NEUROPATHIC JOINT DISEASE.

This received its first full and classical description from Charcot in 1868. The term refers to joint lesions which follow and are apparently connected with certain injuries and diseases of the spinal cord, or the peripheral nervous system. The non-traumatic forms are mostly associated with locomotor ataxia and syringomyelia. Some of them have an abrupt onset, while others come on very insidiously. Pain is usually notable by its absence, and the involved joints show few, if any, evidences of hyperemia or inflammation. They become unnaturally mobile and relaxed and usually much, sometimes enormously, distended with fluid. The morbid changes within the joints comprise imaginary combinations of atrophy and hypertrophy, with proliferative formations in bone cartilages. Osteophytes and exostoses are met with, and ossification may occur in the neighboring tendons and ligaments. Surprising alterations take place in certain joints; thus, as shown in Fig. 197, the head of the humerus may disappear and corresponding changes may occur in other joints. While it is the knee which suffers most frequently, no joints, not even those of the spine or jaw, are exempt.

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).

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.

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.

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.

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.

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.

With a better appreciation of the pathology of the condition numerous methods were devised by which the germs should be attacked in loco. Thus various antiseptics have been injected in varying strengths, either into joint cavities or around them. Lannelongue devised a “sclerotic method,” by which zinc chloride solutions were injected into the peri-articular tissues, to so condense and harden them as to imprison and destroy their contained germs. The method, however, is an extremely painful one and has not found general favor. For a long time iodoform was employed for the same purpose, in emulsions of 10 per cent. and 20 per cent. strength, in sterilized glycerin or olive oil. It affords a curious paradox that the iodoform itself must be sterilized before being thus used. This emulsion has been injected into the peri-articular tissues or into joint cavities, which, when containing appreciable amounts of fluid, should be first emptied and washed out; all of which can be done through the same small trocar used for introduction of the iodoform. The verdict of surgeons today is rather against the employment of iodoform, since they have learned to not rely upon it because of disappointment so often following its use.

Bier, in 1891, advised the so-called congestion treatment of tuberculous joints, basing it upon the fact that tuberculosis does not develop in lungs which are the seat of venous stasis from valvular heart disease. He proposed to produce an artificial stasis, in the joint structures and about them, by which living germs should be destroyed and their disease products encapsulated, claiming that as the result of the hyperemia thus produced the alexins are thus brought into more complete contact with the bacilli. The method is applicable to the limbs below the shoulder and hip. It consists in the application of an Esmarch bandage above the affected joint, applied with sufficient firmness to obstruct the returning blood, but not to interfere with the arterial supply. If there be room the limb is also bandaged below the joint with an ordinary cotton roller. This congestion is kept up at daily intervals for increasing periods, beginning with perhaps half an hour and continuing until it is in operation at least half of the time. Meantime other methods of treatment are not interdicted. In the earlier stages of tuberculous joint disease this method has given very encouraging and pleasing results. (See Fig. 208.)

Tuberculous hydrops may be treated by aspiration and elastic compression. Should fluid distend the joint it should be opened and thoroughly cleaned, then closed and perhaps drained.

The treatment of pyarthrosis and of peri-articular cold abscess has long been a mooted subject. The orthopedic surgeons still adhere to mildly or absolutely non-operative measures, whereas the general surgeon prefers to adopt more radical methods. Each case should be judged on its own merits, and these should include a careful estimation of the general condition of the patient. Should evidences of septic intoxication be present or the ordinary general signs of the presence of pus, then these collections should be opened and cleaned out. If hectic can be excluded, then other considerations will indicate what is best. At all events there will be seen many cases where a delay in operation will be advisable, in order to permit of improvement of the general condition by measures above described. To merely open up a tuberculous focus and leave at least two fresh raw surfaces exposed to contamination is rather to invite the spread of the disease than to correctly meet the indication. Every old focus will be lined or surrounded with a more or less dense membrane formerly called pyogenic, but now more correct knowledge shows it to be pyophylactic. (See p. 113.) To leave this in situ is to leave germ-laden walls, while to dissect it thoroughly is to make a larger, fresh raw surface and to open up innumerable absorbent vessels. Thus, whether it be removed in whole or in part, or allowed to remain, some sufficiently strong caustic material should be promptly employed, by which both destruction of living residual germs and closure of the mouths of the absorbents shall be effected. This has been set forth more fully when dealing with cold abscesses in general, but is of so much importance that it may be reiterated here. Whether the actual cautery, pure carbolic acid, strong zinc chloride solution, or some other agent be used should depend upon circumstances, but every portion of the surface which it is proposed to leave more or less exposed to the possibility of infection should be thus protected. In proportion to the intensity of the caustic action there will be separation of more or less cauterized and sloughing material, for whose escape provision should be made; but it will be separated by the granulation process, aided by an active phagocytosis, and when removed will leave a granulating surface which is but slightly absorbent. These facts pertain to small incisions for drainage as well as to extensive arthrectomies.

