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]).