Chapter XXXI (1)

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.

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.

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.

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.

Charcot’s disease of elbow.]

Atrophic disappearance of bone after chronic joint disease.]

Tabetic arthropathy. (Case of E. A. Smith.)]

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).

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

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.