Manual of Surgery, Alexis Thomson [new books to read txt] 📗

trabeculæ—caries. With the destruction of the ligaments, the stability of the joint is lost, and it becomes disorganised.

The clinical features vary with the extent of the infection. When this is confined to the synovial and peri-synovial tissues—acute serous and purulent synovitis—there is the usual general reaction, associated with pyrexia and great pain in the joint. The part is hot and swollen, the swelling assuming the shape of the distended synovial sac, fluctuation can usually be elicited, and the joint is held in the flexed position.

When the joint is infected by extension from the surrounding cellular tissue, the joint lesion may not be recognised at an early stage because of the swollen condition of the limb, and because there are already symptoms of toxæmia. We have observed a case in which both the hip and knee joints were infected from the cellular tissue.

If the infection involves all the joint structures—acute arthritis—the general and local phenomena are intensified, the temperature rises quickly, often with a rigor, and remains high; the patient looks ill, and is either unable to sleep or the sleep is disturbed by starting pains. The joint is held rigid in the flexed position, and the least attempt at movement causes severe pain; the slightest jar—even the shaking of the bed—may cause agony. The joint is hot, tensely distended, and there may be œdema of the peri-articular tissues or of the limb as a whole. If the pus perforates the joint capsule, there are signs of abscess or of diffuse suppuration in the cellular tissue. The final disorganisation of the joint is indicated by abnormal mobility and grating of the articular surfaces, or by spontaneous displacement of the bones, and this may amount to dislocation. In the acute arthritis of infants, the epiphysis concerned may be separated and displaced.

When the joint is infected through an external wound, the anatomical features are similar to those observed when the infection has reached the joint by the blood-stream, but the destructive changes tend to be more severe and are more likely to result in disorganisation.

The terminations vary with the gravity of the infection and with the stage at which treatment is instituted. In the milder forms recovery is the rule, with more or less complete restoration of function. In more severe forms the joint may be permanently damaged as a result of fibrous or bony ankylosis, or from displacement or dislocation. From changes in the peri-articular structures there may be contracture in an undesirable position, and in young subjects the growth of the limb may be interfered with. The persistence of sinuses is usually due to disease in one or other of the adjacent bones. In the most severe forms, and especially when several joints are involved, death may result from toxæmia.

The treatment is carried out on the same principles as in other pyogenic infections. The limb is immobilised in such an attitude that should stiffness occur there will be the least interference with function. Extension by weight and pulley is the most valuable means of allaying muscular spasm and relieving intra-articular tension and of counteracting the tendency to flexion; as much as 15 or 20 pounds may be required to relieve the pain.

The induction of hyperæmia is sometimes remarkably efficacious in relieving pain and in arresting the progress of the infection. If the fluid in the joint is in sufficient quantity to cause tension, if it persists, or if there is reason to suspect that it is purulent, it should be withdrawn without delay; an exploring syringe usually suffices, the skin being punctured with a tenotomy knife, and, as practised by Murphy, 5 to 15 c.c. of a 2 per cent. solution of formalin in glycerin are injected and the wound is closed. In virulent infections the injection may be repeated in twenty-four hours. Drainage by tube or otherwise is to be condemned (Murphy). A vaccine may be prepared from the fluid in the joint and injected into the subcutaneous cellular tissue.

Suppuration in the peri-articular soft parts or in one of the adjacent bones must be looked for and dealt with.

When convalescence is established, attention is directed to the restoration of the functions of the limb, and to the prevention of stiffness and deformity by movements and massage, and the use of hot-air and other baths.

At a later stage, and especially in neglected cases, operative and other measures may be required for deformity or ankylosis.

Metastatic Forms of Pyogenic Infection

In pyæmia, one or more joints may fill with pus without marked symptoms or signs, and if the pus is aspirated without delay the joint often recovers without impairment of function.

In typhoid fever, joint lesions result from infection with the typhoid bacillus alone or along with pyogenic organisms, and run their course with or without suppuration; there is again a remarkable absence of symptoms, and attention may only be called to the condition by the occurrence of dislocation.

Joint lesions are comparatively common in scarlet fever, and were formerly described as scarlatinal rheumatism. The most frequent clinical type is that of a serous synovitis, occurring within a week or ten days from the onset of the fever. Its favourite seat is in the hand and wrist, the sheaths of the extensor tendons as well as the synovial membrane of the joints being involved. It does not tend to migrate to other joints, and rarely lasts longer than a few days. It is probably due to the specific virus of scarlet fever.

At a later stage, especially in children and in cases in which the throat lesion is severe, an arthritis is sometimes observed that is believed to be a metastasis from the throat; it may be acute and suppurative, affect several joints, and exhibit a septicæmic or pyæmic character.

The joints of the lower extremity are especially apt to suffer; the child is seriously ill, is delirious at night, develops bed-sores over the sacrum and, it may happen that, not being expected to recover, the legs are allowed to assume contracture deformities with ankylosis or dislocation at the hip and flexion ankylosis at the knees; should the child survive, the degree of crippling may be pitiable in the extreme; prolonged orthopædic treatment and a series of operations—arthroplasty, osteotomies, and resections—may be required to restore even a limited capacity of locomotion.

