Surgery, with Special Reference to Podiatry Part 11

+Symptoms.+ The symptoms of arthritis are obviously more severe than those of a simple articular synovitis and are both local and general.

The general symptoms arise from the absorption into the circulation of either bacteria or their toxins, and vary greatly in severity. There is either a toxemia or a septicemia, with the usual symptoms of a general sepsis.

The local symptoms are those common to synovitis and arthritis: pain, tenderness, swelling, heat, redness and loss of function. From these alone a differential diagnosis between synovitis and arthritis cannot be made. If, however, there is a sensation of crepitus conveyed to the examiner's hand upon pa.s.sive motion, there is an arthritis present beyond doubt. This symptom is due to the destruction of the synovial covering of the bone ends involved, permitting contact of bone with bone. It is more common to chronic joint disease, but may also accompany acute conditions, especially if they are severe.

Symptoms peculiar to the variety of infection and the history as to duration, causation, course and number of joints involved, must be considered in making a diagnosis or prognosis.

+Varieties.+ Besides simple traumatic arthritis, there are many const.i.tutional disorders which affect the joints conspicuously; these are: tuberculosis, syphilis, gonorrhea, gout and rheumatism.

A prominent cause of many instances of arthritis heretofore regarded as rheumatic in origin, is now known to exist in any area of infection. Such "foci of infection" discharge a certain amount of infective material into the circulation, which may find lodgment in a joint and set up an acute process.

It has been proven in numerous cases that a so-called rheumatism will yield promptly to drainage of a chronic abscess, no matter how remote the location. Oral conditions especially have been found responsible for this form of arthritis. Abscesses at the apexes of teeth and pyorrha alveolaris, when properly operated, yield nothing short of miracles, in the way of relieved symptoms.

In addition to the varieties of arthritis already mentioned, those due to certain infectious diseases, such as measles, scarlet fever, typhoid fever, smallpox or erysipelas, should be included, as well as cases of neuropathic origin.

+TRAUMATIC ARTHRITIS+

+Nonpenetrating and Penetrating+

+Nonpenetrating.+ Ordinary contusions or twisting at a joint, may result in the establishment of an inflammatory process within the joint, evidenced by much swelling and giving the sensation of fluctuation to the examining hands, indicating the presence of fluid within the synovial membrane. This occurs also when there is a detached fibrocartilage in the joint. The synovial membrane is thickened and there is an exudation of serum.

Sprains belong in this cla.s.sification. These are simple, clean, inflammatory conditions.

+Symptoms.+ These are generally limited to those enumerated as belonging to synovitis, except that the disability is more p.r.o.nounced.

+Treatment.+ Rest and wet dressings generally suffice to effect rest.i.tution in a few weeks.

+Penetrating.+ Should the joint be injured by violence so that there is a loss of continuity of the tissues leading into the joint proper, there is every probability of infective material gaining entrance.

These are serious accidents, though restoration of an efficient joint is possible, but when improperly treated or neglected, local destruction, or even loss of life may occur.

Penetrating wounds of joints usually occur in consequence of accidents with firearms, sharp tools, or falling upon sharp objects. Frequently, penetration of a joint follows suppuration in the immediate neighborhood.

+Symptoms.+ The extent of the injury, the particular joint involved, and the nature of the vulnerating body will affect the train of symptoms.

An escape of synovial fluid, pain and some swelling will occur even with a very small penetration. Should the joint escape infection, the synovitis quickly subsides and recovery takes place with little or no impairment of the functional value of the part. The opening in the capsule closes, the extravasated blood is absorbed and the synovial surface is again smooth. If, however, the wound has been inflicted with an unclean instrument, or if at any time before healing it becomes septic, a very different and graver condition obtains.

+Septic Arthritis.+ Infection with bacteria of suppuration, chiefly the staphylococcus albus or the streptococcus pyogenes, produces an acute arthritis which frequently, despite the most careful treatment, will result in the destruction of the joint, and not seldom in the loss of life.

The infection may occur in one of several ways: (1) directly through a dirty instrument, or the lodgment of infective material in the tract leading to the joint cavity; (2) by the extension of a suppurative process, either of the bones or soft tissue adjacent; or, by (3) the deposition into the joint of infective organisms circulating in the blood stream.

