. With each
attack of this kind the condition is aggravated and the limits of the
lesion extend. After a time the member becomes enlarged to a degree
which disables, while the skin itself undergoes changes that alter
its appearance; not only is it thickened, but there develop upon it
papillomatous projections, with infiltration of the corium, that give
it an unnatural appearance and feeling. Epithelial proliferation is
also rapid, and is accompanied by a sort of caseous discharge which may
decompose and add extremely offensive features to these cases.
The management of these cases becomes very difficult. Total disability
finally succeeds inability, and patients in the last stages are often
bedridden. The repeated attacks of erysipeloid should be treated with
antiseptic applications and elevation of the part, but without too much
compression, as germs may be forced into the circulation.
In elephantiasis of the lower extremities it has been suggested to tie
the femoral arteries, hoping thereby to deprive the limb of at least a
portion of its fluid supply. This may be of some avail early, but when
it is done late it is likely to be followed by gangrene of the limb,
from whose consequences not even amputation can save the patient.
In the tropics, especially where the external genitals are sometimes
involved, extensive operations have been of great service, and among
the surgeons of India reports of operations of this kind are frequent.
[Illustration: FIG. 189
Elephantiasis (“Barbadoes leg”). (E. J. Meyer.)]
Elephantiasis is most common in men; occurring in women it is not
limited to the external genitals, for the writer has seen illustrations
of the disease in the legs alone. In the Western Hemisphere it is met
frequently in the Barbadoes, and is called _Barbadoes leg_ (Fig. 189).
The principal dangers from operations on these cases pertain to the
risks of hemorrhage, shock, and infection. Nothing short of amputation
of limbs or ablation of the genitals is of real benefit. In all these
operations the veins as well as the arteries should be ligated, and the
ligatures used _en masse_, introduced with a needle. There is usually
copious oozing, and drainage should be provided.
CHYLOCELE.
This term is applied to a condition also referred to as _chylous
hydrocele_. It implies a collection of milky fluid in the cavity of
the tunica vaginalis. Occurring in a patient known to be suffering
from filariasis it may be diagnosticated before exploration. In some
instances where the sac of fluid is less translucent than usual, if
the candle test fail when applied, chylocele may be suspected. Careful
examination of the sac may show widely opened lymph vessels or lymph
spaces. It is to be distinguished from spermatocele, whose contents
also are milky fluid, but rarely collecting to the same amount.
Chylocele may be treated by tapping, or by open division or extirpation
of the sac, exactly as recommended elsewhere for the treatment of
hydrocele. (See Fig. 187.)
Chylocele is to be distinguished from _lymph scrotum_, which is
a form of localized lymphangitis of mild degree rather than a
circumscribed collection of chylous fluid. It presents febrile, not to
say inflammatory features, and in the chronic form the skin will be
frequently seen to ooze fluid closely resembling lymph, which condition
is called lymphorrhagia. The scrotum rarely becomes as large as in
extreme cases of dropsy, and yet may assume an uncomfortable size. This
condition, like that previously mentioned, is usually associated with
filariæ. It may appear, however, spontaneously, and after persisting
for a long time disappear, with as little apparent reason as that which
produced it. When the condition becomes unbearable ablation may be
practised. (See Fig. 187.)
CHYLURIA.
The presence of chyle in the urine gives it an appearance as if
emulsified oil had been mixed with it. It occurs with or without known
reason. Sometimes it co-exists with lesions like lymph scrotum, etc.;
at other times it seems to neither produce nor be accompanied by
other disturbances. Ordinarily the urine or the blood when examined
_at night_--_i. e._, the sleeping hours-will reveal the pathogenic
organisms, _i. e._, filariæ. It is a condition but little influenced
by treatment, which should be symptomatic in the absence of special
indications.
MACROMELIA.
The more typical congenital forms of occlusion of lymph vessels produce
such changes as we see, for instance, in macrochilia, where the lips
and cheeks are affected; macroglossia, where the tongue is too large
to be retained inside the mouth; and sometimes macrodactylia and
macropodia, where the fingers and hands or toes and feet are involved
(Figs. 190 and 191). It is difficult to separate some of these cases
from gigantism, as already stated. The more distinctive lymphatic
lesions are frequently accompanied by pigmentary, cutaneous, or
papillomatous conditions, which stamp them as something more than mere
expressions of disproportionate growth. The patient of Dr. Gerrish,
whose condition is illustrated in Fig. 190, presented lesions which
might be assigned to either of these groups. It will usually require a
careful study to make a proper assignment of such cases as macromelia.
[Illustration: FIG. 190
Macromelia. (Gerrish.)]
[Illustration: FIG. 191
Macroglossia. (Neisser.)]
MACROCHEILIA.
While this condition is usually regarded as an expression of
lymphangiectasis, it has been shown that it may be due to multiple
adenopathy of the mucous glands in the lips. The lips are well supplied
with such glands, which lie beneath mucous membrane in a mixture of
more or less connective and vascular tissue. When the lips undergo
marked hypertrophy in adult life, it is very likely that the affection
may be explained by the hypertrophy of these collective glands, and
this is particularly true when anything like nodular arrangement can be
detected. A recognition of this cause will indicate the proper remedy,
_i. e._, excision of the affected tissue. The writer has on more than
one occasion made an elliptical incision both from the lower and upper
lip and accomplished its purpose, with great improvement of appearance.
LYMPHANGIOMA.
Lymphangioma has been described in the chapter on Tumors. It seems
necessary to allude to but one expression of this kind in this place,
_i. e._, the so-called _lymphangioma circumscriptum_. This presents as
a cutaneous area dotted with vesicles, sometimes regularly, sometimes
irregularly distributed, usually in annular form, seen most commonly
on the upper limbs and in the region of the shoulders. The vesicles
occasionally become sufficiently large to be called bullæ, while the
contained bloodvessels are dilated and discolor the area involved,
which may also be more or less pigmented. Here, as in elephantiasis,
there is great liability to surface infection of low grade, which
may perhaps be called erysipeloid. The tissues gradually become
thickened and covered with scabs or warty collections of epithelium.
It is met with early in life, rather than late, and is supposed to
be of congenital origin. It may be distinguished from herpes by the
pronounced vascular changes and by the discharge of lymph.
=Treatment.=--Treatment has been too often unsatisfactory and the
trouble often re-appears after apparent recovery. If the area involved
be not too large complete excision will probably prove the most
satisfactory method of attack.
LYMPHANGITIS.
This term applies rather to gross and visible lesions of the larger
lymphatics than to the involvement of the ultimate lymph-filled
ramifications. When the smaller lymph capillaries and interspaces are
involved the lesion takes the type of an erysipelas or cellulitis,
but as the collected products return through the lymph channels from
such an involved area they will disturb and infect the lymph vessels
themselves, and this leads to what is called a lymphangitis. Formerly
the term spontaneous or idiopathic was given to some of these cases.
Assuming, as is done throughout this work, that there is no true
inflammation that is not of microbic origin, we may expunge the term
“idiopathic” and say that lymphangitis is also an expression of
infection, and that the inflamed vessel represents a channel through
which products of inflammation are being conveyed. Histologically the
walls of these vessels become infiltrated with a coagulating exudate,
which may completely occlude the vessel. The bloodvessels immediately
adjoining the lymphatics also become involved, and, being engorged,
give rise to the peculiar red lines or streaks which are frequently
seen when cutaneous lymphatics are thus involved, this appearance
being due to a _perilymphangitis_. The infected lymph passing through
this channel is filtered out in the first lymph nodes with which it
communicates, which themselves become thus infected; hence the rapidity
with which these enlarge and break down, so that by their own sacrifice
they may perhaps protect the rest of the body from serious infection.
Under these circumstances suppuration and necrosis of these lymph nodes
is to be regarded as a vicarious destruction on their own part.
Lymphangitis proceeds from the periphery toward the centre, and is
followed by a certain amount of pain, with great soreness and sense
of stiffness in the parts; the skin overlying the infected vessels
becomes reddened in streaks, which indicate their course, or becomes
more or less infiltrated and involved throughout in a form of
infectious dermatitis. According to the virulence of the germ, and the
susceptibility of the individual and his tissues, there will or will
not occur suppuration. This may perhaps be averted by prompt treatment.
Should deep tenderness and pain take the place of or be added to their
more superficial expressions it may be inferred that the superficial
lymphatics have now infected the deeper ones, and that there is greater
danger of phlebitis and a generalized septic infection.
Constitutionally, at least, the expressions are those of septic
intoxication, often of true septicemia or septic infection. Local
appearances, increasing temperature, or accession of chills may
indicate the presence of pus.
In proportion to the distance of the diseased part from the body
centres the prognosis becomes more favorable. When an entire limb is
involved the matter is very serious; when in the face or abdomen, still
more so, the fear being of septic phlebitis and a fatal termination by
a more or less typical pyemic process.
=Treatment.=--All exciting causes, including sloughing tissues, foreign
bodies, pus, etc., should be thoroughly removed. Pus, when present,
should be evacuated, and when its presence is suspected suitable
exploration should be made. Tension should always be relieved by
incision. In cases where breaking down has already begun, continuous
immersion in hot water is beneficial. Nothing, however, will take the
place of removal of pus or necrotic tissue, and this should be first
attended to or proved to be unnecessary. In an open and sloughing
wound nothing is as satisfactory as brewers’ yeast; next to this is
hot water. Over an unbroken area which is simply edematous and pits
on pressure, may be applied the ichthyol-mercurial ointment (10 per
cent. ichthyol, 40 per cent. mercurial ointment) or the Credé silver
ointment. This should not be rubbed in, but smeared freely over the
surface, and then covered with oiled silk, twice daily, in acute cases.
