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 Fig. 198 Fig. 199

Tabetic arthropathy. (Case of E. A. Neuropathic arthritis (tabetic joints).

Smith.) (Lexer.)

Locomotor ataxia is a common disease, but syringomyelia has

been regarded as exceedingly rare. Nevertheless, Schlesinger has
collected 130 cases of it, in one-fourth of which bone and joint
symptoms were present. That the nervous system is primarily at fault
is made clear, among other things, by the rapidity of involvement
occasionally seen, where, for instance, an entire limb becomes
edematous, with every indication of severe disturbance. In tabes the
lower extremities suffer more often than the others; the reverse is
true in cases of syringomyelia. While floating bodies in the joints and
ossification of the muscles and soft parts are common in arthritis
deformans, they seldom occur in the neuropathic lesions.
Suppuration and necrosis are rare in any of these forms, occurring
more frequently in the finger than elsewhere, and are probably due
to infection of those areas where sensibility is lost and trifling injuries
less guarded against. The neuropathic lesions are more commonly
symmetrical, and are often accompanied by a cretinic general
appearance (Figs. 196, 197, 198, 199, 200 and 201).

Fig. 200

Skiagram of joints shown in Fig. 199. (Lexer.)

 Fig. 201

Arthropathy of syringomyelia. Left elbow, illustrating disintegration, etc., without

ulceration or suppuration. (Quenu.)

The joint complications of syringomyelia are frequently

characterized by skin lesions which tend to suppurate, by sudden
edema, occasionally followed by phlegmon and even necrosis, also
by other disturbances of innervation.
Surgical treatment of these lesions is less discouraging than would
at first appear, as even in these patients serious wounds heal readily,
while in healthy tissues primary union may occur. The wisdom,
therefore, of incision, resection, or even amputation may be decided
on their merits, and there can be no objection to open drainage when
it would otherwise be indicated. Even in cases of spontaneous
fracture proper treatment usually gives good results, although the
amount of callus may seem disproportionate.
In any of the joints distorted by deforming osteoarthritis or
neuropathic lesions, the question of partial or complete resection or
exsection may be discussed upon its merits, since these operations,
when duly indicated, have often given satisfactory results, even in
elderly people.
Diagnosis.—Differential diagnosis will be made more easy by the
exclusion of syphilis and of the acute or ordinary
infectious forms of disease. The relative freedom from pain, the
relaxation of the joint structures, the large amount of fluid present,
and the age of the patient will aid in excluding all but the neuropathic
elements associated with spinal disease.
Treatment.—Treatment is rarely curative; usually it can be
palliative at best. Measures above mentioned, when
they seem indicated, coupled with mechanical support, by which the
parts may be maintained as nearly as possible in their proper
position, will give the best result. If the disease be monarticular,
exsection will frequently give a satisfactory result. Multiple lesions
rarely permit of serious operations.

HYSTERIA AND HYSTERICAL JOINTS.

A different form of distinctly neuropathic joint affection is the so-
called hysterical joint. This is characterized by the absence of every
objective and the presence of nearly every subjective symptom. It
occurs most often in young women and girls, follows perhaps some
trifling injury, and involves most commonly the joints of the lower
limbs. These cases are characterized by a disproportion between the
character of the complaint and the actual condition. Imitation of
organic trouble is a predominant feature of all hysterical complaints,
and is nowhere seen to better advantage than in these cases. The
pain, the tenderness, the loss of ability and even the muscle spasm
and muscle atrophy of genuine lesions will be simulated. So true is
this that diagnosis largely rests on the exaggeration of symptoms
which have no apparent existence. Hyperesthesia is sometimes
extreme, but pertains usually to the waking hours. Rarely is there
actual swelling or thickening, or any objective evidence whatever of
disease, save perhaps muscle atrophy due to disuse. It is possible to
have the hysterical element as a complication of actual joint disease,
but the truly hysterical joints usually are easily recognizable.
Treatment.—The treatment of such a joint should be psychical as
well as physical. Sometimes appeals to reason, at
other times to fear or necessity, will be the wiser course. Restoration
of self-confidence is an important feature, and these are the cases
where any form of faith cure will produce its most brilliant results.
Many of these cases are bedridden, and need to have elimination
stimulated in every possible way. They also need sunlight, fresh air,
massage, and renewed use of the parts. Hyperesthesia is best
treated by continuous application of ice-cold compresses, intermitted
perhaps daily for the purpose of using the “flying cautery,” as already
described.

