Part 10

In acute inflammation of the synovial membrane, and in cases where the cartilage is ulcerated, the pain is very intense, and the spasms of the limb most distressing. This happens when the surface is ulcerated, and perhaps to no great extent. We know that in the horse an ulcerated hollow in the cartilaginous covering of the navicular bone, not so large as to contain a grain of barley, will cause such lameness and suffering as to render the animal so affected perfectly useless. If he is not destroyed at this stage, as many valuable animals have been, the mischief extends, and terminates in extensive disease of that and the neighbouring bones and articulations. It is different if the disease commence, as it sometimes does, in the human subject, in the cancelli of the bone, and on the attached surface of the cartilage, the free surface remaining some time entire and smooth. When the synovial membrane is primarily affected by chronic disease, the pain is in general trifling, often not complained of, and swelling of the part, from effusion, into the joint or neighbouring bursæ, first attracts attention, after it has existed, perhaps, in a slight degree, for a considerable time. The joint is stiff, and pain is experienced from extensive motion; on this account the patient is disinclined to use it, and it is soon tired by the slightest exertion. The swelling becomes more solid, though still remaining elastic, and the feeling of fluctuation diminishes. Effusion of lymph follows that of serum, the latter having been absorbed; the motion of the joint is still further impeded, and the articulation is distorted; the patient keeps the limb in the most easy position, generally that of partial flexion, in which it becomes almost immovably fixed. The cause of the flexed position, which is almost pathognomonic of knee disease, being preserved, seems to be that the limb is insensibly brought into it in order to take the pressure off the interarticular apparatus, the ligamenta mucosa and alaria,—these swell—the muscles of the hamstrings get contracted from habit, and a difficulty, even after the disease is completely subdued, is often enough experienced in procuring complete extension. The muscles, from disuse, shrink, the adipose substance is absorbed, the shafts of the bones also are diminished in size, get into an atrophied state, as the phrase is, and thus the whole limb is rendered slender and wasted, so as to make the swelling of the diseased articulation still more conspicuous. The bones are softened, and the muscles are of a white colour, as in the limbs of the paralytic or bedridden, and resemble more cellular than muscular tissue. The wasting of the muscles and loss of power often precede the appearance of disease; this is frequently observed in the shoulder-joint, the deltoid shrinking, and almost disappearing, before any disease in the articulation is suspected by the patient. Not unfrequently, also, this wasting occurs without obvious cause, or any affection of the joint. When the disease is advancing, the patient may feel no acute pain, but merely a reluctance to use the limb; and from this, if long continued, the muscles, and afterwards the bones, become wasted. Wasting of the limbs in children, often of one of the lower, frequently arises from disorder of the bowels, and the irritation and debility attendant on teething. This must be distinguished from the wasting accompanying diseased joint. The history of the case, the period at which the weakness of the limb was observed, and its appearance, will lead to a correct diagnosis.

The swelling is often irregular, being more protuberant at one part than another, from the fluid or the addition of solid matter being accumulated where the least resistance is afforded; but the slighter inequalities are generally filled up by œdema of the cellular texture. As the disease proceeds, matter forms in the joint, and is often attended with great pain and fever; or the pus is effused into the bursæ, into the surrounding cellular tissue, or into the filamentous tissue amongst the tendinous sheaths of the muscles in the neighbourhood; being allowed to remain without an outlet, it at length communicates with the cavity of the joint. Portions of the cartilages are absorbed, though this, as already noticed, may occur at the very commencement of the disease; the subjacent bone becomes affected by ulceration, or perhaps its vitality is partially destroyed. When matter has accumulated, a portion of the capsular ligament generally ulcerates, the pus escapes, and is ultimately discharged externally.

When the disease begins with swelling, which is of a chronic character, and produces but little inconvenience, and when the more urgent symptoms supervene after the swelling has continued for a considerable time, there is every reason to suppose that the disease has originated in the synovial membrane, or perhaps in the osseous cancelli, and this is generally met with in poorly fed and strumous subjects. But when the first symptoms have been pain and stiffness of the joint, without change of its appearance, and when the swelling has occurred after these symptoms have been of some duration, then it is probable that the cartilages are the primary seat of mischief. For the most part, however, the symptoms have a general resemblance in most chronic affections of the joints, and all the apparatus is sooner or later involved. When the cartilage has been extensively absorbed, a grating sensation is felt in moving the articular surfaces of the bones upon each other. In consequence, also, of the softening and disorganisation of the lateral and other ligaments, the affected articulation at length becomes unnaturally loose, which is owing in some measure, also, to the muscles being wasted and paralysed from pain and disuse. At an earlier stage of the disease, the joint may be rigid from deposition of lymph into the contiguous cellular tissue, and contraction of the muscles.

