Manual of Surgery by Alexis Thomson (golden son ebook .TXT) đź“•
Read free book «Manual of Surgery by Alexis Thomson (golden son ebook .TXT) 📕» - read online or download for free at americanlibrarybooks.com
- Author: Alexis Thomson
- Performer: -
Read book online «Manual of Surgery by Alexis Thomson (golden son ebook .TXT) 📕». Author - Alexis Thomson
Proliferative changes in the synovial membrane are attended with increased vascularity and thickening of the membrane and an enlargement of its villi and fringes. When the fatty fringes are developed to an exaggerated degree, the condition is described as an arborescent lipoma (Fig. 159). Individual fringes may attain the size of a hazel nut, and the fibro-fatty tissue of which they are composed may be converted into cartilage and bone; such a body may remain attached by a narrow pedicle or stalk, or this may be torn across and the body becomes loose and, unless confined in a recess of the joint, it wanders about and may become impacted between the articular surfaces. These changes in the synovial membrane are often associated with an abundant exudate or hydrops. These degenerative and hypertrophic changes, while usually attended with marked restriction of movement and sometimes by “locking” of the joint, practically never result in ankylosis.
The ankylosing type of chronic arthritis is fortunately much rarer than those described above, and is chiefly met with in the joints of the fingers and toes and in those of the vertebral column. The synovial membrane proliferates, grows over the cartilage, and replaces it, and when two such articular surfaces are in contact they tend to adhere, thus obliterating the joint, cavity, and resulting in fibrous or bony ankylosis. The changes progress slowly and, before they result in ankylosis, various sub-luxations and dislocations may occur with distortion and deformity which, in the case of the fingers, is extremely disabling and unsightly (Fig. 160).
Clinical Features.—It is usually observed that in patients who are still young the tendency is for the disease to advance with considerable rapidity, so that in the course of months it may cause crippling of several joints. The course of the disease as met with in persons past middle life is more chronic; it begins insidiously, and many years may pass before there is pronounced disability. The earliest symptom is stiffness, especially in the morning after rest, which passes off temporarily with use of the limb. As time goes on, the range of movement becomes restricted, and crackings occur. This stage of the disease may be prolonged indefinitely; if it progresses, stiffness becomes more pronounced, certain movements are lost, others develop in abnormal directions, and deformed attitudes add to the disablement. The disease is compatible with long life, but not with any active occupation, hence those of the hospital class who suffer from it tend to accumulate in workhouse infirmaries.
Hydrops is most marked in the knee, and may affect also the adjacent bursæ. As the joint becomes distended with fluid, the ligaments are stretched, the limb becomes weak and unstable, and the patient complains of a feeling of weight, of insecurity, and of tiredness. Pain is occasional and evanescent, and is usually the result of some extra exertion, or exposure to cold and wet. This form of the disease is extremely chronic, and may last for an indefinite number of years. It is to be diagnosed from the other forms of hydrops already considered—the purely traumatic, the pyogenic, gonorrhœal, tuberculous, and syphilitic—and from that associated with Charcot's disease.
Hypertrophied fringes and pedunculated or loose bodies often co-exist with hydrops, and give rise to characteristic clinical features, particularly in the knee. The fringes, especially when they assume the type of the arborescent lipoma, project into the cavity of the joint, filling up its recesses and distending its capsule so that the joint is swollen and slightly flexed. Pain is not a prominent feature, and the patient may walk fairly well. On grasping the joint while it is being actively flexed and extended, the fringes may be felt moving under the fingers. Symptoms from impaction of a loose body are exceptional.
Fig. 160.—Arthritis Deformans of Hands, showing symmetry of lesions, ulnar deviation of fingers, and nodular thickening at inter-phalangeal joints.
The dry form of arthritis deformans, although specially common in the knee, is met with in other joints, either as a mon-articular or poly-articular disease; and it is also met with in the joints of the spine and of the fingers as well as in the temporo-mandibular joint. In the joints of the fingers the disease is remarkably symmetrical, and tends to assume a nodular type (Heberden's nodes) (Fig. 160); in younger subjects it assumes a more painful and progressive fusiform type (Fig. 161). In the larger joints the subjective symptoms usually precede any palpable evidence of disease, the patient complaining of stiffness, crackings, and aching, aggravated by changes in the weather. The roughness due to fibrillation of the articular cartilages causes coarse friction on moving the joint, or, in the knee, on moving the patella on the condyles of the femur. It may be months or even years before the lipping and other hypertrophic changes in the ends of the bones are recognisable, and before the joint assumes the deformed features which the name of the disease suggests.
The capsular ligament, except in hydrops, is the seat of connective-tissue overgrowth, and tends to become contracted and rigid. Intra-articular ligaments, such as the ligamentum teres in the hip, are usually worn away and disappear. The surrounding muscles undergo atrophy, tendons become adherent to their sheaths and may be ossified, and the sheaths of nerves may be involved by the cicatricial changes in the surrounding tissues.
