Alexis Thomson and Alexander Miles - Manual of Surgery

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Lastly, Poncet and other members of the Lyons school regard arthritis
deformans as due to an attenuated form of tuberculous infection, and
draw attention to the fact that a tuberculous family history is often
met with in the subjects of the disease.

[Illustration: FIG. 158.--Arthritis Deformans of Knee, showing
eburnation and grooving of articular surfaces.

(Anatomical Museum, University of Edinburgh.)]

_Morbid Anatomy._--The commonest type is that in which the articular
surfaces undergo degenerative changes. The primary change involves the
articular cartilage, which becomes softened and fibrillated and is worn
away until the subjacent bone is exposed. If the bone is rarefied, the
enlarged cancellous spaces are opened into and an eroded and worm-eaten
appearance is brought about; with further use of the joint, the bone is
worn away, so that in a ball-and-socket joint like the hip, the head of
the femur and the acetabulum are markedly altered in size and shape.
More commonly, the bone exposed as a result of disappearance of the
cartilage is denser than normal, and under the influence of the
movements of the joint, becomes smooth and polished--a change described
as _eburnation_ of the articular surfaces (Fig. 158). In hinge-joints
such as the knee and elbow, the influence of movement is shown by a
series of parallel grooves corresponding to the lines of friction
(Fig. 158).

[Illustration: FIG. 159.--Hypertrophied Fringes of Synovial Membrane in
Arthritis Deformans of Knee.

(Museum of Royal College of Surgeons, Edinburgh.)]

While these degenerative changes are gradually causing destruction of
the articular surfaces, reparative and hypertrophic changes are taking
place at the periphery. Along the line of the junction between the
cartilage and synovial membrane, the proliferation of tissue leads to
the formation of nodules or masses of cartilage--_ecchondroses_--which
are subsequently converted into bone (Fig. 157). Gross alterations in
the ends of the bone are thus brought about which can be recognised
clinically and in skiagrams, and which tend to restrict the normal range
of movement. The extension of the ossification into the synovial
reflection and capsular ligament adds a collar or "lip" of new bone,
known as "lipping" of the articular margins, and also into other
ligaments, insertions of tendons and intermuscular septa giving rise to
bony outgrowths or osteophytes not unlike those met with in the
neuro-arthropathies.

Proliferative changes in the synovial membrane are attended with
increased vascularity and thickening of the membrane and an enlargement
of its villi and fringes. When the fatty fringes are developed to an
exaggerated degree, the condition is described as an _arborescent
lipoma_ (Fig. 159). Individual fringes may attain the size of a hazel
nut, and the fibro-fatty tissue of which they are composed may be
converted into cartilage and bone; such a body may remain attached by a
narrow pedicle or stalk, or this may be torn across and the body becomes
loose and, unless confined in a recess of the joint, it wanders about
and may become impacted between the articular surfaces. These changes in
the synovial membrane are often associated with an abundant exudate or
hydrops. These degenerative and hypertrophic changes, while usually
attended with marked restriction of movement and sometimes by "locking"
of the joint, practically never result in ankylosis.

The _ankylosing type_ of chronic arthritis is fortunately much rarer
than those described above, and is chiefly met with in the joints of the
fingers and toes and in those of the vertebral column. The synovial
membrane proliferates, grows over the cartilage, and replaces it, and
when two such articular surfaces are in contact they tend to adhere,
thus obliterating the joint, cavity, and resulting in fibrous or bony
ankylosis. The changes progress slowly and, before they result in
ankylosis, various sub-luxations and dislocations may occur with
distortion and deformity which, in the case of the fingers, is extremely
disabling and unsightly (Fig. 160).

_Clinical Features._--It is usually observed that in patients who are
still young the tendency is for the disease to advance with considerable
rapidity, so that in the course of months it may cause crippling of
several joints. The course of the disease as met with in persons past
middle life is more chronic; it begins insidiously, and many years may
pass before there is pronounced disability. The earliest symptom is
stiffness, especially in the morning after rest, which passes off
temporarily with use of the limb. As time goes on, the range of movement
becomes restricted, and crackings occur. This stage of the disease may
be prolonged indefinitely; if it progresses, stiffness becomes more
pronounced, certain movements are lost, others develop in abnormal
directions, and deformed attitudes add to the disablement. The disease
is compatible with long life, but not with any active occupation, hence
those of the hospital class who suffer from it tend to accumulate in
workhouse infirmaries.