The surgeon should satisfy himself as to the presence or absence
of pus; even when only suspected it is advisable to make incision
early, as tissue and possibly life may thus be saved. Constitutional
treatment should not be neglected. It will consist in improving
elimination, maintaining nutrition, and overcoming the acute toxemia
due to absorption, the toxins being best antidoted by alcohol in some
palatable form, strychnine and quinine being serviceable, but not so
valuable. (See chapter on Septic Infections.)
=Chronic Lymphangitis.=--Chronic lymphangitis is seen in connection
with the slower infections, tuberculosis--syphilis, filariasis, etc.
Here the lymph vessels are not involved so much as the lymph nodes.
Chronic lymphangitis does not occur without a toxic or infectious
process behind it.
LYMPH NODES.
For the surgeon’s purpose, at least, he may assume that lymph nodes
are never enlarged except in the presence of toxemic or infectious
processes. The role which they play as filters of the fluid returning
through the lymph vessels subjects them to daily possibilities of
contamination. They may be acutely infected and actually break down by
a phlegmonous process, or their lesions may be very slow, chronic, and
intractable. The lymph nodes, like the leukocytes, are among our best
friends; they serve as guardians at the various portals of the system,
excluding, sometimes at the risk of their own existence, various
deleterious elements.
The term “lymph gland” should be expunged from medical terminology,
the node having, so far as known, no secretion nor any title to be
considered a gland. This would mean abandonment also of the expression
“lymphadenitis,” and so the writer would prefer to use the expressions
lymphitis, lymphangitis, etc., which at least do not imply a wrong
conception of the process. The morbid activity which the lymph nodes
present will be an expression of the general virulence of the whole
process which has produced it. To a tender enlargement, in acute
cases, there will succeed rapid swelling, with pain and soreness
commensurate with the density of the surrounding tissues and the degree
of tension thus produced. The result is essentially an abscess, or
multiple abscess, which necessitates prompt treatment by free incision,
evacuation, and drainage, as does any other abscess. It is as often
necessary to use a curette as a knife, and when so-called specific
features are present, as in chancroidal bubo, a strong antiseptic
should also be used. Under these conditions the collection of lymph
nodes in the axilla or in the groin may become involved in multiple
abscess, and it is then good practice to make a complete cleaning
out of these regions. The ultimate effect of such extirpation is
beneficial, and the patient does not seem to suffer from the loss of
the involved lymph nodes; indeed, it is probable that new ones form to
replace those which are destroyed.
The _chronic affections of the lymphatics_ which come under the
surgeon’s care are expressions of tuberculosis, syphilis, gonorrhea,
cancer, or of some of the other less frequent surgical diseases. In
every one of these instances the disease has assumed constitutional
proportions, and the lymph-node involvement will be general. The
ultimate fate of these affected nodes will differ with the different
diseases; in _tuberculosis_ they sometimes suppurate by secondary
infection, and they frequently caseate, or remain enlarged for
indefinite periods, often throughout life. Around them will be found
an area of infiltration which produces firm adhesions and frequently
makes their extirpation very difficult. The lymph vessels which connect
the various nodes will also be involved in a similar process, which
adds to the difficulty of operation. In many cases these involved
nodes can be felt where they cannot be attacked--for example, in tabes
mesenterica. If, under suitable climatic and constitutional conditions,
it be possible to favorably affect other tuberculous conditions, these
expressions of the disease may also subside or at least cease to
trouble.[29]
[29] At date of going to press I do not feel justified in lauding too
highly the work done by numerous workers with the _opsonins_. Justice
to what has been done with and claimed for them demands, however,
their extensive trial, and suspension of any judgment not as yet
favorable.
_Syphilis of the lymph nodes_ has already been considered, as well
as the frequency, nay, the certainty, with which the lymphatics
become involved in this disease. So true is this that any general
lymphatic involvement which cannot be accounted for in some other
manner is usually attributable to syphilis. The condition of the
lymphatics may be considered a fair index as to the success and
effect of antisyphilitic treatment, for if, under such treatment,
these enlargements subside completely it may be regarded as eminently
successful. On the other hand, it is not felt by many that it is
safe to discontinue treatment in the presence of these enlargements.
Syphilitic enlargements may, moreover, undergo secondary infection,
either acute or chronic, _i. e._, may suppurate or become tuberculous.
In _gonorrheal bubo_ the pus which the lymph-node abscesses contain
will often be found almost a pure culture of the gonococcus, thus
illustrating the specificity of this kind of infection.
The extent to which the lymphatics are involved in cases of cancer
will often be the guide for the surgeon in advising removal or the
reverse. The principal advance in the modern operative surgery of
cancer has come through a better working knowledge of the area of
lymph distribution of given regions. All cancerous lymph nodes which
can be reached should be extirpated. If others can be discovered which
are beyond reach it raises a doubt whether the operation should be
performed. At all events, in these cases it should be represented as a
temporary rather than an absolutely curative resort, not only because
this is true, but because the surgeon may need to protect himself
against charges which may be made later by disappointed patients.
The advisability of removing diseased lymph nodes is often a matter
for serious discussion. There is little to justify their removal when
the exciting cause cannot also be taken with them. It is a mistake to
operate on nodes in the neck and leave diseased teeth through which
the infection may be spread. So, too, it is a mistake to operate on
nodes which may prove to be syphilitic. In many instances, then, it is
best to apply the therapeutic test. In cancerous disease it can rarely
be advisable to remove lymph nodes alone except for purely temporary
purposes, as to check hemorrhage, remove breaking-down material, or
something of the kind. In the neck, groin, or axilla the operation is
not to be lightly undertaken, for it is made extremely difficult by
adhesion of the surrounding structures. The surgeon should be prepared
then for careful dissection, which should be made with a not too sharp
knife, and he should be ready to sew up a rent in the jugular vein or
tie it, as it and its large branches are frequently so displaced and
obscured as to be injured, even by the most careful operator.
HODGKIN’S DISEASE.
This is one of many names applied to a condition whose most conspicuous
characteristics are a progressive anemia, with enlargement of lymph
nodes, as well as usually of the spleen, with secondary or metastatic
growths in the viscera, bone-marrow, and elsewhere. That its
etiology hitherto has been considered obscure and that its clinical
characteristics vary in different cases may be shown by a partial list
of the names by which it has been previously known: _lymphadenoma_,
_malignant lymphoma_, _infective lymphoma_, _progressive glandular
hypertrophy_, _lymphosarcoma_, and _pseudoleukocythemia_. To the
writer’s mind, if the disease is to be known by any other name rather
than that of the one who first described it, it might be called
malignant lymphomatosis, as its tendency is downward, in which sense it
is malignant in an almost hopeless degree.
The changes which occur in the blood are at first in the direction of
simple anemia, followed by marked reduction in the number of red cells,
with poverty of hemoglobin and increase in the number of leukocytes.
In the anemia of extreme cases the red cells may be reduced 1,000,000
per Cm., while the leukocytes, especially the polynuclear forms, may be
numbered by the hundreds of thousands. In one case recently under my
observation the leukocytes amounted to about 300,000 when treatment was
begun. (See chapter on the Blood.) It is a disease of early rather than
of later life, and occurs more often in males than in females. The most
pronounced objective changes occur in the lymph nodes, which enlarge
steadily, the swellings thus formed being hard or soft according to
the rapidity of the disease. The swellings thus formed will appear
conspicuously in the neck and will be noted also in the axilla and the
groin. Careful examination will show that every lymph node in the body
which is accessible is involved in the course of the disease. Sometimes
the tumors become so large as to cause serious pressure, and when in
the neck perhaps to require tracheotomy to prevent suffocation. Fig.
192 illustrates a case under the writer’s observation, in which he had
to resort to this emergency measure. The microscopic picture of this
enlargement is that of hyperplasia of the tissues composing the lymph
nodes, while the lymphoid cells are multiplied in number.[30]
[30] Pathologists have long suspected that Hodgkin’s disease and
sarcoma have, at least, certain features in common if they are
not more or less actually associated in character. Yamasaki has
recently reported several cases of typical Hodgkin’s disease without
any suspicion of tuberculosis, in which there were unmistakable
sarcomatous formations in various parts of the body, especially in
the viscera, and he believes, as do others, that the affection which
begins as Hodgkin’s disease may later assume the characteristics of a
general sarcomatosis.
[Illustration: FIG. 192
Hodgkin’s disease.]
Less conspicuous but equally distinctive changes occur in the spleen in
four-fifths of the cases, it becoming enormously enlarged and occupying
the left half of the abdominal cavity, being universally enlarged and
preserving its original outlines. This splenic enlargement sometimes
is simply an hypertrophy, but in many instances the spleen itself will
be occupied by tumors, _i. e._, lymphomas, which are scattered through
it and cause part of its enormous dimensions. Late in the disease the
liver also becomes enlarged and lymphomas are also scattered throughout
its substance. The same lymphomatous or adenoid tissue may be met with
in many other parts of the body, the bone-marrow, the alimentary canal,
the ductless glands, kidney, lung, etc.
Hodgkin’s disease is doubtless closely related to other varieties of
leukemia and to Banti’s disease, or splenic anemia, all of which should
be regarded as expressions of an infection by organisms not yet clearly
described, although their better recognition and identification are
clearly foreshadowed in work now under way. Death comes as the result
of the exhaustion and poisoning of a terminal infection, save when it
is produced earlier by absolute starvation or suffocation. To run its
entire course an average case consumes from eighteen months to two and
a half years.
