Fig. 145.—Radiogram of Myeloma of Humerus. (Mr. J.W. Struthers' case.)Fig. 145.—Radiogram of Myeloma of Humerus.(Mr. J. W. Struthers' case.)
Fig. 145.—Radiogram of Myeloma of Humerus.
(Mr. J. W. Struthers' case.)
Fibromais met with chiefly as a periosteal growth in relation to the mouth and pharynx, thesimple epulisof the alveolar margin and thenaso-pharyngeal polypusbeing the most common examples. We have met with a fibroma in the interior of the lower end of the femur of an adult, causing expansion of the bone with decided increase in girth and liability to pathological fracture; it is possible that this represents the cured stage of osteomyelitis fibrosa.
Myxoma,lipoma, andangiomaof bone are all rare.
Myeloma.—The myeloid tumour, which is sometimes classified with the sarcomas, contains as its chief elements large giant cells, like those normally present in the marrow. On section these tumours present a brownish-red or chocolate colour, and, being highly vascular, are liable to hæmorrhages, and therefore also to pigmentation, and to the formation of blood cysts. Sometimes the arterial vessels are so dilated as to impart to the tumour an aneurysmal pulsation and bruit. The enlargement or “expansion” of the bone results in the cortex being represented by a thin shell of bone, which may crackle on pressure—parchment or egg-shell crackling.
The myeloma is most often met with between the ages of twenty-five and forty in the upper end of the tibia or lower end of the femur. It grows slowly and causes little pain, and may long escape recognition unless an examination is made with the X-rays. Although these tumours have been known to give rise to metastases, they are, as a rule, innocent and are to be treated as such. When located in the shaft of a long bone, pathological fracture is liable to occur.
Diagnosis and X-ray Appearances of Myeloma.—The early diagnosis of myeloma is made with the aid of the X-rays: the typical appearance is that of a rounded or oval clear area bounded by a shell of bone of diminishing thickness (Fig. 145). The inflammatory lesions at the ends of the long bones—tubercle, syphilitic gumma, and Brodie's abscess, that resemble myeloma, are all attended with the formation of new bone in greater or lesser amount. The myeloma is also to be diagnosed from chondroma, from sarcoma, and from osteomyelitis fibrosa cystica.
Treatment.—In early cases the cortex is opened up to give free access to the tumour tissue, which is scraped out with the spoon. Bloodgood advises the use of Esmarch's tourniquet, and that the curetting be followed by painting with pure carbolic acid and then rinsing with alcohol; a rod of bone is inserted to fill the gap. In advanced cases the segment of bone is resectedand a portion of the tibia or fibula from the other limb inserted into the gap; a tube of radium should also be introduced.
Fig. 146.—Periosteal Sarcoma of Femur in a young subject.Fig. 146.—Periosteal Sarcoma of Femur in a young subject.
Fig. 146.—Periosteal Sarcoma of Femur in a young subject.
The coexistence of diffuse myelomatosis of the skeleton and albumosuria (Bence-Jones) is referred to onp. 474. Myeloma occurs in the jaws, taking origin in the marrow or from the periosteum of the alveolar process, and is described elsewhere.
Sarcomaandendotheliomaare the commonest tumours of bone, and present wide variations in structure and in clinical features. Structurally, two main groups may be differentiated: (1) the soft, rapidly growing cellular tumours, and (2) those containing fully formed fibrous tissue, cartilage, or bone.
Fig. 147.—Periosteal Sarcoma of Humerus, after maceration. (Anatomical Museum, University of Edinburgh.)Fig. 147.—Periosteal Sarcoma of Humerus, after maceration.(Anatomical Museum, University of Edinburgh.)
Fig. 147.—Periosteal Sarcoma of Humerus, after maceration.
(Anatomical Museum, University of Edinburgh.)