GONORRHEAL OR POSTGONORRHEAL ARTHRITIS.

This condition may occur during the active stage of gonorrhea or
after its apparent subsidence. It was probably the discovery of the
pathogenic gonococcus by Neisser, in 1879, which gave to this
lesion an identity of its own, and induced the profession to abandon
the name gonorrheal rheumatism, by which it had been known. It
has nothing to do with rheumatism, and should not be linked with it in
name any more than in idea. In well-marked cases the gonococcus
will nearly always be found, usually in pure culture, in the joint fluid.
It appears in different degrees of severity, from a mere hydrops,
which is mild, accompanied by slight tissue changes, to a
phlegmonous condition, with widespread destruction of joint
structures and serious constitutional disturbances. As between these
extremes there may be a pyarthrosis or empyema, which is usually
the result of a mixed infection.
 As a complication of urethritis it occurs in 4 or 5 per cent. of cases,
the percentage being larger in children than in adults, the knee being
affected in about one-third of these cases. It is not necessarily
monarticular, however, and sometimes several joints will be involved.
Along with the joint condition there will frequently occur cardiac
lesions (endocarditis) and eye complications. In fact, some of these
cases terminate fatally through the mechanism of a seriously
involved heart, i. e., septic endocarditis or myocarditis. When it
occurs in the ankle or in the tarsal joints the ligaments and
surrounding bursæ are often involved. This involvement, unless
recognized and properly treated, may lead to serious deformity, e. g.,
flat-foot of the most painful kind. Many of these lesions at the heel
are accompanied by true exostoses, which are often painful and
more or less disabling (“painful heel”). Thus, Jaeger has recently
reported a group of ten such cases. These may require excision. In
general this form of arthritis is characterized by severe pain, often
worse at night, and a peculiar distortion of the swollen joint, because
it is usually complicated by a distention of the adjoining tendon
sheaths and bursæ, which is rare in other forms of arthritis. It has
been aptly stated that if in these cases the same zeal were displayed
in seeking for gonococci that has often been shown in looking for
uric acid it would be less often neglected. So far as treatment is
concerned, I desire in this place only to call attention to the absolute
inutility of all the so-called antirheumatic remedies and diet.
However, if the urine be hyperacid it should be corrected by ordinary
means. At first absolute rest, with the local use of the ichthyol-
mercurial or Credé ointment, should be given. Such antiseptics as
one has most confidence in may also be administered internally for
their general beneficial effect. An overdistended joint should be
tapped and irrigated. As soon as the presence of pus can be
determined, either with or without exploration, the joint should be
opened, thoroughly irrigated, and drained. If this were always done
in time the more severe phlegmonous and destructive cases would
rarely occur.

