In cases coming late under observation, hopeless destruction of bone and cartilage may be discovered which will require the radical surgical measures suitable for the treatment of chronic joint disease: even amputa tion of the limb may be demanded to save life.
In mild cases the rest should not be too prolonged, and when the more acute symptoms have been thus combated, and all pain has disappeared for a time, passive motion may be carefully commenced, the surgeon feeling his way cautiously. Many joints have been hopelessly destroyed by rest prolonged long after the inflammatory action had subsided. It is this mistake which enables the unscrupulous bone-setter to thrive. Getting a joint affection in which all inflammatory action has long ceased, owing to treatment by some surgeon whose prevents h im beginn passive or forcible movements. the bone-setter pronounces the limb to be " out of joint," and after a few forcible movements he assures the patient that he has " put in " the and the mobility and painlessness of the limb which follow apparently corroborate his statements. When the value of early massage and movements of a passive or forcible nature are universally appreciated, the principal occupation of the bone-setter will be gone. The arthritis which sometimes follows typhoid, influenzal and pneumococcal infection usually yields readily to the above measures.
Thickening from exuded inflammatory products outside the joint or effusion into the synoyial sac may be dissipated by strapping or by the uniform continuous pressure of a Martin's rubber bandage. Any old sinuses in the neighbourhood of the joint should be injected with Bismuth Jelly.
Chronic joint disease, when rheumatism, gonorrhcea and rheumatoid arthritis are excluded, nearly always is tuberculous, commencing either in the synovial membrane or in the bones. In the former case the clinical type of the disease is recognised as " white swelling," which, if neglected, passes into the type in which the articular ends of the bones become finally invaded, causing destruction of the joint and abscesses.
The treatment of tuberculous joint affection has been described under Hip-Joint and Knee-Joint Disease, and is in the main applicable to all the other articulations affected by the tubercle bacillus. The principles to be carried out are in the first place those indicated in all other forms of localised tuberculosis—viz., (i) Rest, (2) open air, (3) improved feed ing with abmidance of fats (Cod-liver Oil, &c.), and (4) a carefully carried out course of Vaccine treatment by the injection of minute doses of Tuberculin regulated by a series of observations on the opsonic index and temperature. Tuberculin R. (human) should always be used.
Local treatment consists, as in acute arthritis, of absolute immobility of the joint surfaces for a very prolonged period in the most suitable position of the limb should ankylosis become established, extension by weight and pulley to diminish intra-articular pressure and the induction of passive hyperaemia, together with the application of soothing lotions for the relief of pain. Seldom are leeching, blistering, the actual cautery or severe counter-irritation indicated in tuberculosis of joints. The aim of the surgeon should he to assist the natural efforts towards resolution by these conservative or preventive methods, perseveringly employed for many months or a couple of years, without any attempt at passive motion or operative procedures as long as hopeless disintegration of the joint structures has not occurred. The injection of Iodoform emulsion (to per
cent. in glycerin) is a valuable method of sterilising the joint after this has been washed out through a small canula by a stream of saline solution, and where the disease is limited to the synovial membrane a speedy improvement may be expected, and the X rays applied to superficial joints have been productive of good. Some surgeons publish excellent results from the injection of 5 mins. of a ro per cent. solution of Zinc Chloride.
When disorganisation of the joint has occurred the operation of incision suitable in acute arthritis is contra-indicated unless carried out in a more radical manner. The whole cavity must be freely opened by a large incision, and the operation of arthrectonty or erasion performed. After freely opening the articulation, and if necessary doing it in such a manner as will cause disarticulation, the diseased synovial membrane is to he completely removed by scraping or dissection, and any diseased cartilage cut away at the same time. The joint is next swabbed firmly with a strong Antiseptic, and the skin-wound sutured without any provision for drainage if the surgeon is satisfied that he has been able to remove every scrap of the diseased structure.
Where the exploration of the joint reveals disease already affecting the bones, a more radical operation than,arthrectomy is clearly indicated. f the hone disease he limited to the layer beneath the synovial membrane gouging should he resorted to. Evcision or resection of the joint may be demanded, the affected bone 'icing cut away along with the articular cartilages and synovial membrane in order to establish firm osseous ankylosis in such joints as the hip and knee and a fibrous union with a movable joint when the wrist, elbow and shoulder are operated upon.
No erasion, arthreetomy or excision m a tuberculous joint should be undertaken unless the joint he in a condition of quiescence, otherwise a return of disease is likely to occur.
Rarely will ampirtztion he necessary, and it should only he resorted to when the above measures fail or where secondary suppurative infection threatens to exhaust the strength of the patient, or where am vloid disease is supervening. The introduction of the treatment of long-standing sinuses by the injection of Bismuth Jelly has considerably lessened the necessity for amputation, as these often heal up completely after resisting scraping and dissection and the introduction of powerful antiseptic solutions.
It is hardly necessary to insist upon the importance of the rest cure being persevered with for a long period and of the dangers arising from any attempt to move the joint by active or passive motion till all evidence of the subsidence of the tuberculous inflammation has passed away. Disastrous results are more liable to follow premature movements than in the case of the more acute forms of arthritic infection after the subsidence of inflammation.