(1) Thesoft cellular tumoursare composed mainly of spindle or round cells; they grow from the marrow of the spongy ends or from the periosteum of the long bones, the diploë of the skull, the pelvis, vertebræ, and jaws. As they grow they may cause little alteration in the contour of the bone, but they eat away its framework and replace it, so that the continuity of the bone is maintained only by tumour tissue, and pathological fracture is a frequent result. The small round-celled sarcomas are among the most malignant tumours of bone, growing with great rapidity, and at an early stage giving rise to secondary growths.
(2) The second group includes thefibro-,osteo-, andchondro-sarcomas, and combinations of these; in all of them fully formed tissues or attempts at fully formed tissues predominate over the cellular elements. They grow chiefly from the deeper layer of the periosteum, and at first form a projection on thesurface, but later tend to surround the bone (Fig. 150), and to invade its interior, filling up the marrow spaces with a white, bone-like substance; in the flat bones of the skull they may traverse the diploë and erupt on the inner table. The tumour tissue next the shaft consists of a dense, white, homogeneous material, from which there radiate into the softer parts of the tumour, spicules, needles, and plates, often exhibiting a fan-like arrangement (Fig. 151). The peripheral portion consists of soft sarcomatous tissue, which invades the overlying soft parts. The articular cartilage long resists destruction. The ossifying sarcoma is met with most often in the femur and tibia, less frequently in the humerus, skull, pelvis, and jaws. In the long bones it may grow from the shaft, while the chondro-sarcoma more often originates at the extremities. Sometimes they are multiple, several tumours appearing simultaneously or one after another. Secondary growths are met with chiefly in the lungs, metastasis taking place by way of the veins.
Clinical Features.—Sarcoma is usually met with before the age of thirty, and is comparatively common in children. Males suffer oftener than females, in the proportion of two to one.
Inperiosteal sarcomathe presence of a swelling is usually the first symptom; the tumour is fusiform, firm, and regular in outline, and when it occurs near the end of a long bone the limb frequently assumes a characteristic “leg of mutton” shape (Fig. 146). The surface may be uniform or bossed, the consistence varies at different parts, and the swelling gradually tapersoff along the shaft. On firm pressure, fine crepitation may be felt from crushing of the delicate framework of new bone.
Fig. 148.—Chondro-Sarcoma of Scapula in a man æt. 63; removal of the scapula was followed two years later by metastases and death.Fig. 148.—Chondro-Sarcoma of Scapula in a man æt. 63; removal of the scapula was followed two years later by metastases and death.
Fig. 148.—Chondro-Sarcoma of Scapula in a man æt. 63; removal of the scapula was followed two years later by metastases and death.
Incentral sarcomapain is the first symptom, and it is usually constant, dull, and aching; is not obviously increased by use of the limb, but is often worse at night. Swelling occurs late, and is due to expansion of the bone; it is fusiform or globular, and is at first densely hard, but in time there may be parchment-like or egg-shell crackling from yielding of the thin shell. The swelling may pulsate, and a bruit may be heard over it. In advanced cases it may be impossible to differentiate between aperiosteal and a central tumour, either clinically or after the specimen has been laid open.
Fig. 149.—Central Sarcoma of Lower End of Femur, invading the knee-joint. (Museum of Royal College of Surgeons, Edinburgh.)Fig. 149.—Central Sarcoma of Lower End of Femur, invading the knee-joint.(Museum of Royal College of Surgeons, Edinburgh.)
Fig. 149.—Central Sarcoma of Lower End of Femur, invading the knee-joint.
(Museum of Royal College of Surgeons, Edinburgh.)
Pathological fracture is more common in central tumours, and sometimes is the first sign that calls attention to the condition. Consolidation rarely takes place, although there is often an attempt at union by the formation of cartilaginous callus.
Fig. 150.—Osseous Shell of Osteo-Sarcoma of Upper Third of Femur, after maceration.Fig. 150.—Osseous Shell of Osteo-Sarcoma of Upper Third of Femur, after maceration.