=Diagnosis.=--So far as diagnosis is concerned the microscope will
serve a certain purpose even early in the disease, enabling one
to recognize an increasing anemia and leukocytosis, but not until
perceptible enlargement of lymph nodes and of the spleen is found
can the diagnosis be made absolutely certain. One has to distinguish
mainly between those forms of leukemia in which lymphomatous changes
are not conspicuous, cachexia of cancer and syphilis, and the condition
of lymphosarcoma, as it has been called by some, in which there is the
involvement of the lymph nodes without the characteristic blood changes
met with in Hodgkin’s disease. In splenomegaly we may have enormous
enlargement of the spleen without the marked involvement of the lymph
nodes. From lymphatic tuberculosis it is to be distinguished by absence
of fever, the tendency to universal involvement of the lymphoid tissues
in all parts of the body, and the absence of suppuration and caseation
which occur so distinctively in tuberculous disease.
=Treatment.=--Few drugs are of much or any avail in this disease. Of
them all nothing compares with arsenic, which should be given for a
long period and pushed to the physiological limit. The formula which
was given in the chapter on Cancer will serve in the treatment of
Hodgkin’s disease (p. 296, note). Next to this, and especially in
patients with enlargement of the spleen, the _x_-rays are the most
effective. In one case much of this character, in which I began active
treatment by both methods, I saw in forty-eight hours a diminution of
100,000 leukocytes. This did not persist, however, for the proportion
was later somewhat increased, but the immediate effect as well as the
benefit were very pronounced. All the affected regions may be exposed
to the x-rays, which should be used with great care.
TUMORS OF THE LYMPHATICS.
The term _lymphoma_ has been indiscriminately ascribed to various
enlargements of the lymph nodes and lymphoid tissue throughout the
body, so much so as to have really lost its significance. If by the
term is meant simply a tumor of a lymph node it will usually fall
under the proper classification as being a granuloma, a syphiloma, a
carcinoma, etc. If by the term is meant a general involvement of lymph
tissue throughout the body, such as is seen in status lymphaticus, then
it would be best to use some other term. Finally it may be questioned
whether there is any distinctly marked lymphoma, _i. e._, a tumor of
true lymphatic structure, which is not of infectious origin. The term
_lymphosarcoma_ is still in use and probably will not be expunged until
our notions of pathology are clearer. The expression _lymphadenoma_
should be discarded. Multiple malignant lymphoma, as stated above, is
but another name for the condition ordinarily described as Hodgkin’s
disease. That sarcoma and endothelioma may arise in the lymph nodes is
universally conceded, although as primary neoplasms in these localities
they are rare. Not much can be said, then, that is distinctive about
lymphoma.
In a general way, it may be said of any tumors of the lymph nodes that
if isolated or not too multiple they should be extirpated.
CHAPTER XXXI.
SURGICAL DISEASES OF THE JOINTS AND JOINT STRUCTURES.
The joints, by virtue of their function and anatomical relations, are
liable to a variety of injuries and affections, most of which are
essentially surgical. The joints most subject to traumatism belong to
the extremities. On the other hand, the deeper joints (_e. g._, of
the spine) are quite prone to toxic and infectious diseases and less
liable to serious injury. The surgeon cannot disregard the structure of
the joint when considering the pathology of its surgical affections.
More or less completely protected externally, though sometimes with
but a thin coating of integument and fibrous textures, it is composed
largely of resistant, white, fibrous tissue, seen in its ligaments,
of spongy bone in the expanded bone ends, covered with cartilage of
incrustation, the articular termination of the bone shaft not being
firmly affixed until a certain age has been reached, while the interior
is lined with a serous membrane whose lymphatic connections are most
abundant, portions of which are often loaded with fat. In certain
joints--particularly the knee-there enter separate considerations in
the shape of interarticular cartilages which are not so firmly attached
but that they may be sometimes displaced.
Lymphatic connection between the exterior and the interior is often
free, and after trifling abrasions or infections of the overlying
skin the joint beneath may suffer seriously or even fatally. Many of
the surgical diseases of the joints begin within the joint membranes
proper, _i. e._, the synovia. Numerous other expressions, particularly
of tuberculosis, have their origin in the bony structure contiguous to
the joint cavity.
In any destructive affection of the joint in childhood the
corresponding epiphyses are often involved. This is also true of
fractures extending into joints or occurring near them in the young.
Below will be found a table of the time when the epiphyses are usually
consolidated with the main portion of the bone. In general, they unite
earlier in the upper limb than in the lower, or, as Sappey puts it, the
upper limb first arrives at maturity. The following table represents
simply the average, there being considerable variance on either side of
it in different individuals:
UPPER EXTREMITIES.
Clavicle 23d year.
Humerus, upper 20th year.
Humerus, lower 17th year.
Radius, upper 16th year.
Radius, lower 20th year.
Ulna, upper 16th year.
Ulna, lower 19th year.
Phalanges 18th to 20th year.
LOWER EXTREMITIES.
Femur, head and great trochanter 19th year.
Femur, lower epiphysis 21st year.
Tibia, upper 21st year.
Tibia, lower 18th year.
Fibula, upper 21st year.
Fibula, lower 20th year.
Phalanges 18th year.
These dates should be remembered, as an ununited epiphysis may be
involved in a necrotic or suppurative process and thus break down
and require removal. Moreover, these facts will also be of value in
considering fractures, for up to these dates epiphyseal separations
will often be met.
INJURIES TO JOINTS
=Sprains.=--A sprain is either the result of a momentary dislocation
of a joint, the parts returning immediately to their proper position,
or else is produced when a joint has been strained beyond its
probable physiological limit without any true displacement. It
may be the consequence of direct or indirect violence, or even of
incessant muscular action. It always implies a certain degree of
tissue injury, which may vary from minute lacerations of ligaments,
fasciæ, aponeuroses and periosteum, up to a degree where ligaments are
violently sundered or torn out of their bony attachments.
A sprain is generally followed by hyperemia, with its attendant
phenomena, as described in a previous chapter, and as long as
possibility of infection can be excluded the resulting outpour which
produces the extreme joint swelling will more or less quickly disappear.
In fact, as insisted throughout this work, the differences between
hyperemia and its consequences, and true inflammation with its results,
can nowhere be more perfectly demonstrated than in such a case as this.
Even with great damage and effusion there can be complete repair, so
long as infection is excluded. Once the germ element enter, the whole
aspect is altered and a serious feature is then introduced.
=Symptoms.=--The symptoms of sprain are loss of function, swelling,
pain, and later ecchymosis. The first is usually immediate, the
swelling takes place rapidly, and ecchymosis occurs after two or three
days, unless the joint be near the surface. The degree of tenderness
will afford a measure of the amount of damage done. The swelling may
be produced either by serous outpour or by hemorrhage, or by both.
Ecchymosis is usually due to minute lacerations, and may spread to
a considerable distance. Where there has been much outpour of blood
into a joint it sometimes produces a reactional hydrarthrosis, which
appears only after a week or more. Such hemorrhage is serious, and is
frequently the cause of more or less pseudo-ankylosis by organization
of clot.
Sprain may then be of all degrees of severity. From the mildest of
these one may expect perfect functional recovery in short time, while
in the more severe cases chronic thickening, with hydrarthrosis, tender
areas, and muscle atrophies, often persist for a long time or even
permanently.
=Treatment.=--The ordinary treatment of a sprain consists, first, in
physiological rest. If the swelling be already pronounced when seen
by the surgeon he will endeavor to promote absorption by elevation,
gentle compression, perhaps with an elastic bandage, and by cold wet
compresses. If seen _early_ and before much swelling has occurred it
will often give great relief, especially in certain joints (_e. g._,
the ankle), to partially immobilize the part by _strapping_ it with a
series of adhesive strips, 2 Cm. in width, cut sufficiently long to
encircle the foot, ankle, and lower part of the leg. The strapping
should be begun at the base of the toes, and each strap as thus applied
should be made to slightly overlie the preceding one. It is possible by
neatly compressing the involved region in this way to almost prevent
swelling, and to give such support that function is but slightly
impaired, and pain reduced to a minimum. The objection to plaster of
Paris or the more fixed dressings is that they are usually allowed to
remain too long. Far better in most of these cases is either a splint
or a dressing which permits of daily examination. With the subsidence
of acute symptoms, massage and passive movement should be practised.
There are cases in which swelling will be so extreme that aspiration or
even incision may be advisable for the purpose of emptying the joint.
The surgeon sees many a case of this kind after it has become chronic
and after domestic or simple applications have failed. Most of these
cases require massage, practised skilfully, and with intelligence, by
which absorption is much promoted. The same result, as well as relief
of soreness or pain, follows the constant use of cold wet compresses,
perhaps combined with the use of ice-bags. If the material used for
these compresses be dipped in solution of sodium or ammonium chloride,
say 5 per cent., the effect is much enhanced, while laudanum can also
be used upon them. Tenderness and localized pain in old cases may be
treated by a succession of blisters, but can be better treated by the
application of the _flying cautery_, _i. e._, by the light touch of a
glowing cautery point swept rapidly over the surface involved. This is
one of the most powerful agents for the relief of pain. Occasionally
the cautery point may be applied more deeply, _i. e._, _ignipuncture_.
If localized collections of fluid form they may be incised.
The statements and advice given in regard to sprain will apply equally
well to the ordinary contusions of joints.
PENETRATING WOUNDS OF THE JOINTS.
These are inflicted as are wounds elsewhere, and, while always serious,
have an importance proportionate to the infection which may have
occurred with the injury or afterward. In practise it may be assumed
that the skin, like the clothing outside, is always dirty and infected,
and that every penetrating wound should be regarded as an infected
wound. Not every wound in the vicinity of a joint is penetrating,
and it is advisable to ascertain whether a joint cavity be actually
open, as much of the method of treatment will depend upon this fact.