_Hydrops_ is most marked in the knee, and may affect also the adjacent
bursae. As the joint becomes distended with fluid, the ligaments are
stretched, the limb becomes weak and unstable, and the patient complains
of a feeling of weight, of insecurity, and of tiredness. Pain is
occasional and evanescent, and is usually the result of some extra
exertion, or exposure to cold and wet. This form of the disease is
extremely chronic, and may last for an indefinite number of years. It is
to be diagnosed from the other forms of hydrops already considered--the
purely traumatic, the pyogenic, gonorrhoeal, tuberculous, and
syphilitic--and from that associated with Charcot's disease.

_Hypertrophied fringes and pedunculated or loose bodies_ often co-exist
with hydrops, and give rise to characteristic clinical features,
particularly in the knee. The fringes, especially when they assume the
type of the arborescent lipoma, project into the cavity of the joint,
filling up its recesses and distending its capsule so that the joint is
swollen and slightly flexed. Pain is not a prominent feature, and the
patient may walk fairly well. On grasping the joint while it is being
actively flexed and extended, the fringes may be felt moving under the
fingers. Symptoms from impaction of a loose body are exceptional.

[Illustration: FIG. 160.--Arthritis Deformans of Hands, showing
symmetry of lesions, ulnar deviation of fingers, and nodular thickening
at inter-phalangeal joints.]

_The dry form of arthritis deformans_, although specially common in the
knee, is met with in other joints, either as a mon-articular or
poly-articular disease; and it is also met with in the joints of the
spine and of the fingers as well as in the temporo-mandibular joint. In
the joints of the fingers the disease is remarkably symmetrical, and
tends to assume a nodular type (Heberden's nodes) (Fig. 160); in younger
subjects it assumes a more painful and progressive fusiform type
(Fig. 161). In the larger joints the subjective symptoms usually precede
any palpable evidence of disease, the patient complaining of stiffness,
crackings, and aching, aggravated by changes in the weather. The
roughness due to fibrillation of the articular cartilages causes coarse
friction on moving the joint, or, in the knee, on moving the patella on
the condyles of the femur. It may be months or even years before the
lipping and other hypertrophic changes in the ends of the bones are
recognisable, and before the joint assumes the deformed features which
the name of the disease suggests.

The capsular ligament, except in hydrops, is the seat of
connective-tissue overgrowth, and tends to become contracted and rigid.
Intra-articular ligaments, such as the ligamentum teres in the hip, are
usually worn away and disappear. The surrounding muscles undergo
atrophy, tendons become adherent to their sheaths and may be ossified,
and the sheaths of nerves may be involved by the cicatricial changes in
the surrounding tissues.

_The X-ray appearances of arthritis deformans_ necessarily vary with the
type of the disease and the joint affected; in the joints of the fingers
there is a narrowing of the spaces between the articular ends of the
bones as a result of absorption of the articular cartilage, and
rarefaction of the cancellous tissue in the vicinity of the joints; in
the larger joints there is "lipping" of the articular margins,
osteophytes, and other evidence of abnormal ossification in and around
the joint. Eburnation of the articular surfaces is shown by increase in
the density of the shadow of the bone in the areas affected.

[Illustration: FIG. 161.--Arthritis Deformans affecting several
Joints, in a boy aet. 10.

(Dr. Dickson's case.)]

_Treatment._--Treatment is for the most part limited to the relief of
symptoms. On no account should the affected joints be kept at rest by
means of splints or other apparatus. Active movements and exercises of
all kinds are to be persevered with. When pain is a prominent feature,
it may be relieved either by douches of iodine and hot water (tincture
of iodine 1 oz. to the quart), or by the application of lint saturated
with a lotion made up of chloral hydrate, gr. v, glycerin [dram]j, water
[ounce]j, and covered with oil-silk. Strain and over-use of the joint
and sudden changes of temperature are to be avoided. The induction of
hyperaemia by means of massage, the elastic bandage, and hot-air baths is
often of service. Operative interference is indicated when the disease
is of a severe type, when it is mon-articular, and when the general
condition of the patient is otherwise favourable. Excision has been
practised with success in the hip, knee, elbow, and temporo-mandibular
joints. Limitation of movement and locking at the hip-joint when due to
new bone round the edge of the acetabulum may be greatly relieved by
removal of the bone--a procedure known as _cheilotomy_. Loose bodies and
hypertrophied fringes if causing symptoms may also be removed by
operation.