Fig. 150.—Osseous Shell of Osteo-Sarcoma of Upper Third of Femur, after maceration.
The soft parts over the tumour for a long time preserve their normal appearance; or they become œdematous, and the subcutaneous venous network is evident through the skin. Elevation of the temperature over the tumour, which may amount to two degrees or more, is a point of diagnostic significance, as it suggests an inflammatory lesion.
The adjacent joint usually remains intact, although its movements may be impaired by the bulk of the tumour or by effusion into the cavity.
Enlargement of the neighbouring lymph glands does not necessarily imply that they have become infected with sarcomafor the enlargement may disappear after removal of the primary growth; actual infection of the glands, however, does sometimes occur, and in them the histological structure of the parent tumour is reproduced.
To obtain a reasonable prospect of cure, thediagnosismust be made at an early stage. Great reliance is to be placed on information gained by examination with the X-rays.
X-ray Appearances.—In periosteal tumours that do not ossify, there is merely erosion of bone, and the shadow is not unlike that given by caries; in ossifying tumours, the arrangement of the new bone on the surface is characteristic, and when it takes the form of spicules at right angles to the shaft, it is pathognomic.
In soft central tumours, there is disappearance of bone shadow in the area of the tumour, while above and below or around this, the shadow is that of normal bone right up to the clear area. In many respects the X-ray appearancesresemble those of myeloma. In tumours in which there is a considerable amount of imperfectly formed new bone, this gives a shadow which barely replaces that of the original bone, in parts it may even add to it—the resulting picture differing widely in different cases; but it is usually possible to differentiate it from that caused by bacterial infections of the bone and from lesions of the adjacent joint.
Fig. 151.—Radiogram of Osteo-Sarcoma of Upper Third of Femur.Fig. 151.—Radiogram of Osteo-Sarcoma of Upper Third of Femur.
Fig. 151.—Radiogram of Osteo-Sarcoma of Upper Third of Femur.
Skiagraphy is not only of assistance in differentiating new growths from other diseases of bone, but may also yield information as to the situation and nature of the tumour, which may have important bearings on its treatment by operation.
Fig. 152.—Radiogram of Chondro-Sarcoma of Upper End of Humerus in a woman æt. 29.Fig. 152.—Radiogram of Chondro-Sarcoma of Upper End of Humerus in a woman æt. 29.
Fig. 152.—Radiogram of Chondro-Sarcoma of Upper End of Humerus in a woman æt. 29.
When fracture of a long bone takes place in an adolescent or young adult from comparatively slight violence, disease of the bone should be suspected and an X-ray examination made.
In difficult cases the final appeal is to exploratory incision and microscopical examination of a portion of the tumour; this should be done when the major operation has been arranged for, the surgeon waiting until the examination is completed.
Theprognosisvaries widely. In general, it may be said that periosteal tumours are less favourable than central ones, because they are more liable to give rise to metastases. Permanent cures are unfortunately the exception.
Treatment.—When one of the bones of a limb is involved, the usual practice has been to perform amputation well above the growth, and this may still be recommended as a routine procedure. There are reasons, however, which may be urged against its continuance. High amputation is unnecessary in the more benign sarcomas, and in the more malignant forms is usually unavailing to prevent a fatal issue either from local recurrence or frommetastasesin the lungs or elsewhere. Following the lead of Mikulicz, a considerable number of permanent cures have been obtained by resecting the portion of bone which is the seat of the tumour, and substituting for it a corresponding portion from the tibia or fibula of the other limb. In a cellular sarcoma of the humerus of a boy we resected the shaft and inserted his fibula ten years ago, and he shows no sign of recurrence. When resection is impracticable, a subcapsular enucleation is performed, followed by the insertion of radium.
