Alexis Thomson and Alexander Miles - Manual of Surgery

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#Clinical Features.#--These vary with the different anatomical forms of
the disease, and with the joint affected.

Sometimes the disease is ushered in by a febrile attack attended with
pains in several joints--described by John Duncan as _tuberculous
arthritic fever_. This is liable to be mistaken for rheumatic fever,
from which, however, it differs in that there is no real migration from
joint to joint; there is an absence of sweating and of cardiac
complications; and no benefit follows the administration of salicylates.

In exceptional cases, tuberculous joint disease follows an acute course
resembling that of the pyogenic arthritis of infants. This has been
observed in children, especially in the knee, the lesion being in the
synovial membrane, and attended with an accumulation of pus in the
joint. If promptly treated by incision and drainage, recovery is rapid,
and free movement of the joint, may be preserved.

The onset and early stages of tuberculous disease, however, are more
often insidious, and are attended with so few symptoms that the disease
may have obtained a considerable hold before it attracts notice. It is
not uncommon for patients or their friends to attribute the condition to
injury, as it often first attracts attention after some slight trauma or
excessive use of the limb. The symptoms usually subside under rest, only
to relapse again with use of the limb.

The initial local symptoms may be due to the presence of a focus in the
neighbouring bone, perhaps causing neuralgic pains in the joint, or
weakness, tiredness, stiffness, and inability to use the limb, these
symptoms improving with rest and being aggravated by exertion.

It is rarely possible by external examination to recognise deep-seated
osseous foci in the vicinity of joints; but if they are near the surface
in a superficial bone--such as the head of the tibia--there may be local
thickening of the periosteum, oedema, pain, and tenderness on pressure
and on percussion.

_X-ray Appearances of Tuberculous Joints._--Gross lesions such as
caseous foci in the marrow of the adjacent bone show as clear areas with
an ill-defined margin; a sclerosed focus gives a denser shadow than the
surrounding bone, and a sequestrum presents a dark shadow of irregular
contour, and a clear interval between it and the surrounding bone.

Caries of the articular surface imparts a woolly appearance or irregular
contour in place of the well-defined outline of the articular end of the
bone. In bony ankylosis the shadow of the two bones is a continuous one,
the joint interval having been filled up. The minor changes are best
appreciated on comparison with the normal joint of the other limb.

_Wasting of muscles_ is a constant accompaniment of tuberculous joint
disease. It is to be attributed partly to want of use, but chiefly to
reflex interference with the trophic innervation of the muscles. It is
specially well seen in the extensor and adductor muscles of the thigh in
disease of the knee, and in the deltoid in disease of the shoulder. The
muscles become soft and flaccid, they exhibit tremors on attempted
movement, and their excitability to the faradic current is diminished.
The muscular tissue may be largely replaced by fat.

_Impairment of the normal movements_ is one of the most valuable
diagnostic signs, particularly in deeply seated joints such as the
shoulder, hip, and spine. It is due to a protective contraction of the
muscles around the joint, designed to prevent movement. This muscular
fixation disappears under anaesthesia.

_Abnormal attitudes of the limb_ occur earlier, and are more pronounced
in cases in which pain and other irritative symptoms of articular
disease are well marked, and are best illustrated by the attitudes
assumed in disease of the hip. They are due to reflex or involuntary
contraction of the muscles acting on the joint, with the object of
placing it in the attitude of greatest ease; they also disappear under
anaesthesia. With the lapse of time they not only become exaggerated, but
may become permanent from ankylosis or from contracture of the soft
parts round the joint.

_Startings at night_ are to be regarded as an indication that there is
progressive disease involving the articular surfaces.

_The formation of extra-articular abscess_ may take place early, or it
may not occur till long after the disease has subsided. The abscess may
develop so insidiously that it does not attract attention until it has
attained considerable size, especially when associated with disease of
the spine, pelvis, or hip. The position of the abscess in relation to
different joints is fairly constant and is determined by the anatomical
relationships of the capsule and synovial membrane to the surrounding
tissues. The bursae and tendon sheaths in the vicinity may influence the
direction of spread of the abscess and the situation of resulting
sinuses. When the abscess is allowed to burst, or is opened and becomes
infected with pyogenic bacteria, there is not only the risk of
aggravation of the disease and persistent suppuration, but there is a
greater liability to general tuberculosis.