When stiffness and grating on movement are prominent features we have
found the injection of from half to one ounce of sterilised white
vaseline afford decided relief.

The patient should be nourished well, and there need be no restriction
in the diet such as is required in gouty patients, so long as the
digestion is not impaired. Benefit is also derived from the
administration of cod-liver oil, and of tonics, such as strychnin,
arsenic, and iron, and in some cases of iodide of potassium. Luff
recommends the administration over long periods of guaiacol carbonate,
in cachets beginning with doses of 5-10 grs. and increased to 15-20 grs.
thrice daily. A course of treatment at one of the reputed spas--Aix,
Bath, Buxton, Gastein, Harrogate, Strathpeffer, Wiesbaden, Wildbad--is
often beneficial.

In some cases benefit has followed the prolonged internal administration
of liquid paraffin.

On the assumption that the condition is the result of an
auto-intoxication from the intestinal tract, saline purges and
irrigation of the colon are indicated, and Arbuthnot Lane claims to have
brought about improvement by short-circuiting or by resecting the colon.

Residence in a warm and dry climate, with an open-air life, has been
known to arrest the disease when other measures have failed to give
relief.

The application of radium and the ingestion of radio-active waters have
also been recommended.

#Haemophilic# or #Bleeder's Joint#.--This is a rare but characteristic
affection met with chiefly in the knee-joint of boys who are the
subjects of haemophilia. After some trivial injury, or even without
apparent cause, a haemorrhage takes place into the joint. The joint is
tensely swollen, cannot be completely extended, and is so painful that
the patient is obliged to lie up. The temperature is often raised (101
to 102 F.), especially if there are also haemorrhages elsewhere. The
blood in the joint is slowly re-absorbed, and by the end of a fortnight
or so, the symptoms completely disappear. As a rule these attacks are
repeated; the pain attending them diminishes, but the joint becomes the
seat of permanent changes: the synovial membrane is thickened,
abnormally vascular, and coloured brown from the deposit of blood
pigment; on its surface, and in parts of the articular cartilage, there
is a deposit of rust-coloured fibrin; there may be extensive adhesions,
and in some cases changes occur like those observed in arthritis
deformans with erosion and ulceration of the cartilage and a form of dry
caries of the articular surfaces, which may terminate in ankylosis.

As the swelling of the joint is associated with wasting of the muscles,
with stiffness, and with flexion, the condition closely resembles
tuberculous disease of the synovial membrane. From errors in diagnosis
such joints have been operated upon, with disastrous results due to
haemorrhage.

The treatment of a recent haemorrhage consists in securing absolute rest
and applying elastic compression. The introduction of blood-serum (10-15
c.c.) into a vein may assist in arresting the haemorrhage;
anti-diphtheritic serum is that most readily obtainable.

After an interval, measures should be adopted to promote the absorption
of blood and to prevent stiffness and flexion; these include massage,
movements, and extension with weight and pulley.

JOINT DISEASES ASSOCIATED WITH LESIONS OF THE NERVOUS SYSTEM:
NEURO-ARTHROPATHIES

_In Lesions of Peripheral Nerves._--In the hand, and more rarely in the
foot, when one or other of the main nerve-trunks has been divided or
compressed, the joints may become swollen and painful and afterwards
become stiff and deformed. Bony ankylosis has been observed.

_In Affections of the Spinal Medulla._--In myelitis, progressive
muscular atrophy, poliomyelitis, insular sclerosis, and in traumatic
lesions, joint affections are occasionally met with.

The occurrence of joint lesions in _locomotor ataxia_ (tabes dorsalis)
was first described by Charcot in 1868--hence the term "Charcot's
disease" applied to them. Although they usually develop in the ataxic
stage, one or more years after the initial spinal symptoms, they may
appear before there is any evidence of tabes. The onset is frequently
determined by some injury. The joints of the lower extremity are most
commonly affected, and the disease is bilateral in a considerable
proportion of cases--both knees or both hips, for instance, being
implicated.

Among the theories suggested in explanation of these arthropathies the
most recent is that by Babinski and Barre, which traces the condition to
vascular lesions of a syphilitic type in the articular arteries.

The first symptom is usually a swelling of the joint and its vicinity.
There is no redness or heat and no pain on movement. The peri-articular
swelling, unlike ordinary oedema, scarcely pits even on firm pressure.

