Metastatic Forms of Pyogenic Infection

In pyæmia, one or more joints may fill with pus without marked symptoms or signs, and if the pus is aspirated without delay the joint often recovers without impairment of function.

In typhoid fever, joint lesions result from infection with the typhoid bacillus alone or along with pyogenic organisms, and run their course with or without suppuration; there is again a remarkable absence of symptoms, and attention may only be called to the condition by the occurrence of dislocation.

Joint lesions are comparatively common in scarlet fever, and were formerly described as scarlatinal rheumatism. The most frequent clinical type is that of a serous synovitis, occurring within a week or ten days from the onset of the fever. Its favourite seat is in the hand and wrist, the sheaths of the extensor tendons as well as the synovial membrane of the joints being involved. It does not tend to migrate to other joints, and rarely lasts longer than a few days. It is probably due to the specific virus of scarlet fever.

At a later stage, especially in children and in cases in which the throat lesion is severe, an arthritis is sometimes observed that is believed to be a metastasis from the throat; it may be acute and suppurative, affect several joints, and exhibit a septicæmic or pyæmic character.

The joints of the lower extremity are especially apt to suffer; the child is seriously ill, is delirious at night, develops bed-sores over the sacrum and, it may happen that, not being expected to recover, the legs are allowed to assume contracture deformities with ankylosis or dislocation at the hip and flexion ankylosis at the knees; should the child survive, the degree of crippling may be pitiable in the extreme; prolonged orthopædic treatment and a series of operations—arthroplasty, osteotomies, and resections—may be required to restore even a limited capacity of locomotion.

Pneumococcal affections of joints, the result of infection with the pneumococcus of Fraenkel, are being met with in increasing numbers. The local lesion varies from a synovitis with infiltration of the synovial membrane and effusion of serum or pus, to an acute arthritis with erosion of cartilage, caries of the articular surfaces, and disorganisation of the joint. The knee is most frequently affected, but several joints may suffer at the same time. In most cases the joint affection makes its appearance a few days after the commencement of a pneumonia, but in a number of instances, especially among children, the lung is not specially involved, and the condition is an indication of a generalised pneumococcal infection, which may manifest itself by endocarditis, empyema, meningitis, or peritonitis, and frequently has a fatal termination. The differential diagnosis from other forms of pyogenic infection is established by bacteriological examination of the fluid withdrawn from the joint. The treatment is carried out on the same lines as in other pyogenic infections, considerable reliance being placed on the use of autogenous vaccines.

In measles, diphtheria, smallpox, influenza, and dysentery, similar joint lesions may occur.

The joint lesions which accompany acute rheumatism or “rheumatic fever” are believed to be due to a diplococcus. In the course of a general illness in which there is moderate pyrexia and profuse sweating, some of the larger joints, and not infrequently the smaller ones also, become swollen and extremely sensitive, so that the sufferer lies in bed helpless, dreading the slightest movement. From day to day fresh joints are attacked, while those first affected subside, often with great rapidity. Affections of the heart-valves and of the pericardium are commonly present. On recovery from the acute illness, it may be found that the joints have entirely recovered, but in a small proportion of cases certain of them remain stiff and pass into the crippled condition described under chronic rheumatism. There is no call for operative interference.

Gonococcal Affections of Joints.—These include all forms of joint lesion occurring in association with gonorrhœal urethritis, vulvo-vaginitis, or gonorrhœal ophthalmia. They may develop at any stage of the urethritis, but are most frequently met with from the eighteenth to the twenty-second day after the primary infection, when the organisms have reached the posterior urethra; they have been observed, however, after the discharge has ceased. There is no connection between the severity of the gonorrhœa and the incidence of joint disease. In women, the gonorrhœal nature of the discharge must be established by bacteriological examination.

As a complication of ophthalmia, the joint lesions are met with in infants, and occur more commonly towards the end of the second or during the third week.