TUBERCULOUS ARTHRITIS.
 Tuberculous disease of the joints is one of the most frequent of
surgical lesions. It has produced characteristic appearances which
have been known under the name of “scrofula of joints,” until a
clearer recognition of the pathology of the condition led to the
abandonment of the term scrofula. Tumor albus, or white swelling,
was another term commonly applied to these lesions, because of the
anemic appearance of the surface of the swollen joint.
Tuberculous arthritis assumes different phases in proportion to the
involvement of the different component structures of the joint. Some
cases begin purely as a tuberculous synovitis, and may for a long
time be limited to the synovial structures. Others begin within the
spongy texture of the expanded joint ends of the long bones, the
disease spreading from such foci and involving everything in the
path which its products take in the effort to secure spontaneous
evacuation, products of softening and infection travelling in the
direction of least resistance.
It has been the writer’s custom to always follow Savory, in his
suggestion to students to let their mental pictures of consumption of
the lungs and pleuræ serve for illustration in similar disease of joints.
Thus the cancellous bone structure much resembles the lung tissue
in its spongy character. In both a capsule surrounds the mass of
tubercle, and in each, by breaking down of its contents, a cavity is
formed. Moreover, the pleura bears practically the same
resemblance and relation to the lung and the chest wall that the
synovialis does to the bone end and the joint cavity; as we may have
pleuritis with phthisis, so we may have synovitis with tuberculous
ostitis; and as adhesions tend to form in the pleural cavity, so also do
they in the synovial cavity. Furthermore, in each case obliteration of
deeper veins causes the more prominent appearance of the
subcutaneous veins, and as tuberculous pleurisy often terminates in
empyema, so does tuberculous hydrarthrosis often terminate in
pyarthrosis, perhaps with fungous ulceration. In almost every
feature, then, the progress and effect of tuberculosis in the lung and
bone end may be likened to each other.
In some clinics bone and joint tuberculosis constitute nearly one-
third of the total of cases treated. Joints of the lower limb are the
ones most frequently involved in children, while in the adult those of
the upper extremity are generally attacked. It is not often that more
than one joint is involved at one time. The relation of traumatism to
this disease has been frequently discussed, and is variously
regarded. The disease is more common in those who are
predisposed to it by environment or by heredity, in the latter case
hereditary evidences usually being well marked. In such predisposed
individuals, especially in the early years of life, severe injuries are
usually promptly repaired, while the milder traumatisms, which are
often frequent and to which too little attention is paid, seem often to
so far lower tissue resistance as to favor an infection to which the
individual is already favorably predisposed. The true position to take,
then, would appear to be this, that traumatisms rarely lead directly to
joint tuberculosis, but only indirectly by affecting tissue susceptibility.
Thus lesions which begin in the epiphyses lead to what is known
as osteopathic joint disease, while those which have their origin in
the synovia give rise to the arthropathic forms. The former are more
common in children and the latter in adults (Fig. 202).
Pathology.—In regard to the pathology of these conditions it does
not vary from that mentioned in the earlier portion of
this work in connection with the general subject of Surgical
Tuberculosis. The deposit of tubercle in the tissue whose resistance
has been weakened is followed by the formation of granulation
tissue, which, so long as the germs survive, tends to increase and to
make room for itself at the expense of surrounding tissue. At the
same time there occurs a tissue struggle by which the attempt is
made to throw around an active focus a protecting barrier, which in
soft tissues consists of condensed fibrous and connective tissue,
and, in bone, of a sclerotic capsule, as though the intent were to
imprison the disturbing cause, and, by completely enclosing it, effect
protection. When this attempt at encapsulation is successful
spontaneous recovery follows. It will be made successful, to some
extent at least, by treatment whose most important local feature is
physiological rest. On the other hand, when the attempt is
unsuccessful and the barrier is transgressed by granulation tissue,
the lesion will advance in the direction of least resistance, while its
progress will be made known, especially as it approaches the
surface, by very significant signs: adhesion of the overlying
structures and finally of the skin, with purplish discoloration of the
latter. Finally softening occurs with escape of granulation tissue,
which, so soon as it is freed from pressure, will grow more luxuriantly
and with more color, constituting the fungous granulation tissue, to
which German pathologists so often allude, or so-called “proud
flesh.” When this appears upon the surface it is soon infected with
pyogenic organisms, breaks down, and an abscess cavity results,
connecting with the original focus and its extensions. This may be so
placed as to lie outside the joint capsule, which, in some respects, is
fortunate for the patient. The joint function may then be
compromised to only a minor degree.

Fig. 202

Central sequestrum. (Ransohoff.)

