Syphilitic arthritis is a chronic and mildly but steadily progressive affection. It rarely assumes purulent form without some secondary infection. It is frequently combined with gumma along the epiphyseal border. In hereditary syphilis numerous joints may be involved in changes of the rachitic type.
Gout or some of its allied rheumatoid manifestations may lead to a dry form of synovitis, with deposit of urates or of lymph, and the formation of tophi in the neighborhood, or it may assume the form of a chronic and intractable hydrarthrosis. The acute forms are accompanied by great pain, with redness and swelling, peri-articular and intra-articular. The tendency of these cases is to chronicity and recurrence.
General Treatment.
—Upon the nature of the condition will depend the treatment of joint diseases. The questions of when to operate and when to abstain, when to enforce rest and when to begin passive and when active motion, call for discriminating judgment. An acute or even mild traumatic synovitis should, first of all, be protected from becoming purulent. Should injury be accompanied by a bruise, the greatest care should be given to antisepsis, and the part sterilized and dressed with every precaution. Should there be no external injury we may rely ordinarily upon cold, wet compresses, with suitable elastic compression and physiological rest. Should two or three days of this treatment fail to bring about nearly complete resorption the aspirator may be employed to withdraw the fluid. If this should be found to be bloody or too thick to run through the needle, it will be advisable to make small incisions on either side, under the strictest precautions, and to practise thorough irrigation, by which the joint cavity will be completely cleared of foreign material. As soon, however, as the presence of pus is indicated, or even suspected, the whole character of the treatment should change. The surgeon should now endeavor to be as radical as possible. The more purulent the collection the more are free incision, irrigation, and drainage indicated and the more complicated the condition the more he should make counteropenings here and there, wherever joint pockets may be emptied.
When muscle spasm not only seriously disturbs the patient but threatens to draw the limb into an undesirable position it should be overcome, either by employment of traction with weight and pulley, or by forcible reposition and fixation in suitable splints, such as plaster of Paris. Some of the most extensive operations that are called for are necessitated by neglect to observe these precautions early. Often nothing will afford so much relief as the use of traction, with sufficient weight, tiring out contracted muscles, and thus not actually separating joint surfaces, but overcoming that muscle spasm which brings them tightly together and thus gives pain.
In the more chronic form of cases absorption may be promoted by elastic compression, by massage, by wet compresses, and sometimes by blistering. Ordinarily, and especially in those cases characterized by pain, more can be accomplished with the actual cautery drawn lightly and rapidly over the surface of the joint than by blistering. This application is referred to as the flying cautery, and it is one of the most effective agents known for the relief of deep-seated pain, as well as of cutaneous hyperesthesia. Its use causes little if any unpleasant sensation, and should be repeated at daily intervals until the primary object is attained.
Should aspiration of a distended joint be practised at any time, one should atone for the loss of intra-articular pressure thereby produced by external compression, preferably with an elastic medium.
In the writer’s opinion it is not advisable to use a small aspirating trocar in those cases which are likely to call for irrigation. The aspirating needle should be confined to the non-purulent collections of fluid, although some surgeons advise and practise throwing into a mildly infected joint, through such a needle, some reasonably strong antiseptic fluid or emulsion, hoping thus to gain its bactericidal effect without external incision.
The active manifestations of disease being mastered, one addresses himself naturally to the greatest possible prevention of deformity and restoration of function. Indeed, these should be kept in view from the outset, although we have, for a time, to disregard them in favor of more imperative indications. If ankylosis appear inevitable the joint should be kept in that position in which, when stiff, it will be most useful. This position will be, at the elbow, at a right angle; at the hip or knee, nearly complete extension. When, on the other hand, restoration of function is hoped for it will be obtained through a combination of massage, active and passive movements, with the use perhaps of some sorbefacient ointment, such as the compound ichthyol-mercurial, or by the nearly constant use of cold, wet compresses, combined with the other measures. The greatest care should be exercised in determining the time when absolute rest given to an inflamed joint should be changed to the gentle or more forcible movements required for restoring use to previously inflamed joint surfaces.