[Illustration: FIG. 162.--Bones of Knee-joint in advanced stage of
Charcot's Disease. The medial part of the head of the tibia has
disappeared.

(Anatomical Museum, University of Edinburgh).]

In mild cases this condition of affairs may persist for months; in
severe cases destructive changes ensue with remarkable rapidity. The
joint becomes enormously swollen, loses its normal contour, and the ends
of the bones become irregularly deformed (Fig. 162). Sometimes, and
especially in the knee, the clinical features are those of an enormous
hydrops with fibrinous and other loose bodies and hypertrophied
fringes--and great oedema of the peri-articular tissues (Fig. 163). The
joint is wobbly or flail-like from stretching and destruction of the
controlling ligaments, and is devoid of sensation. In other cases,
wearing down and total disappearance of the ends of the bones is the
prominent feature, attended with flail-like movements and with coarse
grating. Dislocation is observed chiefly at the hip, and is rather a
gross displacement with unnatural mobility than a typical dislocation,
and it is usually possible to move the bones freely upon one another and
to reduce the displacement. A striking feature is the extensive
formation of new bone in the capsular ligament and surrounding muscles.
The enormous swelling and its rapid development may suggest the growth
of a malignant tumour. The most useful factor in diagnosis is the entire
absence of pain, of tenderness, and of common sensibility. The freedom
with which a tabetic patient will allow his disorganised joint to be
handled requires to be seen to be appreciated.

[Illustration: FIG. 163.--Charcot's Disease of Left Knee. The joint is
distended with fluid and the whole limb is oedematous.]

The rapidity of the destructive changes in certain cases of tabes, and
the entire absence of joint lesions in others, would favour the view
that special parts of the spinal medulla must be implicated in the
former group.

In _syringomyelia_, joint affections (gliomatous arthropathies) are more
frequent than in tabes, and they usually involve the upper extremity in
correspondence with the seat of the spinal lesion, which usually affects
the lower cervical and upper thoracic segments. Except that the joint
disease is seldom symmetrical, it closely resembles the arthropathy of
tabes. The completeness of the analgesia of the articular structures
and of the overlying soft parts is illustrated by the fact that in one
case the patient himself was in the habit of letting out the fluid from
his elbow with the aid of a pair of scissors, and that in another the
joint was painlessly excised without an anaesthetic.

[Illustration: FIG. 164.--Charcot's Disease of both Ankles: front view.
Man, aet. 32.]

The disease may become arrested or may go on to complete
disorganisation; suppuration may ensue from infection through a breach
of the surface, and in rare cases the joint has become the seat of
tuberculosis.

[Illustration: FIG. 165.--Charcot's Disease of both Ankles: back view.
Man, aet. 32.]

_Treatment_, in addition to that of the nerve lesion underlying the
arthropathy, consists in supporting and protecting the joint by means of
bandages, splints, and other apparatus. In the lower extremity, the use
of crutches is helpful in taking the strain off the affected limb. When
there is much distension of the joint, considerable relief follows upon
withdrawal of fluid. The best possible result being rigid ankylosis in a
good position, it may be advisable to bring this about artificially by
arthrodesis or resection. Operation is indicated when only one joint is
affected and when the cord lesion is such as will permit of the patient
using the limb. The wounds heal well, but the victims of tabes are
unfavourable subjects for operative interference, on account of their
liability to intercurrent complications. When the limb is quite useless,
amputation may be the best course.

_In cerebral lesions_ attended with hemiplegia, joint affections,
characterised by evanescent pain, redness, and swelling, are
occasionally met with. The secondary changes in joints which are the
seat of paralytic contracture are considered with the surgery of the
Extremities.

In cases of _hysteria_ and other _functional affections of the
nervous system_, an intermittent neuropathic hydrops has been
observed--especially in the knee. Without apparent cause, the joint
fills with fluid and its movements become restricted, and after from two
to eight days the swelling subsides and the joint returns to normal. A
remarkable feature of the condition is that the effusion into the joint
recurs at regular intervals, it may be over a period of years. Psychic
conditions have been known to induce attacks, and sometimes to abort
them or even to cause their disappearance. Hence it has been recommended
that treatment by suggestion should be employed along with tonic doses
of quinine and arsenic.

