CHAPTER LI

THE JOINTS, BONES AND MUSCLES IN TROPICAL DIAGNOSIS

In considering the diagnostic significance of bone and joint manifestations of tropical diseases, it is essential that the practitioner in the tropics bear in mind the cosmopolitan arthropathies.

It should be remembered that lesions of joints may accompany or follow almost all infectious diseases, and that it is often impossible to ascertain if the lesions be due to the actual presence of organisms within the joint or to the action of toxic substances elaborated elsewhere; so that infectious arthritis is broadly defined as arising from the presence within the body of a focus of infection. This definition is further expanded to include joint affections of intestinal origin, and also those in which neither the causal organism nor its focus of origin is discoverable, but which by analogy we unhesitatingly recognize as being due to an infective agent.

It is to be noted that the lesions of arthritis may develop either in the intra-articular membranes or in the bony parts adjacent to a joint, and that they may remain confined to their primary site or eventually extend to involve other tissues.

INFECTIOUS ARTHRITIS

A. Of known etiology.

May be acute or chronic. Examples are: Gonorrhoea, typhoid, tuberculosis, bacillary dysentery, pneumococcus infections, pyogenic cocci, filariasis, Malta fever, secondary to any recognized focus.

B. Of unknown etiology.

May be acute or chronic: Examples are: Acute articular rheumatism, rheumatoid arthritis, four types beginning with acute symptoms, one type having insidious onset. These are often due to unidentified foci.

NONINFECTIOUS ARTHRITIS

A. Traumatic.

1. Acute, due to known traumatism.

2. Chronic, generally static in origin, or due to chronic strain or irritation. Possibly includes villous arthritis of the knee and hypertrophic arthritis in the young.

B. Trophic.

1. Metabolic. Examples are gout, psoriasis and probably hypertrophic arthritis.

2. Senile.

3. Neuropathic. Examples are tabes, leprosy, syringomyelia, Raynaud’s disease, and scleroderma.

4. Arteriosclerotic.

C. Blood dyscrasias, as haemophilia, anaemias and scurvy.

D. Toxic, as lead poisoning.

The diseases of more peculiar importance for the tropics in which joint involvement must be considered in the diagnosis are the following:

_Malta Fever._—This infection offers a good example of a disease in which joint symptomatology is of diagnostic and therapeutic importance. A prolonged typhoid-like course with sudden and painful swelling of various joints, hip, shoulder, ankle or costo-vertebral articulations, if occurring in the endemic area of Malta fever, would at once make one suspect this disease. Typhoid does not give painful joints, dengue is not accompanied by joint swelling, while gonorrhoeal polyarthritis will be accompanied by other evidence of gonorrhoeal infection.

The neuralgias, sciaticas and painful joints, together with the sweats which exhaust the sufferer from Malta fever, often tempt both patient and physician to resort to narcotics. Acute or subacute effusion into one or more joints is present in at least 40 per cent of cases of Malta fever according to Rogers. The Malta fever joint is not red, which fact, taken with its evanescent character, differentiates it from the arthritis of acute rheumatic fever.

_Dengue._—Sporadic dengue is difficult to diagnose. In an epidemic the characteristic pains referable to tendinous insertions about joints are present in at least 50 per cent of cases and is of great diagnostic value. There is no swelling of the joints although the turgescence of the skin over them may give the impression of an arthritis. The intensity of pain varies from a feeling of muscular soreness to excruciating pain when muscles or joints are actively moved. Passive movement is not usually painful. In addition to the rachialgia, bone and joint pains, some writers have described swelling of the joints. This in my experience is unusual. Joint pains are so characteristic that they distinguish dengue from all other eruptive fevers.

Joint pains during convalescence may produce stiffness and crippling continuing for many weeks after the cessation of fever.

_Relapsing Fever._—Bone, muscle and joint pains are practically always present in this disease. In addition rachialgia and headache are prominent symptoms and the aching gnawing pains in loins or nape of neck may make one think of beginning smallpox, dengue or yellow fever. There is no swelling of the joints in relapsing fever. As in dengue the pains in the neighborhood of the joints may be quite persistent.