The majority of these injuries are of the punctured or small incised
variety. The actual joint opening is usually smaller than that in the
skin. It may be so small as to escape observation. Outflow of blood
is not pathognomonic, but escape of synovial fluid always indicates
that some serous cavity, possibly a bursa or tendon sheath, has been
opened. Immediate accumulation of fluid within a joint after probable
wounding of the synovial membrane is quite suggestive, as it is likely
to imply that the joint is filling with blood. After any injury which
may loosen them the epiphyses should be carefully examined, in order
to determine if they have been loosened, while it should be estimated,
so far as possible, whether the epiphyseal junction has been disturbed
or is probably infected. The student should remember that punctured
wounds of joints are not necessarily made from without inward. A
spicule or fragment of bone may, by protruding, produce exactly the
same condition, only in this case there may be a compound fracture to
complicate it. Infection does not invariably follow these injuries.
Their gravity is in large degree measured by the presence or absence of
a suppurative synovitis. This does not necessarily instantly follow the
injury, but develops within the ensuing two or three days. Therefore
the fate of such a joint is not necessarily determined by inspection
within the first few hours. Esmarch’s dictum regarding gunshot wounds
may here be paraphrased. _The fate of every punctured joint depends
upon the man who first takes care of it._ If the proper thing be done
promptly a good result may usually be obtained.
The first indication in every such case is _sterilization of the
parts_, including the area of the wound. If by a small elliptical
incision the wounded skin can be excised, it may perhaps very much
improve the prospect. A small punctured wound may be watched for a day
or two, especially if it be believed that the first attention were
prompt and antiseptic. Should no unpleasant features appear little need
be done except to apply ice externally and maintain rest. On the first
appearance of sepsis or of increasing trouble in the joint it should be
promptly incised, irrigated, and drained.
In the larger openings of joints it should be assumed from the outset
that infection has occurred. In such a case the wound margins should
be trimmed, the joint cavity thoroughly irrigated, and explored for
foreign bodies, by enlarging the existing opening. After thorough
irrigation a drain should be inserted for at least a few hours. For
this purpose a catgut strand or a drainage tube may be employed.
As soon as the _presence of pus_ (acute pyarthrosis) is made clear the
case takes on a larger aspect, in that drainage not alone at one point
is indicated, but probably at two or three. Nothing is so disastrous
to an involved joint as pus retained within its hidden recesses.
Almost every other consideration is sacrificed to its discovery and to
affording a means for its escape. Counteropenings in numbers sufficient
for the purpose are, therefore, indicated, and it will often be best to
draw through the affected joint a drainage tube, of a size sufficient
to prevent its occlusion by thick pus or debris. Daily and continuous
irrigation may be practised to great advantage, or, as is possible with
the ankle, the wrist, or elbow, continuous immersion may be substituted
as a still better measure. Wherever infection and destruction to this
degree have taken place it may be presumed that the future of the joint
is seriously compromised. There will, therefore, be room for display of
judgment as to when to begin passive and when active motion; moreover,
a guarded prognosis concerning restoration of function should be given.
_Gunshot fractures of joints_ constitute almost a category by
themselves. Under the old _regime_, and in the pre-antiseptic era,
gunshot wounds of joints condemned one to amputation and loss of
at least the part below. The mortality attending injuries of this
kind, with the resulting amputations, during our Civil War, and all
others previous to it, was extreme. The Continental surgeons first
appreciated the value of antiseptic occlusion, and taught the rest of
the world that this wholesale sacrifice of limb, and often of life,
was unnecessary and could be avoided. Reyher’s first papers on this
subject revolutionized previous views and practises, and established on
a firm basis the general principle of _primary antiseptic occlusion_ of
those injured joints. The accumulated experience of military surgeons
since his time, as well as of civil surgeons all over the world, has
demonstrated that if a gunshot wound of a joint be afforded prompt
antiseptic occlusion and _rest_ the chances are in favor of restoration
of function, with a minimum of disturbance and a maximum of result.
It was because of these results that soldiers were provided with the
“first aid to the injured” packets, so that a punctured wound might be
protected immediately after its reception. Even the complete tunnelling
of a joint, which the Mauser bullets so often accomplish, does not seem
to be so serious an injury today as was the puncture of a needle or
an awl in the pre-antiseptic era. Therefore the best thing to do with
a gunshot wound is to practise _antiseptic occlusion_. If it become
troublesome it should be treated in accordance with the advice given
above.
This relegates the matter of _amputation_ or of _primary excision_ of
an injured joint to those cases of extensive and mutilating injury
where not only the soft structures are widely opened and infected, but
the joint ends of the bones also are seriously involved. When it comes
to the treatment of _compound dislocations_ it is difficult to lay
down principles which shall be universally applicable. As a general
rule primary excision will usually be indicated, and prove not only
life-saving but limb-saving. In compound dislocations of the astragalus
its removal will be nearly always indicated. Only in cases of extensive
damage will amputation be necessary.
Inasmuch as it is _infection_, leading to suppurative synovitis or
arthritis, which gives to all serious cases their greatest dangers, it
will be sufficient at this point to remind the reader to this effect
and to describe the condition itself a little later.
SYNOVITIS AND ARTHRITIS.
The various surgical affections of a joint may be of primary or
secondary origin, and of rapid or chronic type. The acute are usually
expressions of serious infection, while the chronic are frequently
of toxemic origin, including under this heading manifestations of a
particular diathesis or defective metabolism. Others are so exceedingly
slow in their course and are so intimately connected with other
indications of disease of the central nervous system as to be called
_neuropathic_. (See below.)
Nearly all the acute affections begin in the synovial sac proper.
From this they may spread and involve the adjoining parts. The acute
toxic lesions also arise within the synovial cavity, such as those
which follow gonorrhea, typhoid, scarlatina, pneumonia, influenza,
etc. Tuberculosis may primarily affect either the synovia, in which
case we have a condition corresponding to tuberculous peritonitis, or
it may take its origin in the expanded bone ends or in the epiphyseal
cartilages. Syphilitic affections of the joints are rarely acute. They
lead rather to chronic disintegrations or hypertrophy. No matter how
the lesion may have arisen it will nearly always extend to and involve
other parts; thus in acute suppurations the articular cartilages are
soon attacked, while in the more chronic forms, which have their
origin in the bone, the joint cavity is slowly encroached upon and its
integrity impaired or destroyed.
So long as the type of joint disease be not destructive a complete
or nearly complete restoration of function can be expected, provided
suitable treatment be given early. If, however, a case occur only after
fibrinous outpour has organized into adhesions, muscles have withered
from disuse, and the entire joint become distorted or disarranged,
then it may be too late to cure, and it is a question then of how much
improvement can be effected. Even after acute suppuration, if the
case be properly managed from the outset, very useful joints can be
regained.
=Dry Synovitis.=--In synovitis, as in pleurisy, there may be a minimum
of serous outpour, such exudate as escapes into the joint being
exceedingly rich in fibrin and coagulating easily. This material is
variously disposed of, and may form adhesions which will limit motion,
or masses of condensed fibrin which may be broken up into shreds or
rounded off into seed-like or _rice-grain_ bodies. When tenderness
subsides sufficiently to permit it these may sometimes be felt within
the joint. At other times they lead later to an hydrarthrosis, which
may prove more or less disabling and require subsequent operation.
Another form of _synovitis sicca_ is met with in acute and perhaps
chronic rheumatism, where masses of fibrin become loosened and can be
felt as foreign bodies, or fringes, beneath the joint covering.
=Acute Synovitis.=--The ordinary acute synovitis is characterized by
more or less effusion, and corresponds to pleurisy with effusion. It
is the result usually of external injury, or it is combined with what
has already been described as sprain. The fluid outpour is watery, is
rarely blood-stained, save in cases of lacerations, usually distends
the joint capsule, often to a painful degree, but represents nothing
more than the consequences of hyperemia. If this fluid collection
can be protected from contamination by germs it will disappear under
suitable treatment, with a return to almost normal original conditions.
Let it once become contaminated, however, and the type of disease is
quickly changed, for there will then be an acute inflammation with its
attendant phenomena and consequences.
=Treatment.=--Cases of simple character are of short duration, _i.
e._, one to two weeks. If seen early they should be treated by gentle
compression and the application of ice-cold, wet compresses. Heat
applied at this time may give temporary comfort, but will encourage
effusion. Even if a joint thus affected be not seen until the swelling
is extreme, wet compresses will still afford the simplest and the
most comforting method of treatment, although they need not now be
kept cold; in fact, gentle heat may now promote absorption. If the
compresses be moistened in salt solution, to which a little alcohol
has been added, the stimulating effect will probably be still greater.
Such a joint needs to be placed at rest, save perhaps in the case of an
ankle-joint or wrist-joint, which may be snugly strapped after injury.
In some of these latter cases the patient can resume use of the joint
almost at once.
=Purulent Synovitis.=--This rarely begins as a purulent condition, but
may be the result of the non-inflammatory and non-purulent form. In
such a case the character of the fluid outpour soon merges into the
seropurulent, and later become almost nothing but pus. If the interior
of a joint could be inspected, under these conditions, the intensity
and extent of the vascularity and cellular changes going on within the
synovial membrane and beneath it would present a different picture from
that of the non-purulent form. The appearance of a joint interior,
under these circumstances, is similar to that of a well-marked purulent
conjunctivitis. Articular surfaces are quickly eroded or perforated,
while cartilages thus once affected are often loosened from their
attachments through necrosis and remain as foreign bodies in the fluid
collection. Even strong ligamentous tissues will melt down and become
so weakened as to permit a looseness of motion foreign to the natural
joint. In fact, as between purulent synovitis and acute suppurative
arthritis it is but a matter of extent of destruction, not of character
of lesion. In this way _pathological dislocations_ are produced,
sometimes even within a few days, being the combined result of
destruction of ligaments and the pull of muscles which are thrown into
reflex spasm by the presence of intra-articular disease. Not only do we
see caries of the exposed bone ends, but epiphyseal separations are not
uncommon in the young, while every structure around and outside of the
joint participates, even to the extent of abscess formation. Abscesses
may form without the joint and work into it, or the purulent collection
within may escape at points of least resistance and burrow, forming
perhaps numerous foci at some distance from the joint first affected.