+Symptoms.+ However produced, large numbers of organisms are present and a high grade of inflammation ensues. An abundant amount of pus is soon formed; the synovial membrane, the bone ends and the joint capsule are actively inflamed, and soon become disorganized. Perforation of the capsule is followed by infection and suppuration of the tendons and other structures about the joint, which soon affects the superficial structures and forms an opening through the skin. The pain is intense, generally worse at night; the swelling is great and fluctuation is distinct; the skin is red and hot, and the parts above and below are edematous. Any attempt at motion increases the suffering.

With these local symptoms there is an accompanying train of const.i.tutional symptoms which may eventuate fatally. At first there is a chill, or a sensation of chilliness after which the temperature quickly runs up several degrees, and either remains so, or goes down and up several times in twenty-four hours, as in other septic conditions. The pulse may be strong and full at first, but soon becomes rapid and weak. In very acute cases, death from septicemia may occur in a few days.

In ordinary cases, drainage of the pus, either naturally or artificially, will result in a remission of the symptoms both locally and generally.

+Treatment.+ In this, as in other suppurative processes, safety lies in the prompt opening of the abscesses and the evacuation of the pus, thus accomplishing free drainage, with subsequent disinfection by means of applications or irrigations. Immobilization of the parts and rigid antisepsis will generally yield good results as to life, though recovery with ankylosis is the rule. In the most severe cases, const.i.tutional symptoms are so grave as to warrant immediate amputation above the infected joint.

+Tubercular Arthritis.+ The great majority of chronic joint diseases are tubercular in origin, the tubercle bacilli being deposited in any of the joint structures, or in structures contiguous to a joint; with children, very frequently in the bone substance.

Whether the tubercular process originates in the joint cavity itself or outside of it in the surrounding tissues, destruction of the articular ends of the bones is usual.

The parts become thickened and edematous; there is a gelatinous or cheesy appearance, in which the membrane, cartilaginous bone ends, capsule, and ligamentous structures all share. Frequently the synovial membrane is studded with miliary tubercles and its cavity is filled with an abundant serous secretion. The contour of the joint becomes globular or spindle shaped, because of the atrophy of the parts above and below it and the swelling of the periarticular structures. The skin becomes white and thick because of the obliteration of the superficial vessels and because of its edematous infiltration.

+Symptoms.+ Pain is, as a rule, but slight in the strictly synovial stage of tubercular arthritis, but when the bones are involved, it is severe, though acute symptoms, such as heat and redness, are lacking.

Deformity is a constant accompaniment of the disease; its degree is greater or less according to the joint affected, the extent of the disease, and the treatment pursued. It is due to the natural tendency to a.s.sume the position of greatest ease; to the softening and destruction of the ligaments, and to the effort on the part of nature to immobilize an injured member by means of tonic contraction of the muscles. These causes often result in the creation and persistence of a malformation and malposition of the part.

Cheesy degeneration and liquefaction take place in more or less degree, and though their occurrence is often not evidenced by any aggravation of the symptoms, sinus formation with persisting discharge occurs.

When these sinuses occur, they generally become infected with other pus producing organisms, and aggravate the condition considerably. In the course of months or years, many such openings may occur through which ma.s.ses of soft tissue or bone, either carious or necrosed (_sequestra_), may be discharged.

+Diagnosis.+ This may be easy, difficult, or impossible, depending on the duration, the joint involved, and the character of the disease in any individual case.

At times it is impossible to differentiate from syphilis, which, however, is quite uncommon, but with which tuberculosis has many symptoms in common. The history of the individual, and a blood examination will generally suffice. If the disease is advanced to the stage of abscess and sinus formation, there can be no doubt as the nature of the trouble.

Very often the disease in the articular ends of the bones advances slowly, giving very little pain and no appreciable swelling or atrophy. There may be only an unwillingness to use the part very much, and the disease may very well be overlooked. In such insidious cases a diagnosis can be reached by aspiration and subsequent examination of the serous fluid for tubercle bacilli. An X-ray will show the rarifaction of the bony structures and the thickened periosteum.