The sinuses may be so tortuous that a probe cannot be passed to the
primary focus of disease, and their course and disposition can only be
demonstrated by injecting the sinuses with an emulsion of bismuth and
taking X-ray photographs.

Tuberculous infection of the lymph glands of the limb is exceptional,
but may follow upon infection of the skin around the orifice of a sinus.

A slight rise of temperature in the evening may be induced in quiescent
joint lesions by injury or by movement of the joint under anaesthesia, or
by the fatigue of a railway journey. When sinuses have formed and become
infected with pyogenic bacteria, there may be a diurnal variation in the
temperature of the type known as hectic fever (Fig. 11).

_Relative Frequency of Tuberculous Disease in Different
Joints._--Hospital statistics show that joints are affected in the
following order of frequency: Spine, knee, hip, ankle and tarsus, elbow,
wrist, shoulder. The hip and spine are most often affected in childhood
and youth, the shoulder and wrist in adults; the knee, ankle, and elbow
show little age preference.

_Clinical Variations of Tuberculous Joint Disease._--The above
description applies to tuberculous joint disease in general; it must be
modified to include special manifestations or varieties.

When the main incidence of the infection affects the synovial membrane,
the clinical picture may assume the form of a _hydrops_, or of an
_empyema_ in which the joint is filled with pus. More common than either
of these is the well-known _white swelling_ or _tumor albus_ (Wiseman,
1676) which is the clinical manifestation of diffuse thickening of the
synovial membrane along with mucoid degeneration of the peri-synovial
cellular tissue. It is well seen in joints which are superficial--such
as the knee, ankle, elbow, and wrist. The swelling, which is the first
and most prominent clinical feature, develops gradually and painlessly,
obliterating the bony prominences by filling up the natural hollows. It
appears greater to the eye than is borne out by measurement, being
thrown into relief by the wasting of the muscles above and below the
joint. In the early stage the swelling is elastic, doughy, and
non-sensitive, and corresponds to the superficial area of the synovial
membrane involved, and there is comparatively little complaint on the
part of the patient, because the articular surfaces and ligaments are
still intact. There may be a feeling of weight in the limb, and in the
case of the knee and ankle the patient tires on walking and drags the
leg with more or less of a limp. Movements of the joint are permitted,
but are limited in range. The disability is increased by use and
exertion, but, for a time at least, it improves under rest.

If the disease is not arrested, there follow the symptoms and signs of
involvement of the articular surfaces.

_Influence of Tuberculous Joint Disease on the General
Health._--Experience shows that the early stages of tuberculous joint
disease are compatible with the appearance of good health. As a rule,
however, and especially if there is mixed infection, the health suffers,
the appetite is impaired, the patient is easily tired, and there may be
some loss of weight.

#Treatment.#--In addition to the general treatment of tuberculosis,
local measures are employed. These may be described under two heads--the
conservative and the operative.

_Conservative treatment_ is almost always to be employed in the first
instance, as by it a larger proportion of cures is obtained with a
smaller mortality and with better functional results than by operation.

_Treatment by rest_ implies the immobilisation of the diseased limb
until pain and tenderness have disappeared. The attitude in which the
limb is immobilised should be that in which, in the event of subsequent
stiffness, it will be most serviceable to the patient. Immobilisation
may be secured by bandages, splints, extension, or other apparatus.
_Extension_ with weight and pulley is of value in securing rest,
especially in disease of the hip or knee; it eliminates muscular spasm,
relieves pain and startings at night, and prevents abnormal attitudes of
the limb. If, when the patient first comes under observation, the limb
is in a deformed attitude which does not readily yield to extension, the
deformity should be corrected under an anaesthetic.

_The induction of hyperaemia_ is often helpful, the rubber bandage or the
hot-air chamber being employed for an hour or so morning and evening.

_Injection of Iodoform._--This is carried out on the same lines as have
been described for tuberculous abscess. After the fluid contents of the
joint are withdrawn, the iodoform is injected; and this may require to
be repeated in a month or six weeks.

