Chondritis

CHONDRITIS (chondritis), inflammation of cartilage tissue. Depending on the anatomical-physiological peculiarities of cartilage structure (relative poverty of blood vessels, weak regenerative capacity, etc.), inflammatory processes in it proceed in a distinctive manner. In general, inflammatory processes in cartilages develop comparatively rarely and are usually accompanied by significant alterations. Of greatest interest are those chondritides that develop after infectious diseases. The question of chondritis underwent thorough study during 1920-1927, when after the typhus epidemic (1919-20) a significant number of patients with post-typhoid chondritides appeared. At present, the viewpoint linking the development of chondritis (most often of the rib cartilages, much less frequently of the larynx) with past typhus (most often relapsing, less frequently abdominal, typhus) is generally recognized. In the literature, cases of chondritis developing after other diseases (scarlet fever, rheumatism, influenza, diphtheria, smallpox, cholera, malaria, etc.) have been described. The further exposition concerns mainly post-typhoid chondritides. According to a number of authors, post-typhoid chondritides represent an embolic process (Lampe, Hesse, etc.). There is a viewpoint that considers that the basis of this process is primary necrosis of cartilaginous substance with subsequent introduction of infection (Axhausen, Petrashevskaya, etc.). The question of the causative agents of these processes remains unclear to the present time, although in the pus of these abscesses, according to the research of Belyavtsev, Eliseev and Kruglov, Bory, Lindberg, etc., a rod was found in most cases, morphologically attributed to the paratyphoid group. Pathogenesis, see Perichondritis. Finally, there is an opinion that post-typhoid chondritides arise as a result of complications with scurvy, i.e., due to hemorrhage into the perichondrium and along the line of the bone-cartilage junction of the ribs. In any case, the question of the pathogenesis of these chondritides cannot be considered resolved. Anatomical research relating to the very beginning of the process is very scarce. The matter apparently concerns primary necrosis of cartilage (chondromalacia) with subsequent development within the rib cartilage of a cavity 3-4 mm in diameter, filled with granulation tissue and pus; this process spreads along the cartilage and involves the surrounding soft tissues, as a result of which an infiltrate forms, constituting the characteristic feature of these chondritides. These infiltrates include the affected cartilages and the sclerosed soft tissues covering them, i.e., the perichondrium, muscles, fasciae, subcutaneous tissue; all these tissues adhere to each other, forming a dense tumor, in the center of which is placed a cavity or a curved fistulous tract, beginning in the carious cartilage. In the cavity, flabby, purulently disintegrated granulations and liquid pus of gray, yellow or brown color are noted, sometimes with an admixture of blood; the amount of pus is sometimes very insignificant. The lesion usually involves a number of neighboring cartilages, which is an important feature of all inflammations of the rib cartilages in general. The lesion of the rib cartilages is sometimes bilateral; thus, out of 65 cases of Yasenetsky-Voino, 14 cases showed bilateral lesion; according to Geymanovich, the disease of the rib cartilages is bilateral in 25% of cases. A significant predominance of men among such patients is noted; thus, among 65 patients of Yasenetsky-Voino there were only 10 women. The disease manifests itself most often 1-3 months after the infection through pains in the area of the rib cartilages, followed shortly by the formation of a firm, slightly painful swelling. This swelling usually forms at the level of V-VIII ribs, somewhat outward from the place of articulation of the ribs with the sternum. The skin over it for a long time retains its usual color and acquires a bluish-red color only at the end, when softening of the tumor (formation of an abscess) and its opening occurs; at this time, a small amount of liquid pus with a greater or lesser amount of blood usually flows out and a fistula (sometimes multiple fistulas) forms. The temperature in these patients is either normal or subfebrile. The pains in chondritis are extremely varied in character; relatively little pain of these infiltrates is more often noted, especially after their opening and formation of fistulas; sometimes, however, the development of the process is accompanied by agonizing pains. Occasionally cases are noted where a slight swelling undergoes independent regression, but where the disease has led to the formation of a fistula, spontaneous healing belongs to extremely rare exceptions. Treatment. Conservative treatment usually does not lead to the desired result. Iodide of potassium was administered internally, injections of antiseptic solution, iod-iodoform emulsion were made, Beck's bismuth paste, blue light, etc., were applied, but without particular success. N. N. Petrov proposes to carry out autovaccination of such patients. The method of choice in the treatment of typhoid chondritides is surgical intervention, which sometimes presents considerable difficulties due to the frequent impossibility of establishing exact boundaries between healthy and affected tissues. Surgical treatment must be radical, since otherwise recurrences easily occur, requiring new surgical intervention. In the literature, cases of 5- and 6-fold operations are described with insufficiently radical approach. The basic principles of surgical treatment are the removal of affected areas within healthy tissues. A number of authors, in case of lesions of cartilages below the V rib, recommend removal of the entire cartilaginous arch from V to IX rib (Yasenetsky-Voino, Hesse). The cartilages must be completely removed from the ribs to the sternum; even if small areas of cartilage are left, they may be the cause of subsequent recurrences. Among possible complications during surgical interventions in chondritis, it is necessary to note injury to the pleura with the formation of pneumothorax and infection of the pleural cavity, as well as injury to the a. mammariae int. In case of bilateral lesion, operation in 2 stages is recommended. Lesions of the laryngeal cartilages in typhus are not frequent. Usually the process begins with the formation of an ulcer of the laryngeal mucosa, then the cartilage is exposed, after which its sequestration often follows (see Perichondritis). The processes described in the larynx can lead to edema of the vocal fissure and cause severe disorders of respiration, which often require immediate tracheotomy. For 100 cases of laryngeal cartilage lesions, Fedorovich had to resort to tracheotomy in 20. In chronic cases, severe stenosis of the larynx develops. Syphilitic osteochondritis. The most frequent manifestation of congenital syphilis is osteochondritis (osteochondritis syphilitica Wegner's), localized most often in the cartilage at the border between the epiphysis and diaphysis of long bones. These changes can be characterized as phenomena of dystrophic and inflammatory order. They are very characteristic and frequent in congenital syphilis, sometimes being the only manifestations of it in the absence of lesions of the skin, liver, pancreas, etc.; this fact is widely used by pathologists for sectional diagnosis of congenital syphilis (see Osteochondritis).