The course of tubercular joint disease is entirely dependent upon its extent at the time it is recognized, and the treatment pursued. It is of paramount importance that attention be given any persisting pain or discomfort in or near a joint, and that rest and every diagnostic aid be employed before p.r.o.nouncing a case hysteria, neuralgia or "growing pains." In a few cases the process can be arrested and little or no diminution of function remains. This, however, is the exception; there is usually destruction of the intra-articular cartilages, and of the synovial membrane, and the formation of bands of great density, which impair the motion of the part even to rigidity (_fibrous ankylosis_).

The restriction of motion may be absolute if ossification of the granulation tissue lying between the epiphyses unites their eroded ends (_bony ankylosis_).

At times, though recovery seems to have been secured, a sinus may persist because of some slight area of remaining caries, or because the tract itself is tubercular. In other instances a recurrence may follow after months or years of quiescence. This may be due to the setting free of encapsulated organisms, or because of a new infection at a point of least resistance.

+Treatment+ is that of tubercular disease in general. The most essential features in the conduct of these cases are rest and the establishment of ideal hygienic conditions. Forced feeding, sunlight and air, play as important a part here as in pulmonary tuberculosis. Absolute rest of the part can be secured only with the aid of plaster of Paris braces, or splints of other materials. Such immobilization should include the joints immediately above and below the one affected.

Hyperemia, by the use of a rubber bandage above the joint, or by baking of the joint, is of great value.

In the majority of instances these methods will yield good results in from six months to a year. Operative interference will be necessary in addition to the above, where caseation and secondary infection have occurred. Thorough drainage of the infected joint, either by widening already existing sinuses, or by free incision followed by irrigation, will frequently be necessary.

+Joints Generally Involved+ are the larger ones of the extremities, but this does not preclude the possibility of any joint being the seat of a tubercular inflammation. The vertebral articulations and the digital articulations of the feet and hands are commonly affected. In children, the hip joint is the one most attacked; frequently the knee, ankle and elbow are affected in the order given.

In nearly all cases of arthritis of tubercular origin the original focus of infection is located in the bone, though the synovial membrane, or an adjacent osteomyelitis, may be the first point attacked.

+Syphilitic Arthritis.+ This is rather a rare condition, but must be differentiated from tuberculosis, because of its slow onset and progress, and because of the mildness of the symptoms and the spindlelike shape of the joint. There is usually but one joint involved and eventually a dark fluid will escape should sinus formation occur.

+Diagnosis+ will generally be known in advance from the history, through a Wa.s.sermann test of the blood, or an X-ray picture will often be of value.

In syphilis, the original focus of infection in a joint will be found in the soft tissues, while in tuberculosis, the articular ends of the bone are first involved. An examination of the discharged fragments of tissue in syphilis will show a round cell infiltration; in tuberculosis, possibly typical tubercle tissue.

+Treatment+ by anti-syphilitic remedies, if successful, will also indicate the nature of an obscure case, a p.r.o.nounced response to such treatment being a positive diagnostic aid.

+Gonorrhoeal Arthritis.+ This affection is nearly always very acute, beginning as an acute synovitis and extending to the articular fibrocartilages at an early date.

Const.i.tutional symptoms nearly always accompany this variety of arthritis, a chill and high temperature being the rule.

This condition is often called gonorrhoeal rheumatism. It is due to the lodgment of the gonococcus of Neisser in the joint, from the blood stream.

Gonorrhoeal arthritis is a form of septic arthritis, its pathology and symptomatology being in many respects the same. It may, in favorable cases, limit itself to the synovial membrane, in which event the symptoms will yield more readily to treatment, though the affection in any event is an acute one, and a diagnosis as to extent is difficult to make owing to the extreme pain of even slight motion.

+Symptoms.+ These are similar to those of septic arthritis, except that usually only one joint is affected and the existence of a gonorrhoeal infection can always be determined. Both knees, or both ankles, but more commonly, only one joint, are affected, accompanied by severe const.i.tutional symptoms. There rarely occurs any indication of sinus formation or of spontaneous drainage in this variety of arthritis, and it is held by many, that in cases where this tendency exists, there is a mixed infection, other pus producing organisms being present.