After the injection of iodoform there is usually considerable reaction,
attended with fever (101 F.), headache, and malaise, and considerable
pain and swelling of the joint. In some cases there is sickness, and
there may be blood pigment in the urine. The severity of these phenomena
diminishes with each subsequent injection.

The use of Scott's dressing and of blisters and of the actual cautery
has largely gone out of fashion, but the cautery may still be employed
with benefit for the relief of pain in cases in which ulceration of
cartilage is a prominent feature.

The application of the X-rays has proved beneficial in synovial lesions
in superficial joints such as the wrist or elbow; prolonged exposures
are made at fortnightly intervals, and on account of the cicatricial
contraction which attends upon recovery, the joint must be kept in good
position.

Conservative treatment is only abandoned if improvement does not show
itself after a thorough trial, or if the disease relapses after apparent
cure.

_Operative Treatment._--Other things being equal, operation is more
often indicated in adults than in children, because after the age of
twenty there is less prospect of recovery under conservative treatment,
there is more tendency for the disease to relapse and to invade the
internal organs, and there is no fear of interfering with the growth of
the bones. The state of the general health may necessitate operation as
the most rapid method of removing the disease. The social status of the
patient must also be taken into account; the bread-winner, under
existing social conditions, may be unable to give up his work for a
sufficient time to give conservative measures a fair trial.

The _local conditions_ which decide for or against operation are
differently regarded by different surgeons, but it may be said in
general terms that operative interference is indicated in cases in which
the disease continues to progress in spite of a fair trial of
conservative measures; in cases unsuited for conservative
treatment--that is to say, where there are severe bone lesions.
Operative interference is indicated also when the functional result will
be better than that likely to be obtained by conservative measures, as
is often the case in the knee and elbow. Cold abscesses should, if
possible, be dealt with before operating on the joint.

In many cases the extent of the operation can only be decided after
exploration. The aim is to remove all the disease with the least
impairment of function and the minimum sacrifice of healthy tissue. The
more open the method of operating the better, so that all parts of the
joint may be available for inspection. The methods of Kocher, which
permit of dislocating the joint, are specially to be recommended, as
this procedure affords the freest possible access. Diseased synovial
membrane is removed with the scissors or knife. If the cartilages are
sound, and if a movable joint is aimed at, they may be left; but if
ankylosis is desired, they must be removed. Localised disease of the
cartilage should be removed with the spoon or gouge, and the bone
beneath investigated. If the articular surface is extensively diseased,
a thin slice of bone should be removed, and if foci in the marrow are
then revealed, it is better to gouge them out than to remove further
slices of bone, as this involves sacrifice of the cortex and periosteum.

Operative treatment of deformities resulting from tuberculous joint
disease has almost entirely replaced reduction by force; the contracted
soft parts are divided, and the bone is resected.

_Amputation_ for tuberculous joint disease has become one of the rare
operations of surgery, and is only justified when less radical measures
have failed and the condition of the limb is affecting the general
health. Amputation is more frequently called for in persons past middle
life who are the subjects of pulmonary tuberculosis.

SYPHILITIC DISEASE

Syphilitic affections of joints are comparatively rare. As in
tuberculosis, the disease may be first located in the synovial membrane,
or it may spread to the joint from one of the bones.

In #acquired syphilis#, at an early stage and before the skin eruptions
appear, one of the large joints, such as the shoulder or knee, may be
the seat of pain--_arthralgia_--which is worse at night. In the
secondary stage, a _synovitis_ with serous effusion is not uncommon, and
may affect several joints. Syphilitic _hydrops_ is met with almost
exclusively in the knee; it is frequently bilateral, and is insidious in
its onset and progress, the patient usually being able to go about.

In the _tertiary stage_ the joint lesions are persistent and
destructive, and result from the formation of gummata, either in the
deeper layers of the synovial membrane or in the adjacent bone or
periosteum.

_Peri-synovial_ and _peri-bursal gummata_ are met with in relation to
the knee-joint of middle-aged adults, especially women. They are usually
multiple, develop slowly, and are rarely sensitive or painful. One or
more of the gummata may break down and give rise to tertiary ulcers. The
co-existence of indolent swellings, ulcers, and depressed scars in the
vicinity of the knee is characteristic of tertiary syphilis.