_Yaws._—This disease gives us bone, joint and muscle lesions similar to those of syphilis. From the mother lesion to the tertiary framboesioma the course and symptoms of the two diseases are similar. Thus we may have the flying pains and osteocopic pains of the early days of infection and, as later events, chronic synovitis, frambroesial infiltration of perisynovial membranes, frambroesial infiltration of synovial membranes, chondro-arthritis, epiphysitis and chronic frambroesial periostitis. These pathological processes cause such conditions as we know under the names dactylitis, saber shin, mutilating oro-rhino-palato-pharyngeal ulcerations, Parrot’s nodes and cranio-tabes.

The uncomplicated framboesioma must be pathologically similar to the gumma. Certainly the later effects of bone and joint destruction and scarring are wonderfully like some of the middle-age European descriptions “when lues was in flower.” In framboesial disease the damage from bone destruction or from contracture following cicatrization may be so complete as to render useless a finger, a hand, one of the large joints or even a whole extremity.

_Bacillary Dysentery._—As far back as the 17th century (Sydenham) it was noted that joint pains or actual arthritides were occasional complications of dysentery. We now know that the bacterial types of dysentery are those most likely to show joint complications. Because the joint fluid in these lesions is usually sterile, it is assumed that they are the effect of toxins (or a toxin) produced by _B. dysenteriae_. Of the two hypothetical toxins of the dysentery bacillus one is supposed to produce neuritis and joint complications. Arthritides are more common in some epidemics than in others and with certain strains of bacilli than with others. The Shiga strain is the worst offender in this regard. Manson reports 27% of joint involvement in one epidemic.

Clinically, dysenteric arthritis is more apt to affect one of the larger joints, the knee, ankle and hip, being most affected. The elbow, wrist or shoulder joint may be affected, though this is unusual. The pain and swelling may be an incident of the early part of the attack. Usually it comes on when the acute symptoms are abating or as a sequela. The joint is distended with effusion and this involves the ligaments around the joint. Given an arthritis in the course of a frank dysentery there is nothing it could ordinarily be confused with. It is well to remember, however, that patients with dysentery may have also a concurrent gonorrhoea or arthritis from some focal infection. The dysenteric rheumatism ordinarily completely subsides with the cure of the colitis.

In hepatic abscess following _amoebic_ colitis pain of some type is a frequent symptom. Rheumatic-like pains and swelling of the hands occur rarely, rapidly disappearing when the abscess is evacuated.

_Filariasis._—Maitland and Bahr have noted a synovitis which is apparently a complication of filariasis. Bahr has found a fibrotic ankylosis often to follow such a joint condition. The synovitis may be followed by pus formation with serious or fatal outcome.

_Guinea Worm Disease._—Very rarely the female _Dracunculus_ may penetrate a joint and cause synovitis or arthritis.

_Leprosy._—Occasionally there is joint involvement, especially of the wrist and ankle joints, in which erosion of the cartilage and bone dislocation occur giving us a condition similar to the Charcot joint.

It will be remembered that the Charcot joint is most often seen in tabes and may give one of the greatest joint swellings. As a rule only one joint, usually knee or hip, is involved in tabes and the affection is generally painless. The progress may be acute, subacute or chronic. Syringomyelia, a disease which may be confused with leprosy, may also show joint involvement, usually of the upper extremity.

BONE AFFECTIONS

_Mycetoma._—As the result of the invasion of an extremity—usually the foot—with the causative fungi, disorganization of the tissues involved takes place. The granulomatous process invades muscles and bones and as a result of the sinus formation we have the bones converted into a softened, cheesy mass. This disintegration of bone and other tissues is attended with little or no pain. The granules discharging through the sinuses make for a proper diagnosis.

_Goundou._—In goundou the nasal bones and the nasal processes of the superior maxilla are the seat of symmetrical swellings of the nature of an hypertrophic osteitis. These exostoses may be quite large so that there is interference with vision. There is little or no pain connected with the bony growths and there is no invasive tendency.

_Big Heel._—There has been observed in natives of the Gold Coast an affection of the os calcis somewhat like that involving the superior maxillary bones in goundou. The disease begins with pain and tenderness of one or both heels. The enlargement may involve only one os calcis or affect both bones. There is no joint involvement but locomotion is interfered with. There are periods of improvement which are followed by return of the pains.