If such a case is to be saved it will require numerous openings and
counteropenings, with free drainage, while even then there can be no
expectation of restoring joint function. There is, then, in these cases
at least a sacrifice of joint, sometimes of limb, and in neglected
cases of life itself.
=Symptoms.=--Of the large joints only the shoulder and hip, especially
the latter, are placed so deeply as not to permit of easy examination
and diagnosis. Pain, swelling, and loss of function, with or without
history of injury, will predominate in well-marked cases, while very
early in most, and promptly in all, there will occur reflex spasm of
those muscles which have to do with motion of the affected parts, by
which they become more or less fixed and beyond voluntary control of
the patient. This condition has been described by Sayre as “_muscles on
guard_.” It is a significant feature, and has as much to do with active
joint disease as has abdominal rigidity with surgical intra-abdominal
conditions. Swelling will be proportionate to the acuteness of the
case. Tenderness is nearly always extreme, especially along the
articular line. The joint capsule is frequently distended to its
extreme and the normal contour of the part completely obliterated.
The most common position in which limbs are held is midway between
extremes; thus when the knee is involved the leg will become flexed
upon the thigh, at about 75 degrees. If the shoulder be at fault
the arm is maintained close to the body. In disease of the elbow
the forearm is carried midway between the right angle and complete
extension. This is partly due to the fact that the flexors are always
stronger than the extensors, as it represents a compromise between the
antagonism of the opposing groups of muscles.
_Pus_, when present, is commonly also manifested by the usual signs
of its existence. There will be pitting on pressure or edema of the
overlying parts, while an acutely inflamed joint may be at any time
so swollen as to impede return circulation and lead to edema of the
parts beyond. To the local signs of phlegmon, then, we simply have to
add in greater detail those mentioned above. Along with these there
will be constitutional septic disturbances, usually proportionate to
the gravity of the local condition. The opportunities for absorption
afforded by a large synovial surface are great, and the lymphatics are
sure to carry toxins in abundance. The signs, then, of septicemia,
sometimes even of pyemia, are often pronounced. In the presence of
a joint full of pus the prognosis may be regarded as exceedingly
grave. Pain and tenderness seem to bear but little relation to the
swelling. Usually pain is an expression of distention, yet some of the
non-inflammatory forms of apparently milder type are extremely painful.
Pain is influenced by the position of the joint, and the patient
instinctively seeks that position in which suffering is minimized. In a
joint disorganized by the presence of pus there is less sensitiveness,
except on rough handling, unless the trouble have extended far
beyond the joint limits, and cellulitis be present, with suppuration
threatening. In metastatic joint abscess tenderness rather than pain is
the common rule.
In the presence of an acute inflammation in the joint end of a
long bone the other joint structures will participate to an extent
proportionate to its acuteness. With an acute osteomyelitis--_e. g._,
near the articular surface--the synovial membrane will participate,
just as does the pleura in many cases of pneumonia, and we may look
for fluid in the joint in one case as we do for fluid in the chest
cavity in the other. Moreover, pictures of acute or chronic tuberculous
affections of the synovia correspond very closely to those of the
pleura. Tuberculous disease is liable to spread in every direction
in both diseases. The reverse of this, however, is not true in all
diseases of the chest, and there are many synovial as well as pleural
affections which are confined to their respective sacs.
[Illustration: FIG. 193
Pneumococcus infection of ankle; rapid destruction of all joint
structures. Child aged nine months. (Lexer.)]
The same statement, almost, can be made concerning the bursæ and tendon
sheaths in proximity to infected joints. Particularly is this true when
any of these connect with joint cavities.
The _metastatic forms of pyarthrosis_, as a collection of pus within
the joint capsule is called, are more insidious, though sometimes
equally destructive. They are by no means confined to one joint, and
in pyemia especially many of the joints will become involved. (See
Pyemia.) These secondary affections seem to be purulent from the
outset. In gonorrhea the effused fluids will often be found nearly pure
cultures of the gonococcus; after typhoid they contain typhoid bacilli,
etc. Such expressions are less frequent after pneumonia, influenza,
and the acute exanthemas, but may be seen even after smallpox. It is
often in these severely destructive joint lesions that spontaneous
dislocation occurs (Fig. 193).
=Treatment.=--In the presence of a single joint lesion indications
for treatment are quite clear. When we have multiple and pyemic or
gonorrheal pyarthrosis it is often exceedingly difficult to determine
what is for the best interest of the patient. In general it may be said
that pyemia progressed to this extent will almost certainly be fatal,
and we may rest content with aspirating the affected joints, or perhaps
in leaving them alone; because we may feel that they constitute but
a small proportion of the metastatic foci which eventually determine
death. On the other hand, in other infections with pyarthrosis it would
be better to aspirate or to open and drain, because these cases are
slow and chronic, and the exudate is sometimes so rich in fibrin as to
lead to quite firm spurious ankylosis.
Thus _gonorrheal synovitis_ is usually monarticular, although several
joints may be involved. It is readily recognized in the presence of the
active disease, but there are times when recognition is made difficult
by the latency of urethral symptoms or the concealment of their
existence. The knee is usually the joint most often involved; next
the joints about the foot, and sometimes the tendon sheaths and bursæ
adjoining them.
_Syphilitic arthritis_ is a chronic and mildly but steadily progressive
affection. It rarely assumes purulent form without some secondary
infection. It is frequently combined with gumma along the epiphyseal
border. In _hereditary syphilis_ numerous joints may be involved in
changes of the rachitic type.
_Gout_ or some of its allied rheumatoid manifestations may lead to
a dry form of synovitis, with deposit of urates or of lymph, and
the formation of _tophi_ in the neighborhood, or it may assume the
form of a chronic and intractable hydrarthrosis. The acute forms are
accompanied by great pain, with redness and swelling, peri-articular
and intra-articular. The tendency of these cases is to chronicity and
recurrence.
=General Treatment.=--Upon the nature of the condition will depend
the treatment of joint diseases. The questions of when to operate
and when to abstain, when to enforce rest and when to begin passive
and when active motion, call for discriminating judgment. An acute
or even mild traumatic synovitis should, first of all, be protected
from becoming purulent. Should injury be accompanied by a bruise, the
greatest care should be given to antisepsis, and the part sterilized
and dressed with every precaution. Should there be no external injury
we may rely ordinarily upon cold, wet compresses, with suitable elastic
compression and physiological rest. Should two or three days of this
treatment fail to bring about nearly complete resorption the aspirator
may be employed to withdraw the fluid. If this should be found to be
bloody or too thick to run through the needle, it will be advisable to
make small incisions on either side, under the strictest precautions,
and to practise thorough irrigation, by which the joint cavity will
be completely cleared of foreign material. As soon, however, as the
presence of pus is indicated, or even suspected, the whole character of
the treatment should change. The surgeon should now endeavor to be as
radical as possible. The more purulent the collection the more are free
incision, irrigation, and drainage indicated and the more complicated
the condition the more he should make counteropenings here and there,
wherever joint pockets may be emptied.
When muscle spasm not only seriously disturbs the patient but
threatens to draw the limb into an undesirable position it should be
overcome, either by employment of traction with weight and pulley,
or by forcible reposition and fixation in suitable splints, such as
plaster of Paris. Some of the most extensive operations that are called
for are necessitated by neglect to observe these precautions early.
Often nothing will afford so much relief as the use of traction, with
sufficient weight, tiring out contracted muscles, and thus not actually
separating joint surfaces, but overcoming that muscle spasm which
brings them tightly together and thus gives pain.
In the more chronic form of cases absorption may be promoted by
elastic compression, by massage, by wet compresses, and sometimes by
blistering. Ordinarily, and especially in those cases characterized by
pain, more can be accomplished with the actual cautery drawn lightly
and rapidly over the surface of the joint than by blistering. This
application is referred to as the _flying cautery_, and it is one of
the most effective agents known for the relief of deep-seated pain,
as well as of cutaneous hyperesthesia. Its use causes little if any
unpleasant sensation, and should be repeated at daily intervals until
the primary object is attained.
Should aspiration of a distended joint be practised at any time, one
should atone for the loss of intra-articular pressure thereby produced
by external compression, preferably with an elastic medium.
In the writer’s opinion it is not advisable to use a small aspirating
trocar in those cases which are likely to call for irrigation. The
aspirating needle should be confined to the non-purulent collections
of fluid, although some surgeons advise and practise throwing into a
mildly infected joint, through such a needle, some reasonably strong
antiseptic fluid or emulsion, hoping thus to gain its bactericidal
effect without external incision.
The active manifestations of disease being mastered, one addresses
himself naturally to the greatest possible prevention of deformity
and restoration of function. Indeed, these should be kept in view
from the outset, although we have, for a time, to disregard them in
favor of more imperative indications. If ankylosis appear inevitable
the joint should be kept in that position in which, when stiff, it
will be most useful. This position will be, at the elbow, at a right
angle; at the hip or knee, nearly complete extension. When, on the
other hand, restoration of function is hoped for it will be obtained
through a combination of massage, active and passive movements,
with the use perhaps of some sorbefacient ointment, such as the
compound ichthyol-mercurial, or by the nearly constant use of cold,
wet compresses, combined with the other measures. The greatest care
should be exercised in determining the time when absolute rest given
to an inflamed joint should be changed to the gentle or more forcible
movements required for restoring use to previously inflamed joint
surfaces.