Pulsating HæmatomaorAneurysm of Bone.—A limited number of these are innocent cavernous tumours dating from a congenital angioma. The majority would appear to be the result of changes in a sarcoma, endothelioma, or myeloma. The tumour tissue largely disappears, while the vessels and vascular spaces undergo a remarkable development. The tumour may come to be represented by one large blood-containing space communicating with the arteries of the limb; the walls of the space consist of the remains of the original tumour, plus a shell of bone of varying thickness. The most common seats of the condition are the lower end of the femur, the upper end of the tibia, and the bones of the pelvis.
Theclinical featuresare those of a pulsating tumour ofslow development, and as in true aneurysm, the pulsation and bruit disappear on compression of the main artery. The origin of the tumour from bone may be revealed by the presence of egg-shell crackling, and by examination with the X-rays.
If the condition is believed to be innocent, the treatment is the same as for aneurysm—preferably by ligation of the main artery; if malignant, it is the same as for sarcoma.
Secondary Tumours of Bone.—These embrace two groups of new growth, those which give rise to secondary growths in the marrow of bones and those which spread to bone by direct continuity.
Metastatic Tumours.—Excepting certain cancers which give rise to metastases by lymphatic permeation (Handley), the common metastases arising in the bone-marrow reach their destination through the blood-stream.
Fig. 153.—Epitheliomatous Ulcer of Leg with direct extension to Tibia. (Lord Lister's specimen. Anatomical Museum, University of Edinburgh.)Fig. 153.—Epitheliomatous Ulcer of Leg with direct extension to Tibia.(Lord Lister's specimen. Anatomical Museum, University of Edinburgh.)
Fig. 153.—Epitheliomatous Ulcer of Leg with direct extension to Tibia.
(Lord Lister's specimen. Anatomical Museum, University of Edinburgh.)
Secondary cancer is a comparatively common disease, and, as in metastases in other tissues, the secondary growths resemble the parent tumour. The soft forms grow rapidly, and eat away the bone, without altering its shape or form. In slowly growing forms there may be considerable formation of imperfectly formed bone, often deficient in lime salts; this condition may be widely diffused throughout the skeleton, and, as it is associated with softening and bending of the bones, it is known ascancerous osteomalacia. Secondary cancer of bone is attended with pain, or it suddenly attracts notice by the occurrence of pathological fracture—as, for example, in the shaft of the femur or humerus. In the vertebræ, it is attended with a painful form of paraplegia, which may involve the lower or all four extremities. On the other hand, the disease may show itself clinically as a tumour of bone, which may attain a considerable size, and may be mistaken for a sarcoma, unless the existence of the primary cancer is discovered.
The cancers most liable to give rise to metastasis in bone are those of the breast, liver, uterus, prostate, colon, and rectum; hyper-nephroma of the kidney may also give rise to metastases in bone.
Secondary tumours derived from the thyreoid glandrequire special mention, because they are peculiar in that neither the primary growth in the thyreoid nor the secondary growth in the bones is necessarily malignant. They are therefore amenable to operative treatment.
Secondary sarcoma, whether derived from a primary growth in the bone or in the soft parts, is much rarer than secondary cancer. Its removal by operation is usually contra-indicated, but we have known of cases terminating fatally in which thesectionrevealed only one metastasis, the removal of which would have benefited the patient.
In all of these conditions, examination of the bones with the X-rays gives valuable information and often disclose unsuspected metastases.
Cancer of Bone resulting from Direct Extension from Soft Parts.—In this group there are also two clinical types. The first is met with in relation toepithelioma of a mucous surface—for example, the palate, tongue, gums, antrum, frontal sinus, auditory meatus, or middle ear. They will be described under these special regions.
The second type is met with in relation toepithelioma occurring in a sinus, the sequel of suppurative osteomyelitis, compound fracture, or tuberculous disease. The patient has usually had a discharging sinus for a great number of years: we have known it to last as many as fifty. The epithelioma originates at the skin orifice of the sinus, and spreads to the bone and into its interior, where the progress of the cancer is resisted by dense bone, which obliterates the medullary canal. Although its progress is slow, the infiltration of the bone is usually more extensive than appears externally. It is recognised clinically by the characteristic cauliflower growth at the orifice of the sinus, and by the offensive nature of the discharge. A similar epithelioma may arise in connection with achronic ulcer of the leg. The cancer may infect the femoral lymph glands. The operative treatment is influenced by the extent of the disease in the soft parts overlying the bone, and consists in wide removal of the diseased tissues and resection of the bone, or in amputation.