_Ainhum._—In this disease there is thinning or absorption of the bones of the toe. A fibrous cord replaces the bony structures.

_Oroya Fever._—In this very serious disease of certain areas of Peru the bone pains may be excruciating. These bone pains are especially marked in the sternum but also involve the long bones.

_Trench Fever._—Pain over the shin bone is a prominent complaint in this affection so that the term “trench shin” has been employed.

_Relapsing Fever._—Bone pains, especially referred to the knees, are complained of by patients with the bilious typhoid of Griesinger. This is a type of relapsing fever occurring in Egypt.

_Leprosy._—The bone affections of leprosy are considered under the muscles.

MUSCLE INVOLVEMENT

_Leprosy._—In this ancient disease the course of which is marked by anaesthesia, atrophy, absorption and accidents (cigarette burns, etc.), the lesions of bones, joints, muscles and indeed of all other tissues are, in great part, due to infiltration of nerves by the organism of leprosy. The effects are secondary and trophic on the one hand, and on the other partly due to secondary infection of the leproma by various bacterial agents. Leprosy was for centuries confused with other diseases in which ulceration and mutilation are features. The value of mercury in differentiating syphilis, the recognition of the importance of anaesthesia in this disease, together with the discovery of the bacillus of leprosy and of the etiological factors of several other confusing diseases, have made of leprosy one of the easiest of all diseases to diagnose correctly. It is, however, essentially a laboratory diagnosis.

In nerve leprosy we often get atrophy of the small muscles of the hand and of the muscles of the forearm. The contracture which takes place under these circumstances gives the “claw hand.” In tubercular and mixed forms of leprosy we may get in addition trophic disturbances of the fingers and toes and also extraneous infections which may ultimately result in amputation of fingers or toes. This process, going on over a considerable time or being repeated, results often in stumping of fingers or hands or toes and feet.

In addition to these openly destructive processes there is often seen in leprosy a condition of subcutaneous absorption of all the tissues. In this way the distorted finger nail may come to occupy a seat over the knuckle or even (though rarely) further up the back of the hand or arm. Briefly in leprosy we have, as representing the pathology, muscular atrophy from nerve involvement, periostitis and arthritis, interstitial absorption of bone and contractures resulting in mutilation of fingers, toes, hands and feet from trophic disturbance and intercurrent bacterial infection.

_Beriberi._—In this disease we have muscular atrophies, especially of the muscles innervated by the peroneal and ulnar nerves, similar to those following other forms of peripheral neuritis.

_Amoebiasis._—There have been reported very rarely disintegrating lesions of muscles and cutaneous tissues in which amoebae have been found.

_Heat Cramps._—In those working in firerooms or steel-mills, the excessive heat to which they are subjected may cause various manifestations of heat prostration, among which the painful muscle cramps are prominent. These cramps are similar to those which are such a feature of Asiatic cholera and in each instance are supposed to be the result of dehydration of muscle tissue.

_Trichinosis._—Acute muscle pain is a feature of the stage of muscle penetration by the larval _Trichinella spiralis_. In the disease we have a fever suggestive of typhoid fever and oedema about the face. A marked eosinophilia is characteristic. Another helminthic parasite which may invade the muscles of man is the larval _Taenia solium_. This must be of extreme rarity because infection with the adult _T. solium_ is most rare and it is only accidental that the embryonic stage would occur in man. It is a fact that the common tapeworm of man, _Taenia saginata_, is found in the human host only as a sexually mature parasite in the intestines; there is never a cysticercus stage in the muscles.

_Myositis purulenta tropica._—We may have a suppurative myositis with a single abscess formation or with disseminated foci or a diffuse purulent infiltration. The attending fever and toxaemia are similar to those attending any deep abscess formation. Abscess formation in the muscles has been reported from various parts of the tropics, especially the Gold Coast. It is possible that _F. bancrofti_ infections are concerned in some of these conditions.

_Filariasis._—Filarial abscesses were found in the ilio-psoas muscles in four cases. Wise and Minett found evidences of adult filarial worms (_F. bancrofti_) in 22 out of 28 deep-seated abscesses, which were examined by them.

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