Purulent matter not unfrequently collects in the substance of the bones, which in all cases ultimately become softened in a remarkable manner. In many subjects, without actual disease of the osseous tissue, the heads of the bones are so altered in consistence, are so deficient of earthy matter, as to be easily cut with a knife. It has been a matter of dispute, whether, in this affection, the articulating extremities of the bones are enlarged or not; and the supposition that they are always more or less increased in size, or hypertrophied, has arisen from the extensive effusion and indurated state of the soft parts being mistaken for this enlargement. In the first stages of the disease, they are seldom, if ever, enlarged; but when ulceration of the bone has occurred, new osseous matter is deposited to a greater or less degree in the neighbourhood of the ulcer,—an attempt by nature towards a cure, but too often an ineffectual one. The bones, in strumous subjects, are often much enlarged, from collection of purulent matter in their substance giving rise to a sort of spina ventosa. I removed the upper extremity of a boy lately on account of extensive disease about the elbow. The ulna to near the wrist was swollen enormously by purulent collections in its medullary canal. In cases when the whole of the articulating extremity of the bone is not enlarged, still that portion which is more immediately concerned in the articulation is often considerably expanded.

Frequently when the knee is the seat of the disease, the lymphatic glands in the groin are enlarged; and when the elbow or wrist joints are affected, there is often a similar enlargement of the glands in the axilla: such glandular tumours have not rarely been confounded with those accompanying malignant disease, and measures which were absolutely necessary for the salvation of the patient, have thus been delayed or neglected.

When the disease is extensive, and has endured for a considerable period, hectic fever supervenes, and is aggravated after the abscesses give way. The patient becomes much weakened and emaciated, and loses his appetite; the pulse is rapid, with night sweats, diarrhœa, &c.; and from a continuation of the hectic cause, the life is endangered. In some cases, however, the health is restored, and the disease abates spontaneously; in others, the disease is arrested, and a complete cure accomplished, by the careful employment of such means as will be afterwards mentioned.

The appearances produced by inflammation and consequent disease of the synovial membrane, are the following. In the first stage, the internal surface of the capsular ligament, and the rest of the synovial membrane, is found of a red hue, its formerly colourless vessels being now made apparent, from enlargement and consequent injection with a greater quantity of red blood; and the serum within the cavity of the joint is more abundant than in the natural state. When the disease has been of longer continuance, the membrane is found considerably thickened, its usual smooth glossy surface is destroyed, it is irregularly flocculent, and frequently of a light yellow colour.

The interarticular adipose tissue also seems to be increased in volume, from being infiltrated with a serous fluid, by the discharge of which the diseased bloodvessels may have attempted to relieve themselves. When the inflammation has been intense, or of long duration, lymph is secreted, and deposited on the external surface of the membrane, forming an intimate union between it and the ligaments, and producing thickening of the external apparatus. Or the lymph is also effused on the inner surface of the membrane, to which it adheres and becomes organised; this is generally accompanied by the formation of purulent matter; the organised effusion is often so extensive as to conceal almost the whole of the synovial membrane, excepting portions of its delicate reflexions which invest the articulating cartilages. By the lymphatic deposit, to a less degree, the folds also of the synovial membrane adhere to each other, whereby the motion is still farther impeded, and the pain, when attempted, increased. Occasionally the synovial membrane is found enormously thickened, much softened in texture, and of a brown hue, when the disease has been of a very chronic character. Along with these appearances, serum is generally found effused, in a greater or less quantity, into the cellular tissue exterior to the ligamentous covering. In cases in which the matter has formed and remained long within the cavity of the articulation, the synovial membrane and the ligaments become blended into one soft mass, the internal surface of which is lined with a thick coating of lymph, as in the case of common abscess. If purulent matter is effused externally, and communicate with the joint, the capsular ligament will be found to have ulcerated and given way at certain points, forming apertures, usually of small size, and with ragged margins.

All these appearances may exist without disease of the cartilages or extremities of the bones; but generally they are also affected at the same time. At first the surface of the cartilage is slightly irregular and rough, and the change is not observed, unless on minute inspection. Afterwards the surface is marked with small depressions, which may be numerous, and are surrounded with irregular and somewhat serrated margins. They gradually increase in depth and extent, and the subjacent bone is ultimately exposed at one or more points, as here shown. Often the greater part of the cartilage is removed by absorption; the bone is exposed, opened out in its texture, softened, of an irregular surface, and in some places excavated, containing a thin ichorous fluid; the process of ulceration has also extended to the osseous tissue. Sometimes scales of cartilage of considerable size are either completely detached, having become dead, and been thrown off by the natural process, and are found lying loose in the cavity of the articulation; or they are all but separated, adhering by one or more very slender attachments.