Cysts of Bone.—With the exception of hydatid cysts, cysts in the interior of bone are the result of the liquefaction of solid tissue; this may be that of chondroma, myeloma, or sarcoma, but more commonly of the marrow in osteomyelitis fibrosa.
Definition of Terms.—The termsynovitisis applied to any reaction which affects the synovial membrane of a joint. It is usually associated with effusion of fluid, and this may be serous, sero-fibrinous, or purulent. As the term synovitis merely refers to the tissue involved, it should always be used with an adjective—such as gouty, gonorrhœal, or tuberculous—which indicates its pathological nature.
The termshydrops,hydrarthrosis, andchronic serous synovitisare synonymous, and are employed when a serous effusion into the joint is the prominent clinical feature. Hydrops may occur apart from disease—for example, in the knee-joint from repeated sprains, or when there is a loose body in the joint—but is met with chiefly in the chronic forms of synovitis which result from gonorrhœa, tuberculosis, syphilis, arthritis deformans, or arthropathies of nerve origin.
Arthritisis the term applied when not only the synovial membrane but the articular surfaces, and it may be also the ends of the bones, are involved, and it is necessary to prefix a qualifying adjective which indicates its nature. When effusion is present, it may be serous, as in arthritis deformans, or sero-fibrinous or purulent, as in certain forms of pyogenic and tuberculous arthritis. Wasting of the muscles, especially the extensors, in the vicinity of the joint is a constant accompaniment of arthritis. On account of the involvement of the articular surfaces, arthritis is apt to be followed by ankylosis.
The termempyemais sometimes employed to indicate that the cavity of the joint contains pus. This is observed chiefly inchronic disease of pyogenic or tuberculous origin, and is usually attended with the formation of abscesses outside the joint.
Ulceration of cartilageandcaries of the articular surfacesare common accompaniments of the more serious and progressive forms of joint disease, especially those of bacterial origin. The destruction of cartilage may be secondary to disease of the synovial membrane or of the subjacent bone. When the disease begins as a synovitis, the synovial membrane spreads over the articular surface, fuses with the cartilage and eats into it, causing defects or holes which are spoken of as ulcers. When the disease begins in the bone, the marrow is converted into granulation tissue, which eats into the cartilage and separates it from the bone. Following on the destruction of the cartilage, the articular surface of the bone undergoes disintegration, a condition spoken of ascaries of the articular surface. The occurrence of ulceration of cartilage and of articular caries is attended with the clinical signs of fixation of the joint from involuntary muscular contraction, wasting of muscles, and starting pains. Thesestarting painsare the result of sudden involuntary movements of the joint. They occur most frequently as the patient is dropping off to sleep; the muscles becoming relaxed, the sensitive ulcerated surfaces jar on one another, which causes sudden reflex contraction of the muscles, and the resulting movement being attended with severe pain, wakens the patient with a start. Advanced articular caries is usually associated with some abnormal attitude and with shortening of the limb. It may be possible to feel the bony surfaces grate upon one another. When all its constituent elements are damaged or destroyed, a joint is said to bedisorganised. Should recovery take place, repair is usually attended with union of the opposing articular surfaces either by fibrous tissue or by bone.
Conditions of Impaired Mobility of Joints.—There are four conditions of impaired mobility in joints: rigidity, contracture, ankylosis, and locking.Rigidityis the fixation of a joint by involuntary contraction of muscles, and is of value as a sign of disease in deep-seated joints, such as the hip. It disappears under anæsthesia.