Often the direction of least resistance is toward the joint cavity, this
fungous tissue loosening and perforating cartilage or periosteum
before it enters the joint. Having penetrated it again it grows
extensively until the cavity is distended, its rapidity of growth
diminishing with the degree of pressure produced by its
surroundings. This pressure will also make it less vascular, and
when such a joint is opened it at first appears pale and anemic. In
proportion as the joint distends it loses in motility, while should
recovery occur spontaneously or as the result of treatment this tissue
will to some extent disappear, to be replaced by adhesions by which
pseudo-ankylosis is produced. The extent of the intra-articular
involvement will cause obstruction to the deeper return circulation,
and thus is brought about the prominence with which the
subcutaneous veins appear. The degree of hydrarthrosis is
apparently not limited except by the distensibility of the joint. In the
articular or arthropathic forms there is always more or less synovial
outpour.
Fig. 203
 Tuberculous panarthritis. (Ransohoff.)

To the condition already described may be added the destruction

produced by suppuration, infection occurring either through the
circulation, as is quite possible, or through some trifling surface
abrasion. In more chronic cases caseation may occur, especially in
bone foci. Finally, as the result of a combination of morbid
processes, there is produced more or less complete disorganization,
all of which is summed up in the term tuberculous panarthritis. To
that condition in which the articular surfaces are more or less
studded with fungous patches the term pannus of the joint is often
applied. To reiterate, then, as between a chronic hydrarthrosis and a
destructive panarthritis, perhaps even with necrosis of epiphyses, it
is but a difference of degree and of combination of infectious
processes (Figs. 203, 204, 205 and 206).
Among the other consequences of panarthritis may be the
formation of sequestra in or near the epiphyses, and such
destruction as shall lead to pathological dislocation, the latter being
well illustrated in Figs. 204 and 207. This dislocation is always the
result of the pull of muscles thrown into that condition of reflex
spasm which is a characteristic feature of this disease. It appears
conspicuously at the knee, usually as a backward subluxation (Fig.
207), and at the hip as an upward dislocation, sometimes with more
or less apparent migration of the acetabulum. Another consequence
of tuberculous hydrarthrosis, which frequently persists even long
after the subsidence of the acute stage of the disease, is the
occurrence within the joint cavity of rice-grain or melon-seed bodies,
for whose presence it is not easy to account. The generally received
explanation is that they are the result of fibrinous outpour, whose
fluid portions have been absorbed, while the remaining nearly pure
fibrin is broken up into particles and rounded off by attrition during
the movements of the joint. They may accumulate in astonishing
amount, thus stamping the disease as having a chronic rather than
an acute character. After a time they provoke a fresh outpour of fluid,
as a result of the irritation which they produce. This fluid is at first
usually clear serum, but becomes turbid or seropyoid, and, if
infected, becomes pure pus, in which the rice-grain bodies are
dissolved or disintegrated.

Fig. 204

Bony ankylosis of knee. (Ransohoff.)

 Fig. 205 Fig. 206

Section of bony ankylosis of hip. (Original.) Tuberculous panarthritis,

illustrating various types of
degeneration and destruction.
(Lexer.)

