Читать книгу Elements of Surgery - Robert Liston - Страница 12

Inflammation of the synovial surface occurs in consequence of wounds, bruises, or sprains, and often from exposure to cold; from the latter cause, the knee and elbow joints most frequently suffer, as they are generally more exposed to its influence, and not so well covered with muscular substance as the others. Constitutional diseases, such as certain fevers, are followed sometimes by effusion of serous fluid into joints. Purulent matter is also deposited in joints during certain forms of suppurative fever; and this is attended by rapid change of structure.

There is heat, throbbing, pain, and swelling of the part, sometimes redness of the surface, and great constitutional disturbance; the symptoms and appearances, however, vary much, according to the extent of the joint which is involved. When part of the capsule is affected, the inflammation spreads rapidly over all the surface; the synovial membranes resembling the serous in this respect, as well as in healthy structure and function. Like the serous, too, they are shut sacs, are smooth on their surface, and furnish a secretion, the synovial, for facilitating the motion between opposing surfaces; it is, however, somewhat more glairy than the serous. Neither, in their healthy state, are possessed of much sensibility, nor are ligaments, tendons, tendinous sheaths, and bursæ, which two latter textures resemble in every respect the synovial; when inflamed, they become most exquisitely sensible. The incited action of the bloodvessels is followed by increased discharge, which is less glairy and albuminous, partaking more of the serous character. When the incited action soon terminates, and the activity of the absorbents is diminished, the fluid accumulates within the joint, producing Hydrops Articuli. This accumulation of fluid in joints may take place without being preceded by any apparent inflammation, and may remain a long time without any visible change of structure in the membrane. The knee is more frequently the seat of dropsy than any other joint.

When the action is more violent, and is not actively opposed, lymph is effused on the inner surface of the membrane, or is deposited amongst the ligamentous and cellular tissues external to the joint, in consequence of which, the membrane and external ligaments become thickened, and of an almost cartilaginous consistence. Serum is effused into the more superficial cellular tissue, filling up the hollows around the joint, concealing the protuberances of the bones, and producing a globular swelling. The articulating surfaces become ulcerated, and matter forms within the capsular ligament; or the pus is deposited exteriorly to the joint, and gradually approaches the surface. But although ulceration is so prone to occur in the cartilages, the synovial membranes do not readily take on this action, unless from the progress of matter, formed within the joint, towards the surface. The synovial lining of the bursæ and sheaths of the tendons are extremely indisposed to ulcerate; and it may be remarked, that, while suppuration without ulceration is common in the synovial membranes, the cartilages, on the other hand, afford frequent instances of ulceration without suppuration, of which more particular mention will be made in the sequel. The cartilage is occasionally swelled and softened where the disease has long existed.

Along with ulceration of the cartilage, a portion of it may become dead, or either state may occur separately; and in many cases, the substance of the bone also becomes affected, of which two classes of cases may occur, viz., great inflammation on the articular surface of the bone, with separation of the cartilage by the ulcerative process in this situation; and inflammation of the medullary web, leading to atrophy of the cancelli, collections of pus therein, or even death of a portion of the spongy texture of the bone, as will be more particularly treated of in the chapter on diseases of the osseous tissue. These changes often compose the primary disease, and to them the affections of the synovial membrane and other parts succeed.

Such occurrences are attended with alarming disturbance of the constitution, with fever, and even with the most threatening and dangerous symptoms, such as delirium and coma. If the patient survive, and the matter be evacuated from the joints by openings into its cavity, hectic fever is almost certain to supervene.

An opinion has been broached lately by Mr. Key, that the ulceration of cartilage was consequent upon the increased vascularity and thickening of the synovial membrane, that the cartilage, in fact, was removed by the action of the vessels ramifying in the membrane, and the prolongations or fringes from it in its diseased condition. Occasionally these fringes correspond, in a remarkable manner, to the breach of surface in the cartilage; but again, ulceration is frequently met with far removed from the membrane. It is also seen, in cases where an opportunity is afforded of making the examination in the earlier stage of disease, that ulceration exists to some extent whilst the synovial membrane is unaffected. And certain cases, in which the cartilage is affected with hypertrophy, and the common form of atrophy of this part in old people, are altogether adverse to Mr. Key’s views. When ulceration takes place at a point removed from the attachments of the synovial membrane, it appears to proceed more frequently from the attached than from the free surface of the cartilage; then the adventitious membrane occupying the rugged spaces, and which under the microscope appears highly vascular, is connected apparently with the medullary web.

