Manual of Surgery by Alexis Thomson (golden son ebook .TXT) 📕

Fig. 165.—Charcot's Disease of both Ankles: back view. Man, æt. 32.

Fig. 165.—Charcot's Disease of both Ankles: back view. Man, æt. 32.

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

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

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

Hysterical or Mimetic Joint Affections

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

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

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

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

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

Tumours and Cysts

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

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

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

Loose Bodies

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

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

Clinically, loose bodies composed of fibrin constitute an unimportant addition to the features of the disease with which they are associated. They never give rise to the classical symptoms associated with impaction of a loose body between the articular surfaces. Their presence may be recognised, especially in the knee, by the crepitating sensation imparted to the fingers of the hand grasping the joint while it is flexed and extended by the patient.

The treatment is directed towards the disease underlying the hydrops. If it is desired to empty the joint, this is best done by open incision.