The gonococcus is carried to the joint in the blood-stream and is first deposited in the synovial membrane, in the tissues of which it can usually be found; it may be impossible to find it in the exudate within the joint. The joint lesions may be the only evidence of metastasis, or they may be part of a general infection involving the endocardium, pleura, and tendon sheaths.

The joints most frequently affected are the knee, elbow, ankle, wrist, and fingers. Usually two or more joints are affected.

Several clinical types are differentiated. (1) A dry poly-arthritis met with in the joints and tendon sheaths of the wrist and hand, formerly described as gonorrhœal rheumatism, which in some cases is trifling and evanescent, and in others is persistent and progressive, and results in stiffness of the affected joints and permanent crippling of the hand and fingers.

(2) The commonest type is a chronic synovitis or hydrops, in which the joint—very often the knee—becomes filled with a serous or sero-fibrinous exudate. There are no reactive changes in the synovial membrane, cellular tissue, or skin, nor is there any fever or disturbance of health. The movements are free except in so far as they are restricted by the amount of fluid in the joint. It usually subsides in two or three weeks under rest, but tends to relapse.

(3) An acute synovitis with peri-articular phlegmon is most often met with in the elbow, but it occurs also in the knee and ankle. There is a sudden onset of severe pain and swelling in and around the joint, with considerable fever and disturbance of health. The slightest movement causes pain, and the part is sensitive to touch. The skin is hot and tense, and in the case of the elbow may be red and fiery as in erysipelas.

The deposit of fibrin on the synovial membrane and on the articular surfaces may lead to the formation of adhesions, sometimes in the form of isolated bands, sometimes in the form of a close fibrous union between the bones.

(4) A suppurative arthritis, like that caused by ordinary pus microbes, may be the result of gonococcal infection alone or of a mixed infection. Usually only one joint is affected, but the condition may be multiple. The articular cartilages are destroyed, the ends of the bones are covered with granulations, extra-articular abscesses form, and complete osseous ankylosis results.

The diagnosis is often missed because the possibility of gonorrhœa is not suspected.

The denial of the disease by the patient is not always to be relied upon, especially in the case of women, as they may be ignorant of its presence. The chief points in the differential diagnosis from acute articular rheumatism are, that the gonorrhœal affection is more often confined to one or two joints, has little tendency to wander from joint to joint, and its progress is not appreciably influenced by salicylates, although these drugs may relieve pain. The conclusive point is the recognition of a gonorrhœal discharge or of threads in the urine.

The disease may persist or may relapse, and the patient may be laid up for weeks or months, and may finally be crippled in one or in several joints.

The treatment—besides that of the urethral disease or of the ophthalmia—consists in rest until all pain and sensitiveness have disappeared. The pain is relieved by salicylates, but most benefit follows weight extension, the induction of hyperæmia by the rubber bandage and hot-air baths; if the joint is greatly distended, the fluid may be withdrawn by a needle and syringe. Detoxicated vaccines should be given from the first, and in afebrile cases the injection of a foreign protein, such as anti-typhoid vaccine, is beneficial (Harrison).

Murphy has found benefit from the introduction into the joint, in the early stages, of from 5 to 15 c.c. of a 2 per cent. solution of formalin in glycerin. This may be repeated within a week, the patient being kept in bed with light weight extension. In the chronic hydrops the fluid is withdrawn, and about an ounce of a 1 per cent. solution of protargol injected; the patient should be warned of the marked reaction which follows.

After all symptoms have settled down, but not till then, for fear of exciting relapse or metastasis, the joint is massaged and exercised. Stiffness from adhesions is most intractable, and may, in spite of every attention, terminate in ankylosis even in cases where there has been no suppuration. Forcible breaking down of adhesions under anæsthesia is not recommended, as it is followed by great suffering and the adhesions re-form. Operation for ankylosis—arthroplasty—should not be undertaken, as the ankylosis recurs.