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.
Fig. 207
Backward displacement of tibia due to the muscle spasm of a tuberculous knee-joint, with final bony ankylosis. (Lexer.)
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.