In acute inflammation of the synovial membrane, and in cases where the cartilage is ulcerated, the pain is very intense, and the spasms of the limb most distressing. This happens when the surface is ulcerated, and perhaps to no great extent. We know that in the horse an ulcerated hollow in the cartilaginous covering of the navicular bone, not so large as to contain a grain of barley, will cause such lameness and suffering as to render the animal so affected perfectly useless. If he is not destroyed at this stage, as many valuable animals have been, the mischief extends, and terminates in extensive disease of that and the neighbouring bones and articulations. It is different if the disease commence, as it sometimes does, in the human subject, in the cancelli of the bone, and on the attached surface of the cartilage, the free surface remaining some time entire and smooth. When the synovial membrane is primarily affected by chronic disease, the pain is in general trifling, often not complained of, and swelling of the part, from effusion, into the joint or neighbouring bursæ, first attracts attention, after it has existed, perhaps, in a slight degree, for a considerable time. The joint is stiff, and pain is experienced from extensive motion; on this account the patient is disinclined to use it, and it is soon tired by the slightest exertion. The swelling becomes more solid, though still remaining elastic, and the feeling of fluctuation diminishes. Effusion of lymph follows that of serum, the latter having been absorbed; the motion of the joint is still further impeded, and the articulation is distorted; the patient keeps the limb in the most easy position, generally that of partial flexion, in which it becomes almost immovably fixed. The cause of the flexed position, which is almost pathognomonic of knee disease, being preserved, seems to be that the limb is insensibly brought into it in order to take the pressure off the interarticular apparatus, the ligamenta mucosa and alaria,—these swell—the muscles of the hamstrings get contracted from habit, and a difficulty, even after the disease is completely subdued, is often enough experienced in procuring complete extension. The muscles, from disuse, shrink, the adipose substance is absorbed, the shafts of the bones also are diminished in size, get into an atrophied state, as the phrase is, and thus the whole limb is rendered slender and wasted, so as to make the swelling of the diseased articulation still more conspicuous. The bones are softened, and the muscles are of a white colour, as in the limbs of the paralytic or bedridden, and resemble more cellular than muscular tissue. The wasting of the muscles and loss of power often precede the appearance of disease; this is frequently observed in the shoulder-joint, the deltoid shrinking, and almost disappearing, before any disease in the articulation is suspected by the patient. Not unfrequently, also, this wasting occurs without obvious cause, or any affection of the joint. When the disease is advancing, the patient may feel no acute pain, but merely a reluctance to use the limb; and from this, if long continued, the muscles, and afterwards the bones, become wasted. Wasting of the limbs in children, often of one of the lower, frequently arises from disorder of the bowels, and the irritation and debility attendant on teething. This must be distinguished from the wasting accompanying diseased joint. The history of the case, the period at which the weakness of the limb was observed, and its appearance, will lead to a correct diagnosis.

The swelling is often irregular, being more protuberant at one part than another, from the fluid or the addition of solid matter being accumulated where the least resistance is afforded; but the slighter inequalities are generally filled up by œdema of the cellular texture. As the disease proceeds, matter forms in the joint, and is often attended with great pain and fever; or the pus is effused into the bursæ, into the surrounding cellular tissue, or into the filamentous tissue amongst the tendinous sheaths of the muscles in the neighbourhood; being allowed to remain without an outlet, it at length communicates with the cavity of the joint. Portions of the cartilages are absorbed, though this, as already noticed, may occur at the very commencement of the disease; the subjacent bone becomes affected by ulceration, or perhaps its vitality is partially destroyed. When matter has accumulated, a portion of the capsular ligament generally ulcerates, the pus escapes, and is ultimately discharged externally.

When the disease begins with swelling, which is of a chronic character, and produces but little inconvenience, and when the more urgent symptoms supervene after the swelling has continued for a considerable time, there is every reason to suppose that the disease has originated in the synovial membrane, or perhaps in the osseous cancelli, and this is generally met with in poorly fed and strumous subjects. But when the first symptoms have been pain and stiffness of the joint, without change of its appearance, and when the swelling has occurred after these symptoms have been of some duration, then it is probable that the cartilages are the primary seat of mischief. For the most part, however, the symptoms have a general resemblance in most chronic affections of the joints, and all the apparatus is sooner or later involved. When the cartilage has been extensively absorbed, a grating sensation is felt in moving the articular surfaces of the bones upon each other. In consequence, also, of the softening and disorganisation of the lateral and other ligaments, the affected articulation at length becomes unnaturally loose, which is owing in some measure, also, to the muscles being wasted and paralysed from pain and disuse. At an earlier stage of the disease, the joint may be rigid from deposition of lymph into the contiguous cellular tissue, and contraction of the muscles.