The X-ray appearances of arthritis deformans necessarily vary with the type of the disease and the joint affected; in the joints of the fingers there is a narrowing of the spaces between the articular ends of the bones as a result of absorption of the articular cartilage, and rarefaction of the cancellous tissue in the vicinity of the joints; in the larger joints there is “lipping” of the articular margins, osteophytes, and other evidence of abnormal ossification in and around the joint. Eburnation of the articular surfaces is shown by increase in the density of the shadow of the bone in the areas affected.
Fig. 161.—Arthritis Deformans affecting several Joints, in a boy æt. 10.
(Dr. Dickson's case.)
Treatment.—Treatment is for the most part limited to the relief of symptoms. On no account should the affected joints be kept at rest by means of splints or other apparatus. Active movements and exercises of all kinds are to be persevered with. When pain is a prominent feature, it may be relieved either by douches of iodine and hot water (tincture of iodine 1 oz. to the quart), or by the application of lint saturated with a lotion made up of chloral hydrate, gr. v, glycerin Ʒj, water ℥j, and covered with oil-silk. Strain and over-use of the joint and sudden changes of temperature are to be avoided. The induction of hyperæmia by means of massage, the elastic bandage, and hot-air baths is often of service. Operative interference is indicated when the disease is of a severe type, when it is mon-articular, and when the general condition of the patient is otherwise favourable. Excision has been practised with success in the hip, knee, elbow, and temporo-mandibular joints. Limitation of movement and locking at the hip-joint when due to new bone round the edge of the acetabulum may be greatly relieved by removal of the bone—a procedure known as cheilotomy. Loose bodies and hypertrophied fringes if causing symptoms may also be removed by operation.
When stiffness and grating on movement are prominent features we have found the injection of from half to one ounce of sterilised white vaseline afford decided relief.
The patient should be nourished well, and there need be no restriction in the diet such as is required in gouty patients, so long as the digestion is not impaired. Benefit is also derived from the administration of cod-liver oil, and of tonics, such as strychnin, arsenic, and iron, and in some cases of iodide of potassium. Luff recommends the administration over long periods of guaiacol carbonate, in cachets beginning with doses of 5–10 grs. and increased to 15–20 grs. thrice daily. A course of treatment at one of the reputed spas—Aix, Bath, Buxton, Gastein, Harrogate, Strathpeffer, Wiesbaden, Wildbad—is often beneficial.
In some cases benefit has followed the prolonged internal administration of liquid paraffin.
On the assumption that the condition is the result of an auto-intoxication from the intestinal tract, saline purges and irrigation of the colon are indicated, and Arbuthnot Lane claims to have brought about improvement by short-circuiting or by resecting the colon.
Residence in a warm and dry climate, with an open-air life, has been known to arrest the disease when other measures have failed to give relief.
The application of radium and the ingestion of radio-active waters have also been recommended.
Hæmophilic or Bleeder's Joint.—This is a rare but characteristic affection met with chiefly in the knee-joint of boys who are the subjects of hæmophilia. After some trivial injury, or even without apparent cause, a hæmorrhage takes place into the joint. The joint is tensely swollen, cannot be completely extended, and is so painful that the patient is obliged to lie up. The temperature is often raised (101° to 102° F.), especially if there are also hæmorrhages elsewhere. The blood in the joint is slowly re-absorbed, and by the end of a fortnight or so, the symptoms completely disappear. As a rule these attacks are repeated; the pain attending them diminishes, but the joint becomes the seat of permanent changes: the synovial membrane is thickened, abnormally vascular, and coloured brown from the deposit of blood pigment; on its surface, and in parts of the articular cartilage, there is a deposit of rust-coloured fibrin; there may be extensive adhesions, and in some cases changes occur like those observed in arthritis deformans with erosion and ulceration of the cartilage and a form of dry caries of the articular surfaces, which may terminate in ankylosis.
As the swelling of the joint is associated with wasting of the muscles, with stiffness, and with flexion, the condition closely resembles tuberculous disease of the synovial membrane. From errors in diagnosis such joints have been operated upon, with disastrous results due to hæmorrhage.
The treatment of a recent hæmorrhage consists in securing absolute rest and applying elastic compression. The introduction of blood-serum (10–15 c.c.) into a vein may assist in arresting the hæmorrhage; anti-diphtheritic serum is that most readily obtainable.
After an interval, measures should be adopted to promote the absorption of blood and to prevent stiffness and flexion; these include massage, movements, and extension with weight and pulley.
Joint Diseases associated with Lesions of the Nervous System: Neuro-ArthropathiesIn Lesions of Peripheral Nerves.—In the hand, and more rarely in the foot, when one or other of the main nerve-trunks has been divided or compressed, the joints may become swollen and painful and afterwards become stiff and deformed. Bony ankylosis has been observed.
In Affections of the Spinal Medulla.—In myelitis, progressive muscular atrophy, poliomyelitis, insular sclerosis, and in traumatic lesions, joint affections are occasionally met with.
Fig. 162.—Bones of Knee-joint in advanced stage of Charcot's Disease. The medial part of the head of the tibia has disappeared.
(Anatomical Museum,
Comments (0)