THE PY.EMIC AFFECTIONS OF THE JOINTS Etiology and Course.—As we have mentioned above, infections of the joints may arise from contiguity, as well as from lumnatogenous metastases. Exudations into the joints are a frequent accompaniment not only of purulent processes in other organs, but also of many infec tious diseases (measles, scarlatina, gonorrhica, influenza); purulent inflammations are by no means ra-relv observed in children to be caused by staphylococci and streptococci, also often by pneumococci (see Bur sitis pneumococcica, Kaumheimer).
A close network of blood-vessels and capillaries is situated under the innermost layer of the svnovial membrane and these undoubtedly favor the transmission of germs. According to the virulence, kind and amount of immigrated germs the synovia will respond to the stimulus of the virus by the copious exudation of a serous or cellular-purulent liquid which fills the joint and distends it in all directions.
The normal contour of the joint disappears and we observe the picture of the distended capsule. The bones forming the joint are placed in that particular position in which it is ossiest for the muscles to retain their equilibrium and at the same time to keep the joint as quiet as pos sible, because every movement hurts (position of pain); naturally the joint will now return to that embryonal position in which all parts of its capsule arc equally distended while its muscles are in equilibrium (flexion in hip and knee-joints).
These exudates are accompanied by much fever, which is especially high in cases of purulent inflammation.
The serous exudate usually heals entirely (absorption) while the purulent inflammation leads often to extensive destruction in the joint, roughening of the surface, loosening of the cartilages, adhesions of the folds of the capsule, so that a destroyed and disabled joint may remain after the healing of the process. This disturbance will be still severer in cases in which the exudate has separated the components of the joint and in which the destruction of the ligamentous apparatus has permitted luxation to take place.
In childhood we are especially interested in the frequent infectious arthritis of infancy.
The Staphylococcus pyogenes aureus and the Diplococcus goner rhcex are the germs mostly found, though a streptococcus may be the cause in some rare cases. These affections are observed after diseases of the respiratory organs, after bh•imorrInea of the vulva as well as of the eyes (Ifutan), hut frequently also without any recognizabli port of entry.
Quite often the infection will originate from small intracapsular osteomyelitis foci (Broca, Mohr) situated in the epiphyses near the joints (A. Berg, Fralich) (Fig. 110e). In the hip-joint especially (Bruns,
Muller) suppurations will produce a malposition of the bones which may in later life appear as a congenital luxation (Drehmann). The author has personally observed thirteen such cases of infantile joint-suppura tions, two of which left a luxation of the hip-joint. The large joints arc mostly affected (hip, knee, shoulder), the small ones less often. Older children show these metastatic suppurative arthrites after scarlatina or accompanying an otitis media.
Treatment must always consider the function of the joints and the age of the child. In the arthritis of infancy the author strongly con demns any wide opening of the joint.
Should exploratory aspiration show the presence of diplococci or staphylococci, then repeated aspiration without flushing with irritating liquids will often suffice to bring about recovery. If this should not be sufficient or should we find streptococci, then we make a small incision (not more 1111111 1 ern.) and aspirate the joint with cups (Klapp).
In refractory cases with recurrences we insert a glass drainage tube.
We should never pack the joint, because in doing this we severely injure and disable the scrosa.
The prognosis of streptococcus infections is much more unfavor able. In all others we can by these means stay the process, and we usually succeed in retaining a useful joint. In one ease of postscarla tinal affection of both hip-joints treated by this method one side healed entirely, while the other remained somewhat stiff owing to destruction of bone.
It is advisable even in older children not to sacrifice the function of the joint by adopting early radical operation, although we understand that as soon as the general condition assumes a grave aspect we must attempt to save the patient's life by wide incision, but in infants we refrain from this for exactly the same reason.
Postural treatment of the joint is of great importance in all such cases. This has for its object to fix the joint in the position that will insure the least loss of function in case the joint should remain stiff (fixation with plaster splints).
Chronic diseases of the joints occur similarly in the course of infec tious diseases (influenza, acute articular rheumatism, measles), and in these cases bacteria have been found in the exudate and in the synovial tissue (Schiiller, Spitzy), though the body then comes out victorious; hut even in these chronic processes the joint may easily lose some of its functions owing to the formation of connective tissue, to scars and to other degenerative as well as regenerative processes.