The operative treatment, then, of tuberculous arthritis varies from tapping, with or without drainage, to complete arthrectomy or amputation. When the joints of the foot or ankle are extensively diseased, and the patient, as usually happens, is in poor condition, it may appear that amputation will afford the most complete relief, and that a stump with an artificial member will be of much more use to the individual than a mutilated, tender, and disabled foot.

To incision with or without drainage is given the name arthrotomy. When the joint is widely opened and portions removed with the sharp spoon or otherwise, it is known as arthrectomy. When bone is removed irregularly the measure is called atypical resection. When entire bone ends are removed the operation becomes an exsection or resection. The ordinary arthrectomy is not sufficient when foci are present in the epiphyses. Here at least atypical resection is called for. Arthrectomy may properly include a wide exposure of articular surfaces and the removal of the thickened and diseased synovia, with its fringes, or with the cartilages, by which cancellous structure is more or less widely exposed. When arthrectomy is undertaken it should be thoroughly made and by a large incision, since the more completely the joint cavity can be inspected and attacked the better are the interests of the patient subserved. All fresh or cold abscess cavities which connect with the joint or lie in contact with it should also be attacked at the same time, and those which do not communicate with it should be separately drained. While drainage by tube or other means will usually suffice, there are cases where the disease is so extensive that it will pay to pack the cavity with balsam gauze for a few days, placing secondary sutures by which the incision can be closed after its removal. In the shoulder and hip, for instance, such a method will give satisfactory results.

The advantage of avoidance of resection is the non-interference with the epiphyses and their junctions, thus permitting the growth of the bone to continue. Therefore complete and typical excisions should be practised as seldom as possible, especially in growing children. They may be practised to advantage even in advanced age, and the writer has seen satisfactory results after complete excision of tuberculous joints in senile cases. When operating upon a tuberculous tarsal joint the surgeon is likely to find one or more of the tarsal bones so much involved in the tuberculous disease that he is compelled to scrape it out and thus leave a cavity almost the size of the bone itself. Should he have to do this to a series of the bones it would be better to make a formal resection of the tarsus or possibly an amputation. The cavity should be left open with a sufficiently large incision so that it may be easily packed. A cavity of this kind left unpacked will fill up with clot, which will disintegrate and the result will be much less satisfactory. In the former case there is an open cavity which fills with granulations, but this can be kept accessible under observation and with more effect and comfort. This is equally true of those cavities where both arthrectomy and bone curettage have been practised.

MOVABLE BODIES IN THE JOINTS.

Several different terms have been applied to loose and movable bodies, even in the various joints, depending on their size, arrangement, and appearance. Thus we have the rice-grain or melon-seed bodies (corpora oryzoidea), which have already been described and are now supposed to indicate a form of tuberculous synovitis which has undergone a partial if not complete subsidence. Again we have larger masses occurring singly or in very small number, especially in the knee, to which the Germans have given the significant name of joint mice. Also in the knee, owing to its peculiar construction, another form of movable body is met with, i. e., a displaced and more or less motile semilunar cartilage. This condition was first described by Hey, and especially studied by Allingham, who made it a prominent feature of what he described as “internal derangement of the knee.” Lastly, in those joints in which synovial fringes occur, the knee especially, it is held that portions may become detached by having been infiltrated and cast off or broken loose, and thus form a fourth variety of floating body. The joints most often affected are the knee and the elbow. In many instances there is a history of injury, especially when the mass is of considerable size. The theory of an “osteochondritis dissecans” has also been invoked to account for the resemblance between some of these bodies and the articular cartilages. Some pathologists have held that they may result from the organization of clots, which are subsequently rounded off and shaped by attrition (Fig. 209). These bodies then may consist of condensed fibrinous material, of cartilage, of true bone, or of hyperplastic and fatty synovial tassels. To these may be added rare instances of mucoid connective tissue.