The disease spreads throughout the capsule and synovial membrane, which
becomes diffusely thickened and infiltrated with granulation tissue
which eats into and replaces the articular cartilage. Clinically, the
condition resembles tuberculous disease of the synovial membrane, for
which it is probably frequently mistaken, but in the syphilitic
affection the swelling is nodular and uneven, and the subjective
symptoms are slight, mobility is little impaired, and yet the deformity
is considerable.

_Syphilitic osteo-arthritis_ results from a gumma in the periosteum or
marrow of one of the adjacent bones. There is gradual enlargement of one
of the bones, the patient complains of pains, which are worst at night.
The disease may extend to the synovial membrane and be attended with
effusion into the joint, or it may erupt on the periosteal surface and
invade the skin, forming one or more sinuses. The further progress is
complicated by the occurrence of pyogenic infection leading to necrosis
of bone, in the knee-joint, for example, the patella or one of the
condyles of the femur or tibia, may furnish a sequestrum. In such cases,
anti-syphilitic treatment must be supplemented by operation for the
removal of the diseased tissues. In the knee, excision is rarely
necessary; but in the elbow it may be called for to obtain a movable
joint.

In #inherited syphilis# the earliest joint affections are those in which
there is an effusion into the joint, especially the knee or elbow; and
in exceptional cases pyogenic infection may be superadded, and pus form
in the joint.

In older children, a gummatous synovitis is met with of which the most
striking features are: its insidious development, its chronic course,
symmetrical distribution, freedom from pain, the free mobility of the
joint, its tendency to relapse, and its association with other
syphilitic stigmata, especially in the eyes. The knees are the joints
most frequently affected, and the condition usually yields readily to
anti-syphilitic treatment without impairment of function.

JOINT DISEASES ACCOMPANYING CERTAIN CONSTITUTIONAL CONDITIONS

#Gout.#--_Arthritis Urica._--One of the manifestations of gout is that
certain joints are liable to attacks of inflammation associated with the
deposit of a chalk-like material composed of sodium biurate, chiefly in
the matrix of the articular cartilage, it may be in streaks or patches
towards the central area of the joint, or throughout the entire extent
of the cartilage, which appears as if it had been painted over with
plaster of Paris. As a result of this uratic infiltration, the cartilage
loses its vitality and crumbles away, leading to the formation of what
are known as gouty ulcers, and these may extend through the cartilage
and invade the bone. The deposit of urates in the synovial membrane is
attended with effusion into the joint and the formation of adhesions,
while in the ligaments and peri-articular structures it leads to the
formation of scar tissue. The metatarso-phalangeal joint of the great
toe, on one or on both sides, is that most frequently affected. The
disease is met with in men after middle life, and while common enough in
England and Ireland, is almost unknown in hospital practice in Scotland.

The _clinical features_ are characteristic. There is a sudden onset of
excruciating pain, usually during the early hours of the morning, the
joint becomes swollen, red, and glistening, with engorgement of the
veins and some fever and disturbance of health and temper. In the course
of a week or ten days there is a gradual return to the normal. Such
attacks may recur only once a year or they may be more frequent; the
successive attacks tend to become less acute but last longer, and the
local phenomena persist, the joint remaining permanently swollen and
stiff. Masses of chalk form in and around the joint, and those in the
subcutaneous tissue may break through the skin, forming indolent ulcers
with exposure of the chalky masses (_tophi_). The hands may become
seriously crippled, especially when the tendon sheaths and bursae also
are affected; the crippling resembles that resulting from arthritis
deformans but it differs in not being symmetrical.

The local _treatment_ consists in employing soothing applications and a
Bier's bandage for two or three hours twice daily while the symptoms are
acute; later, hot-air baths, massage, and exercises are indicated. It is
remarkable how completely even the most deformed joints may recover
their function. Dietetic and medicinal treatment must also be employed.

#Chronic Rheumatism.#--This term is applied to a condition which
sometimes follows upon acute articular rheumatism in persons presenting
a family tendency to acute rheumatism or to inflammations of serous
membranes, and manifesting other evidence of the rheumatic taint, such
as chorea or rheumatic nodules.