HYSTERICAL OR MIMETIC JOINT AFFECTIONS

Under this heading, Sir Benjamin Brodie, in 1822, described an affection
of joints, characterised by the prominence of subjective symptoms and
the absence of pathological changes. Although most frequently met with
in young women with an impressionable nervous system, and especially
among those in good social circumstances, it occurs occasionally in men.
The onset may be referred to injury or exposure to cold, or may be
associated with some disturbance of the emotions or of the generative
organs; or the condition may be an involuntary imitation of the symptoms
of organic joint disease presented by a relative or friend.

It is characteristic that the symptoms develop abruptly without
satisfactory cause, that they are exaggerated and wanting in harmony
with one another, and that they do not correspond with the features of
any of the known forms of organic disease. In some cases the only
complaint is of severe pain; more often this is associated with
excessive tenderness and with impairment of the functions of the joint.
On examination the joint presents a normal appearance, but the skin
over it is remarkably sensitive. A light touch is more likely to excite
pain than deep and firm pressure. Stiffness is a variable feature--in
some cases amounting to absolute rigidity, so that no ordinary force
will elicit movement. It is characteristic of this, as of other
neuroses, that the symptoms come and go without sufficient cause. When
the patient's attention is diverted, the pain and stiffness may
disappear. There is no actual swelling of the joint, although there may
be an appearance of this from wasting of the muscles above and below. If
the joint is kept rigid for long periods, secondary contracture may
occur--in the knee with flexion, in the hip with flexion and adduction.

The _diagnosis_ is often a matter of considerable difficulty, and the
condition is liable to be mistaken for such organic lesions as a
tuberculous or pyogenic focus in the bone close to the joint.

The greatest difficulty is met with in the knee and hip, where the
condition may closely simulate tuberculous disease. The use of the
Rontgen rays, or examination of the joint under anaesthesia, is helpful.

The _local treatment_ consists chiefly in improving the nutrition of the
affected limb by means of massage, exercises, baths, and electricity.
Splints are to be avoided. In refractory cases, benefit may follow the
application of blisters or of Corrigan's button. The general condition
of the patient must be treated on the same lines as in other neuroses.
The Weir-Mitchell treatment may have to be employed in obstinate cases,
the patient being secluded from her friends and placed in charge of a
nurse. Complete recovery is the rule, but when the muscles are weak and
wasted from prolonged disuse, a considerable time may elapse before the
limb returns to normal.

TUMOURS AND CYSTS

New growths taking origin in the synovial membrane are rare, and are not
usually diagnosed before operation. They are attended with exudation
into the joint, and in the case of _sarcoma_ the fluid is usually
blood-stained. If the tumour projects in a polypoidal manner into the
joint, it may cause symptoms of loose body. One or two cases have been
recorded in which a _cartilaginous tumour_ growing from the synovial
membrane has erupted through the joint capsule and infiltrated the
adjoining muscles. _Multiple cartilaginous tumours_ forming loose bodies
are described on p. 544.

_Cysts of joints_ constitute an ill-defined group which includes ganglia
formed in relation to the capsular ligament. Cystic distension of bursae
which communicate with the joint is most often met with in the region of
the knee in cases of long-standing hydrops. It was suggested by Morrant
Baker that cystic swellings may result from the hernial protrusion of
the synovial membrane between the stretched fibres of the capsular
ligament, and the name "Baker's cysts" has been applied to these.

In the majority of cases, cysts in relation to joints give rise to
little inconvenience and may be left alone. If interfered with at all,
they should be excised.

LOOSE BODIES

It is convenient to describe the varieties of loose bodies under two
heads: those composed of fibrin, and those composed of organised
connective tissue.

#Fibrinous Loose Bodies# (Corpora oryzoidea).--These are homogeneous or
concentrically laminated masses of fibrin, sometimes resembling rice
grains, melon seeds, or adhesive wafers, sometimes quite irregular in
shape. Usually they are present in large numbers, but sometimes there is
only one, and it may attain considerable dimensions. They are not
peculiar to joints, for they are met with in tendon sheaths and bursae,
and their origin from synovial membrane may be accepted as proved. They
occur in tuberculosis, arthritis deformans, and in Charcot's disease,
and their presence is almost invariably associated with an effusion of
fluid into the joint. While they may result from the coagulation of
fibrin-forming elements in the exudate, their occurrence in tuberculous
hydrops would appear to be the result of coagulation necrosis, or of
fibrinous degeneration of the surface layer of the diseased synovial
membrane. However formed, their shape is the result of mechanical
influences, and especially of the movement of the joint.