Purulent matter not unfrequently collects in the substance of the bones, which in all cases ultimately become softened in a remarkable manner. In many subjects, without actual disease of the osseous tissue, the heads of the bones are so altered in consistence, are so deficient of earthy matter, as to be easily cut with a knife. It has been a matter of dispute, whether, in this affection, the articulating extremities of the bones are enlarged or not; and the supposition that they are always more or less increased in size, or hypertrophied, has arisen from the extensive effusion and indurated state of the soft parts being mistaken for this enlargement. In the first stages of the disease, they are seldom, if ever, enlarged; but when ulceration of the bone has occurred, new osseous matter is deposited to a greater or less degree in the neighbourhood of the ulcer,—an attempt by nature towards a cure, but too often an ineffectual one. The bones, in strumous subjects, are often much enlarged, from collection of purulent matter in their substance giving rise to a sort of spina ventosa. I removed the upper extremity of a boy lately on account of extensive disease about the elbow. The ulna to near the wrist was swollen enormously by purulent collections in its medullary canal. In cases when the whole of the articulating extremity of the bone is not enlarged, still that portion which is more immediately concerned in the articulation is often considerably expanded.

Frequently when the knee is the seat of the disease, the lymphatic glands in the groin are enlarged; and when the elbow or wrist joints are affected, there is often a similar enlargement of the glands in the axilla: such glandular tumours have not rarely been confounded with those accompanying malignant disease, and measures which were absolutely necessary for the salvation of the patient, have thus been delayed or neglected.

When the disease is extensive, and has endured for a considerable period, hectic fever supervenes, and is aggravated after the abscesses give way. The patient becomes much weakened and emaciated, and loses his appetite; the pulse is rapid, with night sweats, diarrhœa, &c.; and from a continuation of the hectic cause, the life is endangered. In some cases, however, the health is restored, and the disease abates spontaneously; in others, the disease is arrested, and a complete cure accomplished, by the careful employment of such means as will be afterwards mentioned.

The appearances produced by inflammation and consequent disease of the synovial membrane, are the following. In the first stage, the internal surface of the capsular ligament, and the rest of the synovial membrane, is found of a red hue, its formerly colourless vessels being now made apparent, from enlargement and consequent injection with a greater quantity of red blood; and the serum within the cavity of the joint is more abundant than in the natural state. When the disease has been of longer continuance, the membrane is found considerably thickened, its usual smooth glossy surface is destroyed, it is irregularly flocculent, and frequently of a light yellow colour.

The interarticular adipose tissue also seems to be increased in volume, from being infiltrated with a serous fluid, by the discharge of which the diseased bloodvessels may have attempted to relieve themselves. When the inflammation has been intense, or of long duration, lymph is secreted, and deposited on the external surface of the membrane, forming an intimate union between it and the ligaments, and producing thickening of the external apparatus. Or the lymph is also effused on the inner surface of the membrane, to which it adheres and becomes organised; this is generally accompanied by the formation of purulent matter; the organised effusion is often so extensive as to conceal almost the whole of the synovial membrane, excepting portions of its delicate reflexions which invest the articulating cartilages. By the lymphatic deposit, to a less degree, the folds also of the synovial membrane adhere to each other, whereby the motion is still farther impeded, and the pain, when attempted, increased. Occasionally the synovial membrane is found enormously thickened, much softened in texture, and of a brown hue, when the disease has been of a very chronic character. Along with these appearances, serum is generally found effused, in a greater or less quantity, into the cellular tissue exterior to the ligamentous covering. In cases in which the matter has formed and remained long within the cavity of the articulation, the synovial membrane and the ligaments become blended into one soft mass, the internal surface of which is lined with a thick coating of lymph, as in the case of common abscess. If purulent matter is effused externally, and communicate with the joint, the capsular ligament will be found to have ulcerated and given way at certain points, forming apertures, usually of small size, and with ragged margins.

All these appearances may exist without disease of the cartilages or extremities of the bones; but generally they are also affected at the same time. At first the surface of the cartilage is slightly irregular and rough, and the change is not observed, unless on minute inspection. Afterwards the surface is marked with small depressions, which may be numerous, and are surrounded with irregular and somewhat serrated margins. They gradually increase in depth and extent, and the subjacent bone is ultimately exposed at one or more points, as here shown. Often the greater part of the cartilage is removed by absorption; the bone is exposed, opened out in its texture, softened, of an irregular surface, and in some places excavated, containing a thin ichorous fluid; the process of ulceration has also extended to the osseous tissue. Sometimes scales of cartilage of considerable size are either completely detached, having become dead, and been thrown off by the natural process, and are found lying loose in the cavity of the articulation; or they are all but separated, adhering by one or more very slender attachments.

The incipient stage of such disease may exist without the synovial membrane being much, if at all, affected; but when the ulceration has made farther progress, all the articulating apparatus is more or less diseased. It may be here remarked, that the synovial membrane may be affected for a long period, thickened portions may extend over the cartilages, and these may have lymph upon them and yet remain intact.