The incipient stage of such disease may exist without the synovial membrane being much, if at all, affected; but when the ulceration has made farther progress, all the articulating apparatus is more or less diseased. It may be here remarked, that the synovial membrane may be affected for a long period, thickened portions may extend over the cartilages, and these may have lymph upon them and yet remain intact.

The cure, resorted to by nature, and in which she may be much assisted by the surgeon, is Anchylosis, ligamentous or osseous. New bone is deposited in the neighbourhood of the disease, and the ulcers become, as it were, cicatrised; the articulating extremities of the bones are joined to each other by a firm osseous matter, either universally disposed or consisting of processes extended between the bones at various points: or again, in consequence of the effusion of lymph into the cellular tissue, and the consequent thickening and induration of that and of the fibrous tissue exterior to the joint, this connecting medium is so strengthened and concentrated as to retain the articulating surfaces in exact apposition; from one, and usually from both, of these changes, the joint is securely fixed and rendered immovable, or nearly so. In complete anchylosis, the cancellous texture of the two bones, after some time, becomes perfectly continuous, so that they in fact constitute but one bone, as seen in cut, p. 84. A very perfect specimen of anchylosed knee joint is also delineated in the cut above. But even after this happens, the disease is still apt to recur from slight causes, the bony or ligamentous union being disturbed or destroyed, and the original disease attacking the parts with fresh activity; abscesses form,—may be extensive both in size and number,—and thereby the health is again undermined. So that the patient, after undergoing much suffering and risk, preserves, perhaps only for a few years, a limb which is almost useless to him, and which must be removed at last. In other cases, the union is permanent, the disease does not return; by care and time the limb is brought into the most convenient position, and proves of considerable service.

The joints are often affected by rheumatic and gouty inflammation; and there are three species of disease, tolerably distinct in their pathological characters, generally attributed to these causes. In one there is a deposit of chalky-looking matter, composed chiefly of super-lithate of soda, on the articular surfaces of the synovial membrane and cartilage, but most abundantly in the cellular tissue outside the joint, an affection in which the cartilage is seldom known to ulcerate. In the second, the cartilages are atrophied, as if worn away by attrition, the articular surfaces of the bone being much modified in shape, more or less denuded of cartilage, and remarkably polished and hard, so as to have been compared to porcelain, as will be described in another section. In the third, the fibrous tissue in the neighbourhood of a joint is primarily affected, the synovial membrane and cartilages not becoming involved till the disease is much advanced. It is not uncommon in the elbow of middle-aged persons who have been much exposed to the atmospherical vicissitudes, and is sometimes attributed to the effect of mercury or syphilis. The periosteum around the articular ends of the bones becomes swelled and painful; the affection is very slow in its progress; abundant deposition of adventitious bone takes place, often in short spiculæ, gradually encroaching around the joint, which ultimately becomes involved. A good specimen is here given. The disease was of twelve months’ duration, and was attributable to rheumatic inflammation supervening upon sprain. The affection involves extensively all the bones composing the articulation.

Although wounds penetrating the larger joints are attended with danger, the synovial membranes are possessed of considerable powers of reparation, and often heal readily after severe injuries. An occasional result of inflammation is adhesion between the layers of the membrane, but this is by no means so frequent as in the serous tissues. The reparative power of cartilage is so low that the best termination that can be expected from the ordinary forms of ulceration, is union between the abraded surfaces. In experiments which have been made on the lower animals, portions of cartilage which had been removed from their joints were never reproduced, but the functions of the part were soon restored by the cut surface becoming smooth. In like manner there is occasionally to be seen in museums a circumscribed indentation in human articular cartilage, as if it had been destroyed by a small ulcer in this situation, which had cicatrized without any reproduction of the destroyed tissue.

ON HYPERTROPHY AND ATROPHY OF THE ARTICULAR CARTILAGES, WITH EBURNATION OF THE SURFACES OF THE BONES.