The changes in the joints involve almost exclusively the synovial
membrane and the ligaments; they consist in cellular infiltration and
exudation, resulting in the formation of new connective tissue which
encroaches on the cavity of the joint and gives rise to adhesions, and
by contracting causes stiffness and deformity. The articular cartilages
may subsequently be transformed into connective tissue, with consequent
fibrous ankylosis and obliteration of the joint. The bones are affected
only in so far as they undergo fatty atrophy from disuse of the limb, or
alteration in their configuration as a result of partial dislocation.
Osseous ankylosis may occur, especially in the small joints of the hand
and foot.

The disease is generally poly-articular and may be met with in childhood
and youth as well as in adult life. In some cases pain is so severe that
the patient resists the least attempt at movement. In others, the
joints, although stiff, can be moved but exhibit pronounced crackings.
When there is much connective tissue formed in relation to the synovial
membrane, the joint is swollen, and as the muscles waste above and
below, the swelling is spindle-shaped. Subacute exacerbations occur from
time to time, with fever and aggravation of the local symptoms and
implication of other joints. After repeated recurrences, there is
ankylosis with deformity, the patient becoming a helpless cripple. On
account of the tendency to visceral complications, the tenure of life is
uncertain.

From the nature of the disease, _treatment_ is for the most part
palliative. Salicylates are only of service during the exacerbations
attended with pyrexia. The application of soda fomentations, turpentine
cloths, or electric or hot-air baths may be useful. Improvement may
result from the general and local therapeutics available at such places
as Bath, Buxton, Harrogate, Strathpeffer, Wiesbaden, or Aix. In selected
cases, a certain measure of success has followed operative interference,
which consists in a modified excision. The deformities resulting from
chronic rheumatism are but little amenable to surgical treatment, and
forcible attempts to remedy stiffness or deformity are to be avoided.

#Arthritis Deformans# (_Osteo-arthritis, Rheumatoid Arthritis, Rheumatic
Gout, Malum Senile, Traumatic or Mechanical Arthritis_).--Under the term
arthritis deformans, which was first employed by Virchow, it is
convenient to include a number of joint affections which have many
anatomical and clinical features in common.

The disease is widely distributed in the animal kingdom, both in
domestic species and in wild animals in the natural state such as the
larger carnivora and the gorilla; evidence of it has also been found in
the bones of animals buried with prehistoric man.

The morbid changes in the joints present a remarkable combination of
atrophy and degeneration on the one hand and overgrowth on the other,
indicating a profound disturbance of nutrition in the joint structures.
The nature of this disturbance and its etiology are imperfectly known.
By many writers it is believed to depend upon some form of
auto-intoxication, the toxins being absorbed from the gastro-intestinal
tract, and those who suffer are supposed to possess what has been called
an "arthritic diathesis."

The localisation of the disease in a particular joint may be determined
by several factors, of which trauma appears to be the most important.
The condition is frequently observed to follow, either directly or after
an interval, upon a lesion which involves gross injury of the joint or
of one of the neighbouring bones. It occurs with greater frequency after
repeated minor injuries affecting the joint and its vicinity, such as
sprains and contusions, and particularly those sustained in laborious
occupations. This connection between trauma and arthritis deformans led
Arbuthnot Lane to apply to it the term _traumatic_ or _trade arthritis_.

The traumatic or strain factor in the production of the disease may be
manifested in a less obvious fashion. In the lower extremity, for
example, _any condition which disturbs the static equilibrium of the
limb as a whole_ would appear to predispose to the disease in one or
other of the joints. The static equilibrium may be disturbed by such
deformities as flat-foot or knock-knee, and badly united fractures of
the lower extremity. In hallux valgus, the metatarso-phalangeal joint of
the great toe undergoes changes characteristic of arthritis deformans.

A number of cases have been recorded in which arthritis deformans has
followed upon antecedent disease of the joint, such as pyogenic or
gonorrhoeal synovitis, upon repeated haemorrhages into the knee-joint in
bleeders, and in unreduced dislocations in which a new joint has been
established.

[Illustration: FIG. 157.--Arthritis Deformans of Elbow, showing
destruction of articular surfaces and masses of new bone around the
articular margins.

(Anatomical Museum, University of Edinburgh.)]