Contractureis the term applied when the fixation is due to permanent shortening of the soft parts around a joint—muscles, tendons, ligaments, fasciæ, or skin. As the structures on the flexor aspect are more liable to undergo such shortening, contracture is nearly always associated with flexion. Contracture may result from disease of the joint, or from conditions outsideit—for example, disease in one of the adjacent bones, or lesions of the nerves.
Fig. 154.—Osseous Ankylosis of Femur and Tibia in position of flexion.Fig. 154.—Osseous Ankylosis of Femur and Tibia in position of flexion.
Fig. 154.—Osseous Ankylosis of Femur and Tibia in position of flexion.
Ankylosisis the term applied when impaired mobility results from changes involving the articular surfaces. It is frequently combined with contracture. Three anatomical varieties of ankylosis are recognised—(a) Thefibrous, in which there are adhesions between the opposing surfaces, which may be in the form of loose isolated bands of fibrous tissue, or may bind the bones so closely together as to obliterate the cavity of the joint. The resulting stiffness, therefore, varies from a mere restriction of the normal range of movement, up to a close union of the bones which prevents movement. Fibrous ankylosis may follow upon injury, especially dislocation or fracture implicating a joint, or it may result from any form of arthritis. (b)Cartilaginous ankylosisimplies the fusion of two apposed cartilaginous surfaces. It is often found between the patella and the trochlear surface of the femur in tuberculous disease of the knee. The fusion of the cartilaginous surfaces is preceded by the spreading of a vascular connective tissue, derived from the synovial membrane, over the articular cartilage. Clinically, it is associated with absolute immobility, (c)Bony ankylosisorsynostosisis an osseous union between articulating surfaces (Figs. 154and155). It may follow upon fibrous or cartilaginous ankylosis, or may result from the fusion of two articular surfaces which have lost their cartilage and become covered with granulations. In the majority of cases it is to be regarded as a reparative process, presenting analogies with the union of fracture.
The termarthritis ossificanshas been applied by Joseph Griffiths to a condition in which the articular surfaces become fused without evident cause.
The occurrence of ankylosis in a joint before the skeleton has attained maturity does not appear to impair the growth inlength of the bones affected; ankylosis of the temporo-maxillary joints, however, greatly impairs the growth of the mandible. When there is arrest of growth accompanying ankylosis, it usually depends on changes in the ossifying junctions caused by the original disease.
To differentiate by manipulation between muscular fixation and ankylosis, it may be necessary to anæsthetise the patient. The nature and extent of ankylosis may be learned by skiagraphy; in osseous ankylosis the shadow of the two bones is a continuous one. In fibrous as contrasted with osseous ankylosis mobility may be elicited, although only to a limited extent; while in osseous ankylosis the joint is rigidly fixed, and attempts to move it are painless.
Fig. 155.—Osseous Ankylosis of Knee in the flexed position following upon Tuberculous Arthritis. (Anatomical Museum, University of Edinburgh.)Fig. 155.—Osseous Ankylosis of Knee in the flexed position following upon Tuberculous Arthritis.(Anatomical Museum, University of Edinburgh.)
Fig. 155.—Osseous Ankylosis of Knee in the flexed position following upon Tuberculous Arthritis.
(Anatomical Museum, University of Edinburgh.)
Thetreatmentis influenced by the nature of the original lesion, the variety of the ankylosis, and the attitude of the joint. When there is restriction of movement due to fibrous adhesions, these may be elongated or ruptured. Elongation of the adhesions may be effected by manipulations, exercises, and the use of special forms of apparatus—such as the application of weights to the limb. It may be necessary to administer an anæsthetic before rupturing strong fibrous adhesions, and this procedure must be carried out with caution, in view of such risks as fracture of the bone—which is often rarefied—or separation of an epiphysis. There is also the risk of fat embolism, and of re-starting the original disease. The giving way of adhesions may be attended with an audible crack; and the procedure is often followed by considerable pain and effusion into the joint, which necessitate rest for some days before exercises and manipulations can be resumed.
