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.
[32] The fundamental idea expressed in all of the methods for enforcing rest by traction is of American origin, and constitutes one of the advances in surgery for which the world is indebted to America. For a long time it was referred to in Germany as the American method, and yet now the Germans claim so much for it that one of their surgeons has written a book of 600 pages devoted to the employment of traction for various surgical purposes, in which but very little credit is given to the men who originated it.