It has been already observed (at page 68), that the cartilages are occasionally swelled and softened in cases of chronic inflammation; and it now remains to notice instances in which they become hypertrophied or atrophied, apparently without inflammatory action. Although these affections are not likely to come often under the treatment of the surgeon in civil life, yet they are of much importance to the naval or military practitioner, since an accurate knowledge of them will lead him to institute a careful inquiry when a man complains of inability to sustain the fatigue of marching with the burden of a heavy knapsack; and they are of considerable interest in a physiological point of view, because they tend to show the inherent vitality of cartilage, and that it is liable to serious organic changes quite independently of diseased action in the surrounding tissues.

Some examples of hypertrophy of cartilage, principally affecting that of the patella, have been described by Mr. Gulliver, and figured in the third fasciculus of drawings from the Army Anatomical Museum. In these the cartilage is swelled so as to form a ridge across the articular surface of the bone, the hypertrophied part being perfectly smooth, except where its continuity is interrupted by irregular fissures, as if the perpendicular cartilaginous fibres were split into bundles of variable size and shape. These cases occurred in young and middle-aged men who died of pulmonary consumption; and it is probable that the disease would be more frequently found, if it were more frequently looked for, since it does not seem to have been accompanied by any change in the surrounding parts, and would perhaps only be indicated by weakness of a joint rendering it unfit for severe work.

The atrophy, or absorption of cartilage, is so frequently seen in the joints of old subjects, that some authors have been disposed to regard it rather as a physiological than a pathological condition. It is, however, unquestionably a disease; and in the drawings above mentioned, are some specimens of it from a soldier under the middle age. The cartilage seems in the first instance to be opened out in its texture, and numerous little villous processes appear on its surface, often as if its fibres were enlarged after absorption of the substance which connected them. The thinning sometimes takes place in patches, occasionally in grooves, corresponding to the motions of the articular surfaces; the subjacent bone becomes at length completely denuded, and soon presents a polished porcelain-like surface, which is so remarkable that it is commonly known under the name of porcellaneous deposit. It is obvious that, when the disease has proceeded thus far, the joint must become more or less deformed, and its motions considerably impeded. Accordingly, old men are often seen at work with much rigidity of the joints, particularly of the knee, which is frequently projected inwards, from absorption of the cartilage from the outer condyle of the femur and corresponding part of the tibia, with a thinning and degeneration of the inner-articular cartilage into a tissue resembling the cellular.

The hard, polished, and ivory-like appearance of the articular surface, would lead us to suppose that it contained an unusual quantity of earthy matter, yet an analysis by Dr. Davy, here given, shows the contrary.

_Composition of the Shaft._ _Composition of the polished Articular Surface._

Phosphate of lime, &c. 58·8 Phosphate of lime 54·2 Animal matter 41·2 Animal matter 45·8 ——-—— ————- 100·0 100·0

In many instances where the disease is of long standing, a deposit of adventitious bone takes place around the articular surfaces, and this may occur to such an extent as to produce anchylosis of the joint, the articular extremities of the bone often presenting several irregular depressions, and becoming variously altered in shapes, as shown in the cuts, p. 86.

It is curious that the atrophy of cartilage is generally seen in its early stage to attack the joints in pairs, and to occur also in corresponding parts of the articular surfaces; a fact which coincides with the disposition of caries to appear simultaneously or successively in corresponding molar teeth.

Of the causes of the disease but little is known, although it is generally attributed, like some other obscure affections, to the effect of rheumatism. It often follows in old people upon long disuse and confinement of a limb to one position, as during the cure of fractures. A very valuable specimen was presented to me lately by my friend Mr. Busk, of the Dreadnought hospital ship. The elbow had been apparently subjected to great injury. The radius and ulna had been fractured: the former had united, whilst a false joint had been formed betwixt the portions of the ulna. There is profuse deposit of bone around the elbow-joint, which must have been quite stiff, or nearly so, as regarded flexion and extension; but the end of the radius and corresponding articulation of the humerus are beautifully polished. This polish is not unfrequently seen also upon disunited fractures, as in the neck of the femur. Atrophy of the cartilages has been seen where no rheumatism was ever known to have troubled the patients; and they are more generally disposed to ascribe it to the effect of incessant hard work. At all events it is comparatively rare among women, and in the upper ranks of society; and the wasting often presents very much the appearance which would result from the effects of attrition, as if the wear of the cartilage had not been supplied by a corresponding reproduction. It is probable, therefore, that the affection is attributable to defective nutrition, somewhat allied to certain changes in the cornea, which are known to proceed from this cause, and which are also unattended by inflammation or the formation of pus.

The symptoms of the disease are generally obvious enough in the more advanced stages by the crackling which may be heard when the joint is moved; and in the early stage a grating may be felt by a careful manipulation.

SCROFULOUS DISEASE OF JOINTS.