=Chronic Synovitis and Arthritis.=--A chronic serous effusion into
a joint is given the term _hydrarthrosis_. This condition is never
primary; it is always the residue of some previous acute lesion, or
else it is the result of neuropathic or rheumatoid changes going on in
and about the joint, accompanied by relaxation of membranes permitting
passive distention with fluid. The contained fluid is ordinarily
pure serum. It may contain a little blood or numerous particles or
shreds of fibrin, while in rare instances there will be found in
it drops of oil or even fat crystals. The degree of distention of
a joint capsule is the measure of the gravity of the case, as this
membrane, like any other, will yield to gradual distention, although
it at the same time undergoes thickening as a protective measure.
Thus the synovia may, under certain circumstances, become as thick
as the pleura. The result is a tough, leathery condition of this
membrane, which makes it exceedingly difficult to manage. The joint
thus involved will appear more prominent than it should, because of
the atrophy of the surrounding structures. Accurate comparisons can
only be made by measuring corresponding joints. Neighboring bursæ and
tendon sheaths often participate in the distention. These collections
are ordinarily painless, or nearly so, but interfere, to varying
extent, with the function of the joint. Anatomical outlines disappear
or are concealed by the bag of fluid. It is rare that there are any
constitutional symptoms except perhaps those of the disease which
causes the disturbance. The amount of fluid which may be contained in a
long-distended knee-joint, for instance, is relatively very large. The
prognosis in these cases will depend much upon the underlying cause, as
well as upon the age, vitality, and docility of the patient.
=Treatment.=--Removal of the fluid is always the indication. After
reasonable effort has shown that this is not possible by the employment
of massage, the actual cautery and elastic compression, combined with
functional rest, it should be withdrawn by the aspirating needle or
trocar. The more experience, however, we have with affections of this
class the more we will realize that the interior of the synovial
membrane is frequently studded with deposits, fringes, etc., which are
not affected by mere aspiration, and the more cogent argument will
be gained for sufficiently free incision to permit inspection of the
interior of the joint, removal of tags of tissue, thorough washing
out and sponging, by which a change in circulation and nutrition
is certainly affected; and this may be combined with excision of a
liberal portion of the thickened membrane, by which the dimensions
of the joint may be materially reduced when the opening is sutured.
For long-standing cases of well-marked hydrarthrosis, especially in
the knee, the writer would urge this method of treatment. Drainage,
if called for at all, can be made with strands of silkworm, or some
temporary material which will quickly disappear or be promptly removed.
This is particularly applicable for the milder forms of tuberculous
synovitis, in which the joint is thus treated on the same principle
that is applied in washing out a tuberculous peritoneal cavity.
[Illustration: FIG. 194
Arthritis deformans, knee. (Ransohoff.)]
ARTHRITIS DEFORMANS AND OSTEO-ARTHRITIS.
Under this general name have been grouped a number of conditions,
including the so-called _rheumatoid arthritis_, and referring to a
variety of chronic progressive lesions of joints which involve the
articular cartilages and synovial membranes, later the bones, and
which produce more or less loss of function and deformity. Although
often spoken of as “rheumatoid,” the condition has nothing to do with
rheumatism as such, whatever that may be. It moreover presents no
analogies to the forms of acute synovitis already described. These
lesions are more common in women than in men, occurring oftener in
those who have been sterile, and during or after the menopause.
So far as their etiology and pathology are concerned, it is true,
though it seem trite to say it, that they are the result of disturbed
nutrition, which itself may be referred back to perverted trophic
influences. Exposure, bad hygienic surroundings, improper food,
mental perturbation, and depression are more or less potent factors
in most of the cases. In some instances occurring in advanced age
they seem to be due to changes ordinarily regarded as senile. When
joint lesions are multiple and symmetrical, and accompanied by other
nutritive changes, we may refer the cause back to the central nervous
system. When monarticular they are more likely to be the residue of
some previous infection or injury, such as gonorrhea, influenza, or an
acute exanthem. If in connection with the joint manifestations we find
the spleen and lymphatics enlarged, then the case may be regarded as
doubtless infectious in nature.
The pathological changes within these joints include almost every
imaginable alteration. Bones soften and atrophy at one point, or at
another become enlarged and thickened, and throw out osteophytic
projections by which the whole shape of the joint is materially
changed. Cartilages atrophy here and thicken there, and disappear, at
times, to an extent by which bone is exposed, the exposed surfaces
frequently becoming polished or _eburnated_. The position of the joint
and its general contour may be materially altered by these changes, and
marked deformity or notable enlargement result. _Subluxations_ are not
infrequent, while the ligamentous structures are sufficiently strong to
perform their function, and the joint yields or “_wabbles_.” Meanwhile
the synovial membrane undergoes corresponding changes, and becomes
distended with fluid so that hydrarthrosis is a frequent accompaniment.
On the other hand, there is another type of analogous changes where
the tendency is atrophic throughout and little if any extra fluid
accumulates. Such a joint may become smaller rather than larger,
especially if, as in some cases, some part of the bone practically
disappears.
At all events muscle atrophy, sometimes with pseudo-ankylosis,
sometimes with actual ankylosis, will characterize most of these cases,
and muscles naturally disappear as they functionate less and less.
_Pain_ is an irregular feature, some of the lesions being quite
painful, others almost free from it. The lesions are essentially
progressive in their character, unless the whole body condition and
environment can be changed for the better. Consequently individuals
become more and more crippled. Muscle spasm is rarely present, but when
such changes occur in the intervertebral joints the individual becomes
gradually bent over or deformed, partly because the muscles no longer
have strength to maintain the erect posture, and partly from actual
changes in the bones and joints. Most of the instances, however, are
characterized by tenderness, while a general _myalgia_ or malaise is
a frequent complaint. There are sometimes exacerbations, during which
both severe neuralgic pains and mild fever are quite pronounced. Not
infrequently on handling the affected joint pseudocrepitus or actual
crepitus will be obtained. Sometimes the joint surfaces are roughened,
and then this sensation is most pronounced. When the synovial membrane
is proliferated, in _pannus_ form, over the cartilages, its enlarged
fringes will give a soft crepitus which is quite distinctive. Fragments
of these fringes, as well as of cartilage, may become detached, and
loose objects of this kind in the joint may be recognized by the sense
of touch.
[Illustration: FIG. 195
General osteo-arthritis, with multiple synostoses (“ossified man”).]
While this is going on within the joint, adjoining tendon sheaths
and bursæ become more or less involved, and even the periosteum will
undergo considerable thickening.
The monarticular type is more frequent in men than in women, and occurs
more often in a large joint or in the spine, in which latter case it
is hardly to be considered monarticular. The changes that may occur
in the _spine_ are distinctive, varying from trifling stiffness and
limitation of motion to pronounced deformity, by which, for instance,
not only the kyphosis of acute spondylitis may be imitated, but the
body flexed to an angle with the axis of the pelvis and fixed there,
so that the individual is bent to nearly a right angle. Some of the
other deformities of this condition are more or less characteristic.
In the _hands_ the fingers are bent toward the ulnar side, and often
strongly flexed, perhaps even overlapped, thus giving the hand a
peculiar claw-like appearance. The _feet_ are extended completely,
the joints rigid, the toes turned outward, and also overlapping. By
such changes in the hip and knee the legs and thighs may be flexed and
the hips perhaps so ankylosed as to prevent separation of the knees.
While these changes are, as stated, most common in the later years of
life, _children are not exempt_, girls being more frequently affected
than boys, the condition coming on at first with more or less acute
symptoms. These children will often be found to have enlarged spleens
and lymph nodes, to show malnutrition, while some of them will display
certain symptoms of exophthalmic goitre. In other words, they are in
that condition included under the term status lymphaticus, to which
subject the reader is referred. (See p. 163.)
It would appear, then, that we can expunge the term chronic articular
rheumatism, since by it is not meant the ultimate result of an acute
rheumatic affection, but rather one of the vague conditions described
above.
Fig. 195, taken from a skeleton in the author’s possession, illustrates
an extreme condition of this kind, characterized by multiple
synostoses, nearly all of the principal joints being involved.
As between the terms _osteo-arthritis_ and _arthritis deformans_ it
is not practicable to make such accurate distinctions as shall be
acceptable to all. In a general way the more the bone participates
the more we may use the former designation, whereas when other joint
structures are chiefly involved we may resort to the latter.
In general, then, all these conditions are evidenced by joint
deformity, especially by irregularities, by more or less effusion, by
considerable tenderness, by creaking of the joints when used, by pain
which is a variable feature and may be referred to nerve disturbances,
occasionally by muscle spasm, but always, in cases of long standing,
by muscle atrophy. A view of the interior of joints thus affected will
give a complex picture of atrophy here and hypertrophy there of each or
all of the component structures of the joint, sometimes with a gradual
overgrowth of articular bone surfaces, sometimes with more or less
complete disappearance of the same, _e. g._, in the acetabulum.