Pneumococcal affections of joints, the result of infection with the pneumococcus of Fraenkel, are being met with in increasing numbers. The local lesion varies from a synovitis with infiltration of the synovial membrane and effusion of serum or pus, to an acute arthritis with erosion of cartilage, caries of the articular surfaces, and disorganisation of the joint. The knee is most frequently affected, but several joints may suffer at the same time. In most cases the joint affection makes its appearance a few days after the commencement of a pneumonia, but in a number of instances, especially among children, the lung is not specially involved, and the condition is an indication of a generalised pneumococcal infection, which may manifest itself by endocarditis, empyema, meningitis, or peritonitis, and frequently has a fatal termination. The differential diagnosis from other forms of pyogenic infection is established by bacteriological examination of the fluid withdrawn from the joint. The treatment is carried out on the same lines as in other pyogenic infections, considerable reliance being placed on the use of autogenous vaccines.

In measles, diphtheria, smallpox, influenza, and dysentery, similar joint lesions may occur.

The joint lesions which accompany acute rheumatism or “rheumatic fever” are believed to be due to a diplococcus. In the course of a general illness in which there is moderate pyrexia and profuse sweating, some of the larger joints, and not infrequently the smaller ones also, become swollen and extremely sensitive, so that the sufferer lies in bed helpless, dreading the slightest movement. From day to day fresh joints are attacked, while those first affected subside, often with great rapidity. Affections of the heart-valves and of the pericardium are commonly present. On recovery from the acute illness, it may be found that the joints have entirely recovered, but in a small proportion of cases certain of them remain stiff and pass into the crippled condition described under chronic rheumatism. There is no call for operative interference.

Gonococcal Affections of Joints.—These include all forms of joint lesion occurring in association with gonorrhœal urethritis, vulvo-vaginitis, or gonorrhœal ophthalmia. They may develop at any stage of the urethritis, but are most frequently met with from the eighteenth to the twenty-second day after the primary infection, when the organisms have reached the posterior urethra; they have been observed, however, after the discharge has ceased. There is no connection between the severity of the gonorrhœa and the incidence of joint disease. In women, the gonorrhœal nature of the discharge must be established by bacteriological examination.

As a complication of ophthalmia, the joint lesions are met with in infants, and occur more commonly towards the end of the second or during the third week.

The gonococcus is carried to the joint in the blood-stream and is first deposited in the synovial membrane, in the tissues of which it can usually be found; it may be impossible to find it in the exudate within the joint. The joint lesions may be the only evidence of metastasis, or they may be part of a general infection involving the endocardium, pleura, and tendon sheaths.

The joints most frequently affected are the knee, elbow, ankle, wrist, and fingers. Usually two or more joints are affected.

Several clinical types are differentiated. (1) A dry poly-arthritis met with in the joints and tendon sheaths of the wrist and hand, formerly described as gonorrhœal rheumatism, which in some cases is trifling and evanescent, and in others is persistent and progressive, and results in stiffness of the affected joints and permanent crippling of the hand and fingers.

(2) The commonest type is a chronic synovitis or hydrops, in which the joint—very often the knee—becomes filled with a serous or sero-fibrinous exudate. There are no reactive changes in the synovial membrane, cellular tissue, or skin, nor is there any fever or disturbance of health. The movements are free except in so far as they are restricted by the amount of fluid in the joint. It usually subsides in two or three weeks under rest, but tends to relapse.

(3) An acute synovitis with peri-articular phlegmon is most often met with in the elbow, but it occurs also in the knee and ankle. There is a sudden onset of severe pain and swelling in and around the joint, with considerable fever and disturbance of health. The slightest movement causes pain, and the part is sensitive to touch. The skin is hot and tense, and in the case of the elbow may be red and fiery as in erysipelas.

The deposit of fibrin on the synovial membrane and on the articular surfaces may lead to the formation of adhesions, sometimes in the form of isolated bands, sometimes in the form of a close fibrous union between the bones.

(4) A suppurative arthritis, like that caused by ordinary pus microbes, may be the result of gonococcal infection alone or of a mixed infection. Usually only one joint is affected, but the condition may be multiple. The articular cartilages are destroyed, the ends of the bones are covered with granulations, extra-articular abscesses form, and complete osseous ankylosis results.

The diagnosis is often missed because the possibility of gonorrhœa is not suspected.

The denial of the disease by the patient is not always to be relied upon, especially in the case of women, as they may be ignorant of its presence. The chief points in the differential diagnosis from acute articular rheumatism are, that the gonorrhœal affection is more often confined to one or two joints, has little tendency to wander from joint to joint, and its progress is not appreciably influenced by salicylates, although these drugs may relieve pain. The conclusive point is the recognition of a gonorrhœal discharge or of threads in the urine.

The disease may persist or may