Recovery is possible in many cases when the lesions have not

advanced too far. It is rarely ideal, and usually leaves some evidence
of its existence in limitation of motion, thickening, or other
recognizable symptom. Constitutional as well as local measures
have much to do with bringing about this result. It is for this reason
that it is so essential to take tuberculous-joint patients out of the
environment in which ordinarily they live and get them outdoors,
exposed to sunlight and benefited by the best of nutrition. Rest,
oxygen, and hypernutrition are the three best general measures for
combating these conditions. When recovery does occur it is by the
death of all active germs, the absorption to varying extent of disease
products, including granulation tissue, and the organization into
fibrous and cicatricial tissue of the unabsorbed residue. No tissue
which has been actually disorganized is completely restored. The
best that can be hoped for is substitution of fibrous or cicatricial
tissue. Function may be more or less completely regained. This will
depend largely upon how early treatment is instituted. In general it
may be said that there is always hope for tuberculous joints if
suitable treatment be instituted early and if the environment can be
made satisfactory. Unfortunately this is not often possible, and the
best that can be hoped for is subsidence of disease at the expense
of more or less ankylosis, perhaps deformity, while, at the worst,
there may be loss of joint if not of life. It might be misinterpreted
should it be said that there is one kind of treatment for the wealthy
and another for the poor, yet so much does depend upon what the
patient or the parents can afford in the way of change of
surroundings that the whole plan of treatment often depends upon
the patient’s circumstances. Radical measures may therefore be
deemed best in those who cannot afford long delay and
temporization, while at other times expensive apparatus and change
of residence may bring about the desired result.
The general appearance of a tuberculous joint is one of manifest
enlargement which is made more conspicuous by wasting of the limb
above and below. Nevertheless by actual measurement it will usually
be found to have a greater circumference than its fellow of the
opposite side. Its covering skin is pale and often glistening, with
prominent veins, while in proportion to the distention by fluid there
will be more or less distinct fluctuation. When the joint is evidently
distended and does not fluctuate the inference is that it is filled with
granulation tissue. There will also be marked thickening of all the
articular coverings, the synovial membrane itself being often as thick
as sole leather. At points where perforation may threaten there may
be dimpling and retraction of the skin, with fixation and discoloration.
Symptoms.—Tuberculous joint disease is characterized
especially by loss of function, muscle spasm, muscle
atrophy, pain and tenderness of rather significant character, and the
other joint features already mentioned. Loss of function may be
partial or complete. It depends on the amount of tenderness and the
deformity already produced by muscle spasm. Motility is more or
less restricted even under an anesthetic. This is induced by actual
limitation of motion by products of exudation, by muscle spasm and
wasting, and by the involuntary shrinking of the patient when tender
joint surfaces are pressed against each other.

Fig. 207

Backward displacement of tibia due to the muscle spasm of a tuberculous knee-

joint, with final bony ankylosis. (Lexer.)