=Treatment.=--So far as treatment of these conditions is concerned,
it should be recalled, first of all, that the disease itself is
exceedingly chronic in its tendency, and due to conditions which
have probably been of long standing. Constitutional treatment is as
essential as local, and must consist in restoring the environment
and the nutrition of the patient to normal standards. Elimination is
deficient in such cases, and should be stimulated by hot-air baths,
massage, and such exercise as may be possible, as well as by the use of
diuretics and laxatives to the degree indicated. The local treatment
may consist also of massage, elastic compression, aspiration in rare
instances, the use of wet packs, and, in many cases, the use of hot,
dry air. Various forms of apparatus are now upon the market by which
almost any of the joints may be subjected to the influence of dry, hot
air at a temperature of 280° F. When properly used, great relief and
improvement may be expected. Their use, however, calls for the best of
judgment and a combination of the measures already mentioned.[31]
[31] The following types of arthritis bear little, if any, relation
to true rheumatic disease, though often spoken of as rheumatoid:
The _chronic villous_ form, most common in the knee, purely local,
without effusion, and giving dry crepitus or creaking. The joint
fringes are numerous, and sometimes vascular. If the crepitus be
marked and the fringes too extensive the latter may be relieved
by operation. Otherwise this form is to be treated by early local
stimulation, with some support, at least with a bandage.
The _atrophic_ form, of unknown etiology, causing progressive and
finally crippling swelling, with later atrophy. There is little if
any fluid present. Here the changes occur in both bone and cartilage,
with a tendency to abnormal calcification. In this form rest and
hypernutrition, especially with normal proteids, are called for, and
every possible stimulus to elimination through all the emunctories.
The _hypertrophic arthritis_, by which cartilages are first thickened
and then ossified, interfering with motion and with contour. This
form causes great limitation of motion and sometimes pressure on
nerves, with referred pains. It seems to have some relation to
cold, exposure, and injury. Detachment of pieces of cartilage is
not uncommon, so that there are loose bodies in the joint cavity.
Treatment here consists of fixation, with improvement of nutrition
and elimination. This form may subside under proper treatment.
The _chronic, gouty arthritis_, with deposits of sodium urate in
and around the joint tissues, with perhaps some bone absorption
beneath them, which are not connected with the bone. In the digits
entire phalanges may disappear by absorption. The treatment here is
essentially constitutional and directed toward the gouty diathesis.
NEUROPATHIC JOINT DISEASE.
This received its first full and classical description from Charcot
in 1868. The term refers to joint lesions which follow and are
apparently connected with certain injuries and diseases of the spinal
cord, or the peripheral nervous system. The non-traumatic forms are
mostly associated with locomotor ataxia and syringomyelia. Some of
them have an abrupt onset, while others come on very insidiously.
Pain is usually notable by its absence, and the involved joints show
few, if any, evidences of hyperemia or inflammation. They become
unnaturally mobile and relaxed and usually much, sometimes enormously,
distended with fluid. The morbid changes within the joints comprise
imaginary combinations of atrophy and hypertrophy, with proliferative
formations in bone cartilages. Osteophytes and exostoses are met with,
and ossification may occur in the neighboring tendons and ligaments.
Surprising alterations take place in certain joints; thus, as shown
in Fig. 197, the head of the humerus may disappear and corresponding
changes may occur in other joints. While it is the knee which suffers
most frequently, no joints, not even those of the spine or jaw, are
exempt.
[Illustration: FIG. 196
Charcot’s disease of elbow.]
[Illustration: FIG. 197
Atrophic disappearance of bone after chronic joint disease.]
[Illustration: FIG. 198
Tabetic arthropathy. (Case of E. A. Smith.)]
[Illustration: FIG. 199
Neuropathic arthritis (tabetic joints). (Lexer.)]
Locomotor ataxia is a common disease, but syringomyelia has been
regarded as exceedingly rare. Nevertheless, Schlesinger has collected
130 cases of it, in one-fourth of which bone and joint symptoms were
present. That the nervous system is primarily at fault is made clear,
among other things, by the rapidity of involvement occasionally seen,
where, for instance, an entire limb becomes edematous, with every
indication of severe disturbance. In tabes the lower extremities
suffer more often than the others; the reverse is true in cases of
syringomyelia. While floating bodies in the joints and ossification
of the muscles and soft parts are common in arthritis deformans, they
seldom occur in the neuropathic lesions. Suppuration and necrosis are
rare in any of these forms, occurring more frequently in the finger
than elsewhere, and are probably due to infection of those areas
where sensibility is lost and trifling injuries less guarded against.
The neuropathic lesions are more commonly symmetrical, and are often
accompanied by a cretinic general appearance (Figs. 196, 197, 198, 199,
200 and 201).
[Illustration: FIG. 200
Skiagram of joints shown in Fig. 199. (Lexer.)]
[Illustration: FIG. 201
Arthropathy of syringomyelia. Left elbow, illustrating disintegration,
etc., without ulceration or suppuration. (Quenu.)]
The joint complications of syringomyelia are frequently characterized
by skin lesions which tend to suppurate, by sudden edema, occasionally
followed by phlegmon and even necrosis, also by other disturbances of
innervation.
Surgical treatment of these lesions is less discouraging than would
at first appear, as even in these patients serious wounds heal
readily, while in healthy tissues primary union may occur. The wisdom,
therefore, of incision, resection, or even amputation may be decided
on their merits, and there can be no objection to open drainage when
it would otherwise be indicated. Even in cases of spontaneous fracture
proper treatment usually gives good results, although the amount of
callus may seem disproportionate.
In any of the joints distorted by deforming osteoarthritis or
neuropathic lesions, the question of partial or complete resection or
exsection may be discussed upon its merits, since these operations,
when duly indicated, have often given satisfactory results, even in
elderly people.
=Diagnosis.=--Differential diagnosis will be made more easy by the
exclusion of syphilis and of the acute or ordinary infectious forms
of disease. The relative freedom from pain, the relaxation of the
joint structures, the large amount of fluid present, and the age of
the patient will aid in excluding all but the neuropathic elements
associated with spinal disease.
=Treatment.=--Treatment is rarely curative; usually it can be
palliative at best. Measures above mentioned, when they seem indicated,
coupled with mechanical support, by which the parts may be maintained
as nearly as possible in their proper position, will give the best
result. If the disease be monarticular, exsection will frequently
give a satisfactory result. Multiple lesions rarely permit of serious
operations.
HYSTERIA AND HYSTERICAL JOINTS.
A different form of distinctly neuropathic joint affection is the
so-called _hysterical joint_. This is characterized by the absence of
every objective and the presence of nearly every subjective symptom.
It occurs most often in young women and girls, follows perhaps some
trifling injury, and involves most commonly the joints of the lower
limbs. These cases are characterized by a disproportion between the
character of the complaint and the actual condition. Imitation of
organic trouble is a predominant feature of all hysterical complaints,
and is nowhere seen to better advantage than in these cases. The pain,
the tenderness, the loss of ability and even the muscle spasm and
muscle atrophy of genuine lesions will be simulated. So true is this
that diagnosis largely rests on the exaggeration of symptoms which
have no apparent existence. _Hyperesthesia_ is sometimes extreme, but
pertains usually to the waking hours. Rarely is there actual swelling
or thickening, or any objective evidence whatever of disease, save
perhaps muscle atrophy due to disuse. It is possible to have the
hysterical element as a complication of actual joint disease, but the
truly hysterical joints usually are easily recognizable.
=Treatment.=--The treatment of such a joint should be psychical as well
as physical. Sometimes appeals to reason, at other times to fear or
necessity, will be the wiser course. Restoration of self-confidence is
an important feature, and these are the cases where any form of faith
cure will produce its most brilliant results. Many of these cases are
bedridden, and need to have elimination stimulated in every possible
way. They also need sunlight, fresh air, massage, and renewed use of
the parts. Hyperesthesia is best treated by continuous application of
ice-cold compresses, intermitted perhaps daily for the purpose of using
the “flying cautery,” as already described.
GONORRHEAL OR POSTGONORRHEAL ARTHRITIS.
This condition may occur during the active stage of gonorrhea or
after its apparent subsidence. It was probably the discovery of the
pathogenic gonococcus by Neisser, in 1879, which gave to this lesion an
identity of its own, and induced the profession to _abandon the name
gonorrheal rheumatism_, by which it had been known. It has nothing to
do with rheumatism, and should not be linked with it in name any more
than in idea. In well-marked cases the gonococcus will nearly always be
found, usually in pure culture, in the joint fluid.
It appears in different degrees of severity, from a mere hydrops,
which is mild, accompanied by slight tissue changes, to a phlegmonous
condition, with widespread destruction of joint structures and serious
constitutional disturbances. As between these extremes there may be
a pyarthrosis or empyema, which is usually the result of a mixed
infection.
As a complication of urethritis it occurs in 4 or 5 per cent. of cases,
the percentage being larger in children than in adults, the knee being
affected in about one-third of these cases. It is not necessarily
monarticular, however, and sometimes several joints will be involved.
Along with the joint condition there will frequently occur cardiac
lesions (endocarditis) and eye complications. In fact, some of these
cases terminate fatally through the mechanism of a seriously involved
heart, _i. e._, septic endocarditis or myocarditis. When it occurs in
the ankle or in the tarsal joints the ligaments and surrounding bursæ
are often involved. This involvement, unless recognized and properly
treated, may lead to serious deformity, _e. g._, flat-foot of the most
painful kind. Many of these lesions at the heel are accompanied by true
exostoses, which are often painful and more or less disabling (“painful
heel”). Thus, Jaeger has recently reported a group of ten such cases.
These may require excision. In general this form of arthritis is
characterized by severe pain, often worse at night, and a peculiar
distortion of the swollen joint, because it is usually complicated
by a distention of the adjoining tendon sheaths and bursæ, which is
rare in other forms of arthritis. It has been aptly stated that if in
these cases the same zeal were displayed in seeking for gonococci that
has often been shown in looking for uric acid it would be less often
neglected. So far as treatment is concerned, I desire in this place
only to call attention to the absolute inutility of all the so-called
antirheumatic remedies and diet. However, if the urine be hyperacid it
should be corrected by ordinary means. At first absolute rest, with the
local use of the ichthyol-mercurial or Credé ointment, should be given.