Operative treatmentmay be called for in cases in which the bones are closely bound to one another by fibrous or by osseous tissue.
Arthrolysis, which consists in opening the joint and dividing the fibrous adhesions, is almost inevitably followed by their reunion.
Arthroplasty.—Murphy of Chicago devised this operation for restoring movement to an ankylosed joint. It consists in transplanting between the bones a flap of fat-bearing tissue, from which a bursal cavity lined with endothelium and containing a fluid rich in mucin is ultimately formed.
Arthroplasty is most successful in ankylosis following upon injury; when the ankylosis results from some infective condition such as tuberculosis or gonorrhœa, it is liable to result in failure either because of a fresh outbreak of the infection or because the ankylosis recurs.
When arthroplasty is impracticable, and a movable joint is desired—for example at the elbow—a considerable amount of bone, and it may be also of periosteum and capsular ligament, is resected to allow of the formation of a false joint.
When bony ankylosis has occurred with the joint in an undesirable attitude—for example flexion at the hip or knee—it can sometimes be remedied by osteotomy or by a wedge-shaped resection of the bone, with or without such additional division of the contracted soft parts as will permit of the limb being placed in the attitude desired.
Bony ankylosis of the joints of a finger, whether the result of injury or disease, is difficult to remedy by any operative procedure, for while it is possible to restore mobility, the new joint is apt to be flail-like.
Locking.—A joint is said to lock when its movements are abruptly arrested by the coming together of bony outgrowths around the joint. It is best illustrated in arthritis deformans of the hip in which new bone formed round the rim of the acetabulum mechanically arrests the excursions of the head of the femur. The new bone, which limits the movements, is readily demonstrated in skiagrams; it may be removed by operative means. Locking of joints is more often met with as a result of injuries, especially in fractures occurring in the region of the elbow. In certain injuries of the semilunar menisci of the knee, also, the joint is liable to a variety of locking, which differs, however, in many respects from that described above.
Errors of Development.—These include congenital dislocations and other deformities of intra-uterine origin, such as abnormal laxity of joints, absence, displacement, or defective growth of one or other of the essential constituents of a joint. The more important of these are described along with the surgery of the Extremities.
Bacterial Diseases.—In most bacterial diseases the organisms are carried to the joint in the blood-stream, and they lodge either in the synovial membrane or in one of the bones, whence the disease subsequently spreads to the other structures of the joint. Organisms may also be introduced through accidental wounds. It has been shown experimentally that joints are among the most susceptible parts of the body to infection, and this would appear to be due to the viscid character of the synovial fluid, which protects organisms from bactericidal agents in the tissues and fluids.
The commoner pyogenic diseases are the result of infection of one or other of the joint structures withstaphylococciorstreptococci, which may be demonstrated in the exudate in the joint and in the substance of the synovial membrane. The mode of infection is the same as in the pyogenic diseases of bone, the metastasis occurring most frequently from the mucous membrane of the pharynx (J. B. Murphy). The localisation of the infection in a particular joint is determined by injury, exposure to cold, antecedent disease of the joint, or other factors, the nature of which is not always apparent.
The effects on the joint vary in severity. In the milder forms, there is engorgement and infiltration of the synovial membrane, and an effusion into the cavity of the joint of serous fluid mixed with flakes of fibrin—serous synovitis. In more severe infections the exudate consists of pus mixed with fibrin, and, it may be, red blood corpuscles—purulentorsuppurative synovitis; the synovial membrane and the ligaments are softened, and the surface of the membrane presents granulations resembling those on an ulcer; foci of suppuration may develop in the peri-articular cellular tissue and result in abscesses. Inacute arthritis, all the structures of the joint are involved; the articular cartilage is invaded by granulation tissue derived from the synovial membrane, and from the marrow of the subjacent bone; it presents a worm-eaten or ulcerated appearance, or it may undergo necrosis and separate, exposing the subjacent bone and leading to disintegration of the osseous trabeculæ—caries. With the destruction of the ligaments, the stability of the joint is lost, and it becomes disorganised.