Muscle spasm is one of the most significant features of these

cases as well as almost the earliest. It is of the greatest diagnostic
value, and, if genuine, should never be neglected. It subsides under
the use of an anesthetic, hence it is not advisable to employ
anesthetics for diagnostic purposes. It produces at first fixation,
without particular deformity, but may lead later to this or to
pronounced subluxation. It is most helpful in the early stages when it
does not particularly interfere with a medium range of motion, and
seems to lock the joint before the extreme of motility is reached.
Muscle spasm is pronounced even after muscle atrophy is well
advanced, and serves more and more to fix joints until they are held
by adhesions formed within. Muscle atrophy is also significant and
begins about the time when diagnosis becomes fairly possible, i. e.,
in the early stage of the disease. With the advance of disease it
becomes more pronounced and a joint which is fixed by intra-
articular lesions will stand out prominently because of the notable
wasting of the muscles by which ordinarily it would be moved. It is
this which gives the elbow and knee especially their spindle shape.
(See Plate XXXIV.)
 Pain is also a characteristic feature, especially that which is
produced by motion and allayed by rest and that which is
accompanied by involuntary muscle spasm, and occurs during sleep,
i. e., the so-called osteocopic or starting pains of tuberculous
panarthritis. These occur most distinctively in children, but may be
complained of at any period of life. Children thus affected will cry out
sharply during their sleep and appear for a few seconds very much
distressed, and yet do not awaken sufficiently to recall or describe
their sensations. The explanation of this phenomenon is a sudden
reflex spasm of the muscles by which tender joint surfaces have
been suddenly pressed tightly together and pain thereby provoked.
Something of this kind may occur in syphilitic bone disease, but,
taken in connection with the other signs and symptoms above
mentioned, such pains are practically pathognomonic.
The various measures to which orthopedists and surgeons resort
for employment of traction, by splints or weights, are directed against
overcoming muscle spasm by tiring out the muscles. It must not be
thought that by any reasonable degree of traction joint surfaces are
actually separated widely from each other. All that it is expected to
accomplish is by a steady pull to exhaust the muscles, and prevent
them from thus exercising deleterious pressure by pulling joint
surfaces together.
The pain complained of is by no means necessarily limited to the
joint involved; in fact, some of the most significant pains are those
which are described as referred. These furnish illustrations of the
fact, well known to physiologists, that irritation in the course of a
nerve is referred to its distribution; thus in hip-joint disease most of
the pain will be centred in the knee, and when the knee is involved
the ankle will be the part to which the patient will refer much of his
discomfort.
There also comes an overuse of the unaffected joints of a limb by
which the diseased joint may be spared as far as possible. The
flexors, as a group, being always stronger than the extensors, the
former will overcome the latter in time, and these joint contractures
are a later expression of chronic muscle spasm. This is true even
when atrophy is well advanced.
 Tuberculous joint disease usually has at first no particular
constitutional complications. These come on later in proportion as
the general health suffers from the confinement entailed by the
disease. General health will suffer quicker when the lower limb is
involved than when it is the upper. By the time joint lesions are well
advanced careful observation will usually reveal a rise of evening
temperature and progressive anemia. The symptoms included under
the term hectic are those belonging to the destructive stage and are
due to a combination of causes in which auto-intoxication figures
largely.
Diagnosis.—Tuberculous joint disease is usually easy of
recognition, except perhaps in the earliest stages. (See
the general subject of Orthopedic Surgery.) Differential diagnosis
between this condition and syphilis, or between it and hysteria, has
occasionally to be made, and may at first cause some difficulty. An
hysterical hip or knee may so strongly simulate tuberculous disease
as to lead one at first into serious doubt. Again, as between the
tuberculous and non-tuberculous forms of hydrarthrosis, there may
often be doubt, even after aspiration and examination of the fluid. In
fact, that which began as one may terminate as the other.
Fortunately in these last cases local treatment is about the same for
each, and, while the question of diagnosis may never be absolutely
satisfactorily decided, the patient may nevertheless recover in either
event.
Treatment.—The treatment of tuberculous arthritis should be both
local and general, one being about as important as the
other. The general treatment for this as for every other tuberculous
disease may be summed up as follows: The remedies for
tuberculous disease are oxygen and hypernutrition. The best place
for the patient is the place where these means can be procured. As
explained above, this will, to a considerable extent, depend upon the
circumstances of the patient or the family. When it can be afforded a
high altitude is almost as good for joint tuberculosis as for that of the
lungs. The nearest approach that can be made to it will be the most
desirable. Hypernutrition will in some cases consist almost in forced
feeding. Here as elsewhere in tuberculous disease it is of at least
theoretical as well as of practical advantage to saturate the system
with some bactericidal remedy, if such there be, and for obvious
reasons. Creosote or its congeners, in more or less palatable form,
seem at present to best serve this purpose. In addition to this
arsenic, iron, and the iodides, the latter especially if there be any
suspicion of syphilitic complication, can be used to advantage. In
proportion as patients become confined to the house their
elimination is usually restricted. All measures then by which
elimination may be improved will be indicated.
The use of tuberculin, or some of its modifications, has been
occasionally followed by excellent results. It is an agent to be
employed with great discretion, but is well worth a trial in those
cases where its effects may be carefully watched.
Locally the most important measure is the enforcement of
physiological rest of the affected parts. This may imply confinement
to bed, especially when the spine, the pelvis, and the hip are
affected, but should be reinforced by mechanical contrivances, by
which traction or “extension” may be carried out. The purpose of
traction, as mentioned above, is to overcome muscle spasm and
thus ensure rest. It is effected by many of the orthopedic
apparatuses. (See chapter XXXIII.[32]) It may be enforced by fixed
dressings of plaster, etc.
[32] The fundamental idea expressed in all of the methods for enforcing
rest by traction is of American origin, and constitutes one of the advances in
surgery for which the world is indebted to America. For a long time it was
referred to in Germany as the American method, and yet now the Germans
claim so much for it that one of their surgeons has written a book of 600
pages devoted to the employment of traction for various surgical purposes,
in which but very little credit is given to the men who originated it.