Such antiseptics as one has most confidence in may also be administered
internally for their general beneficial effect. An overdistended joint
should be tapped and irrigated. As soon as the presence of pus can be
determined, either with or without exploration, the joint should be
opened, thoroughly irrigated, and drained. If this were always done in
time the more severe phlegmonous and destructive cases would rarely
occur.
TUBERCULOUS ARTHRITIS.
Tuberculous disease of the joints is one of the most frequent of
surgical lesions. It has produced characteristic appearances which have
been known under the name of “scrofula of joints,” until a clearer
recognition of the pathology of the condition led to the abandonment of
the term scrofula. _Tumor albus_, or _white swelling_, was another term
commonly applied to these lesions, because of the anemic appearance of
the surface of the swollen joint.
_Tuberculous arthritis_ assumes different phases in proportion to the
involvement of the different component structures of the joint. Some
cases begin purely as a tuberculous synovitis, and may for a long time
be limited to the synovial structures. Others begin within the spongy
texture of the expanded joint ends of the long bones, the disease
spreading from such foci and involving everything in the path which its
products take in the effort to secure spontaneous evacuation, products
of softening and infection travelling in the _direction of least
resistance_.
It has been the writer’s custom to always follow Savory, in his
suggestion to students to let their mental pictures of consumption
of the lungs and pleuræ serve for illustration in similar disease of
joints. Thus the cancellous bone structure much resembles the lung
tissue in its spongy character. In both a capsule surrounds the mass
of tubercle, and in each, by breaking down of its contents, a cavity
is formed. Moreover, the pleura bears practically the same resemblance
and relation to the lung and the chest wall that the synovialis does
to the bone end and the joint cavity; as we may have pleuritis with
phthisis, so we may have synovitis with tuberculous ostitis; and as
adhesions tend to form in the pleural cavity, so also do they in the
synovial cavity. Furthermore, in each case obliteration of deeper veins
causes the more prominent appearance of the subcutaneous veins, and as
tuberculous pleurisy often terminates in empyema, so does tuberculous
hydrarthrosis often terminate in pyarthrosis, perhaps with fungous
ulceration. In almost every feature, then, the progress and effect of
tuberculosis in the lung and bone end may be likened to each other.
In some clinics bone and joint tuberculosis constitute nearly one-third
of the total of cases treated. Joints of the lower limb are the ones
most frequently involved in children, while in the adult those of the
upper extremity are generally attacked. It is not often that more than
one joint is involved at one time. The relation of traumatism to this
disease has been frequently discussed, and is variously regarded.
The disease is more common in those who are predisposed to it by
environment or by heredity, in the latter case hereditary evidences
usually being well marked. In such predisposed individuals, especially
in the early years of life, severe injuries are usually promptly
repaired, while the milder traumatisms, which are often frequent and to
which too little attention is paid, seem often to so far lower tissue
resistance as to favor an infection to which the individual is already
favorably predisposed. The true position to take, then, would appear to
be this, that _traumatisms rarely lead directly to joint tuberculosis,
but only indirectly by affecting tissue susceptibility_.
Thus lesions which begin in the epiphyses lead to what is known as
_osteopathic_ joint disease, while those which have their origin in
the synovia give rise to the _arthropathic_ forms. The former are more
common in children and the latter in adults (Fig. 202).
=Pathology.=--In regard to the pathology of these conditions it does
not vary from that mentioned in the earlier portion of this work in
connection with the general subject of Surgical Tuberculosis. The
deposit of tubercle in the tissue whose resistance has been weakened
is followed by the formation of granulation tissue, which, so long as
the germs survive, tends to increase and to make room for itself at the
expense of surrounding tissue. At the same time there occurs a tissue
struggle by which the attempt is made to throw around an active focus a
protecting barrier, which in soft tissues consists of condensed fibrous
and connective tissue, and, in bone, of a sclerotic capsule, as though
the intent were to imprison the disturbing cause, and, by completely
enclosing it, effect protection. When this attempt at encapsulation is
successful spontaneous recovery follows. It will be made successful,
to some extent at least, by treatment whose most important local
feature is physiological rest. On the other hand, when the attempt is
unsuccessful and the barrier is transgressed by granulation tissue, the
lesion will advance in the direction of least resistance, while its
progress will be made known, especially as it approaches the surface,
by very significant signs: adhesion of the overlying structures and
finally of the skin, with purplish discoloration of the latter. Finally
softening occurs with escape of granulation tissue, which, so soon as
it is freed from pressure, will grow more luxuriantly and with more
color, constituting the _fungous granulation tissue_, to which German
pathologists so often allude, or so-called “proud flesh.” When this
appears upon the surface it is soon infected with pyogenic organisms,
breaks down, and an abscess cavity results, connecting with the
original focus and its extensions. This may be so placed as to lie
outside the joint capsule, which, in some respects, is fortunate for
the patient. The joint function may then be compromised to only a minor
degree.
[Illustration: FIG. 202
Central sequestrum. (Ransohoff.)]
Often the direction of least resistance is toward the joint cavity,
this fungous tissue loosening and perforating cartilage or periosteum
before it enters the joint. Having penetrated it again it grows
extensively until the cavity is distended, its rapidity of growth
diminishing with the degree of pressure produced by its surroundings.
This pressure will also make it less vascular, and when such a joint
is opened it at first appears pale and anemic. In proportion as the
joint distends it loses in motility, while should recovery occur
spontaneously or as the result of treatment this tissue will to some
extent disappear, to be replaced by adhesions by which pseudo-ankylosis
is produced. The extent of the intra-articular involvement will cause
obstruction to the deeper return circulation, and thus is brought about
the prominence with which the subcutaneous veins appear. The degree of
hydrarthrosis is apparently not limited except by the distensibility of
the joint. In the articular or arthropathic forms there is always more
or less synovial outpour.
[Illustration: FIG. 203
Tuberculous panarthritis. (Ransohoff.)]
To the condition already described may be added the destruction
produced by suppuration, infection occurring either through the
circulation, as is quite possible, or through some trifling surface
abrasion. In more chronic cases _caseation_ may occur, especially in
bone foci. Finally, as the result of a combination of morbid processes,
there is produced more or less complete disorganization, all of
which is summed up in the term _tuberculous panarthritis_. To that
condition in which the articular surfaces are more or less studded with
fungous patches the term _pannus of the joint_ is often applied. To
reiterate, then, as between a chronic hydrarthrosis and a destructive
panarthritis, perhaps even with necrosis of epiphyses, it is but a
difference of degree and of combination of infectious processes (Figs.
203, 204, 205 and 206).
Among the other consequences of panarthritis may be the formation of
_sequestra_ in or near the epiphyses, and such destruction as shall
lead to _pathological dislocation_, the latter being well illustrated
in Figs. 204 and 207. This dislocation is always the result of the
pull of muscles thrown into that condition of reflex spasm which is a
characteristic feature of this disease. It appears conspicuously at the
knee, usually as a backward subluxation (Fig. 207), and at the hip as
an upward dislocation, sometimes with more or less apparent migration
of the acetabulum. Another consequence of tuberculous hydrarthrosis,
which frequently persists even long after the subsidence of the acute
stage of the disease, is the occurrence within the joint cavity of
_rice-grain_ or _melon-seed bodies_, for whose presence it is not easy
to account. The generally received explanation is that they are the
result of fibrinous outpour, whose fluid portions have been absorbed,
while the remaining nearly pure fibrin is broken up into particles
and rounded off by attrition during the movements of the joint. They
may accumulate in astonishing amount, thus stamping the disease as
having a chronic rather than an acute character. After a time they
provoke a fresh outpour of fluid, as a result of the irritation which
they produce. This fluid is at first usually clear serum, but becomes
turbid or seropyoid, and, if infected, becomes pure pus, in which the
rice-grain bodies are dissolved or disintegrated.
[Illustration: FIG. 204
Bony ankylosis of knee. (Ransohoff.)]
[Illustration: FIG. 205
Section of bony ankylosis of hip. (Original.)]
[Illustration: FIG. 206
Tuberculous panarthritis, illustrating various types of degeneration
and destruction. (Lexer.)]
_Recovery is possible_ in many cases when the lesions have not advanced
too far. It is rarely ideal, and usually leaves some evidence of its
existence in limitation of motion, thickening, or other recognizable
symptom. Constitutional as well as local measures have much to do
with bringing about this result. It is for this reason that it is so
essential to take tuberculous-joint patients out of the environment
in which ordinarily they live and get them outdoors, exposed to
sunlight and benefited by the best of nutrition. _Rest, oxygen, and
hypernutrition_ are the three best general measures for combating these
conditions. When recovery does occur it is by the death of all active
germs, the absorption to varying extent of disease products, including
granulation tissue, and the organization into fibrous and cicatricial
tissue of the unabsorbed residue. No tissue which has been actually
disorganized is completely restored. The best that can be hoped for is
substitution of fibrous or cicatricial tissue. Function may be more
or less completely regained. This will depend largely upon how early
treatment is instituted. In general it may be said that there is always
hope for tuberculous joints _if suitable treatment be instituted early
and if the environment can be made satisfactory_. Unfortunately this
is not often possible, and the best that can be hoped for is subsidence
of disease at the expense of more or less ankylosis, perhaps deformity,
while, at the worst, there may be loss of joint if not of life. It
might be misinterpreted should it be said that there is one kind of
treatment for the wealthy and another for the poor, yet so much does
depend upon what the patient or the parents can afford in the way of
change of surroundings that the whole plan of treatment often depends
upon the patient’s circumstances. Radical measures may therefore be
deemed best in those who cannot afford long delay and temporization,
while at other times expensive apparatus and change of residence may
bring about the desired result.