Theclinical featuresvary with the extent of the infection.When this is confined to the synovial and peri-synovial tissues—acute serousandpurulent 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 thejoint 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.
Theterminationsvary 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.
Thetreatmentis 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.
Inpyæmia, 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.
Intyphoid 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 inscarlet 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 theextensor 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 asynovitiswith infiltration of the synovial membrane and effusion of serum or pus, to anacute arthritiswith 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.
Inmeasles,diphtheria,smallpox,influenza, anddysentery, similar joint lesions may occur.
The joint lesions which accompanyacute rheumatismor “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 notinfrequently 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) Adry poly-arthritismet 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 achronic synovitisorhydrops, 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 inthe joint. It usually subsides in two or three weeks under rest, but tends to relapse.
(3) Anacute synovitiswith 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) Asuppurative 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.
Thediagnosisis 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 relapse, and the patient may be laid up for weeks or months, and may finally be crippled in one or in several joints.
Thetreatment—besides that of the urethral disease or of the ophthalmia—consists in rest until all pain and sensitiveness have disappeared. The pain is relieved by salicylates, but most benefit follows weight extension, the induction of hyperæmia by the rubber bandage and hot-air baths; if the joint is greatly distended, the fluid may be withdrawn by a needle and syringe. Detoxicated vaccines should be given from the first, and in afebrile cases the injection of a foreign protein, such as anti-typhoid vaccine, is beneficial (Harrison).
Murphy has found benefit from the introduction into thejoint, in the early stages, of from 5 to 15 c.c. of a 2 per cent. solution of formalin in glycerin. This may be repeated within a week, the patient being kept in bed with light weight extension. In the chronic hydrops the fluid is withdrawn, and about an ounce of a 1 per cent. solution of protargol injected; the patient should be warned of the marked reaction which follows.
After all symptoms have settled down, but not till then, for fear of exciting relapse or metastasis, the joint is massaged and exercised. Stiffness from adhesions is most intractable, and may, in spite of every attention, terminate in ankylosis even in cases where there has been no suppuration. Forcible breaking down of adhesions underanæsthesiais not recommended, as it is followed by great suffering and the adhesions re-form. Operation for ankylosis—arthroplasty—should not be undertaken, as the ankylosis recurs.
Tuberculous disease of joints results from bacillary infection through the arteries. The disease may commence in the synovial membrane or in the marrow of one of the adjacent bones, and the relative frequency of these two seats of infection has been the subject of considerable difference of opinion. The traditional view of König is that in the knee and most of the larger joints the disease arises in the bone and in the synovial membrane in about equal proportion, and that in the hip the number of cases beginning in the bones is about five times greater than that originating in the membrane. This estimate, so far as the actual frequency of bone lesions is concerned, has been generally accepted, but recent observers, notably John Fraser, do not accept the presence of bone lesions as necessarily proving that the disease commenced in the bones; he maintains, and we think with good grounds, that in many cases the disease having commenced in the synovial membrane, slowly spreads to the bone by way of the blood vessels and lymphatics, and gives rise to lesions in the marrow.
Morbid Anatomy.—Tuberculous disease in the articular end of a long bone may give rise toreactive changesin the adjacent joint, characterised by effusion and by the extension of the synovial membrane over the articular surfaces. This may result in the formation of adhesions which obliterate the cavity of the joint or divide it into compartments. These lesions are comparatively common, and are not necessarily due to actual tuberculous infection of the joint.
Theinfection of the jointby tubercle originating in the adjacent bone may take place at the periphery, the osseous focus reaching the surface of the bone at the site of reflection of the synovial membrane, and the infection which begins at this point then spreads to the rest of the membrane. Or it may take place in the central area, by the projection of tuberculous granulation tissue into the joint following upon erosion of the cartilage (Fig. 156).