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DISEASES AND INJURIES OF

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Originally appearing in Volume V15, Page 489 of the 1911 Encyclopedia Britannica.
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DISEASES AND INJURIES OF JOINTS The affection of the joints of the human body by specific diseases is dealt with under various headings (RHEUMATISM, &c.) ; in the present article the more direct forms of ailment are discussed. In most joint-diseases the trouble starts either in the synovial lining or in the bone—rarely in the articular cartilage or ligaments. As a rule, the disease begins after an injury. There are three principal types of injury: (I) sprain or strain, in which the ligamentous and tendinous structures are stretched or lacerated; (2) contusion, in which the opposing bones aredriven forcibly together; (3) dislocation, in which the articular surfaces are separated from one another. A sprain or strain of a joint means that as the result of violence the ligaments holding the bones together have been suddenly stretched or even torn. On the inner aspect the ligaments are lined by a synovial membrane, so when the ligaments are stretched the synovial membrane is necessarily damaged. Small blood-vessels are also torn, and bleeding occurs into the joint, which may become full and distended. If, however, bleeding does not take place, the swelling is not immediate, but synovitis having been set up, serous effusion comes on sooner or later. There is often a good deal of heat of the surrounding skin and of pain accompanying the synovitis. In the case of a healthy individual the effects of a sprain may quickly pass off, but in a rheumatic or gouty person chronic synovitis may obstinately remain. In a person with a tuberculous history, or of tuberculous descent, a sprain is apt to be the beginning of serious disease of the joint, and it should, therefore, be treated with continuous rest and prolonged supervision. In a person of health and vigour, a sprained joint should be at once bandaged. This may be the only treatment needed. It gives support and comfort, and the even pressure around the joint checks effusion into it. Wide pieces of adhesive strapping, layer on layer, form a still more useful support, and with the joint so treated the person may be able at once to use the limb. If strap-ping is not employed, the bandage may be taken off from time to time in order that the limb and the joint may be massaged. If the sprain is followed by much synovitis a plaster of Paris or leather splint may be applied, complete rest being se-cured for the limb. Later on, blistering or even " firing " may be found advisable. Synovitis. — When a joint has been injured, inflammation occurs in the damaged tissue; that is inevitable. But sometimes Ligamentum patella the attack of inflammation is so slight and transitory as to be scarcely notice-able. This is specially likely to occur if the joint-tissues were in a state of perfect nutrition at the time of the hurt. But if the individual or the joint were at that time in a state of imperfect nutrition, the effects are likely to be more serious. As a rule, it is the synovial membrane lining the fibrous capsule of the joint which first and chiefly suffers; the condition is termed synovitis. Synovitis may, however, be due to other causes than mechanical injury, as when the interior of the joint is attacked by the micro-organisms of pyaemia (blood-poisoning), typhoid fever, pneumonia, rheumatism, gonorrhoea or syphilis. Under judicious treatment the synovitis generally clears up, but it may linger on and cause the formation of adhesions which may temporarily stiffen the joint; or it may, especially in tuberculous, septic or pynmic infections, involve the cartilages, ligaments and bones in such serious changes as to destroy the joint, and possibly call for resection or amputation. The symptoms of synovitis include stiffness and tenderness in the joint. The patient notices that movements cause pain. Effusion of fluid takes place, and there is marked fullness in the neighbourhood. If the inflammation is advancing, the skin over the joint may be flushed, and if the hand is placed on the skin it feels hot. Especially is this the case if the joint is near the surface, as at the knee, wrist or ankle. The treatment of an inflamed joint demands rest. This may be conveniently obtained by the use of a light wooden splint, padding and bandages. Slight compression of the joint by a bandage is useful in promoting absorption of the fluid. If the inflamed joint is in the lower extremity, the patient had best remain in bed, or on the sofa; if in the upper extremity, he should wear his arm in a sling. The muscles acting on the joint must be kept in complete control. If the inflammation is extremely acute, Opening in interosseous membrane for anterior tibial vessels Transverse ligament Internal semilunar fibrocartilage (From D. Hepburn, Cunningham's Text-book of Anatomy.) a few leeches, followed by a fomentation, will give relief ; or an ice-bag or an evaporating lotion may, by causing constriction of the blood-vessels, lessen the congestion of the part and the associated pain. As the inflammation is passing off, massage of the limb and of the joint will prove useful. If the inflammation is long continued, the limb must still be kept at rest. By this time it may be found that some other material for the retentive apparatus is more convenient and comfortable, as, for instance, undressed leather which has been moulded on wet and allowed to dry and harden; poro-plastic felt, which has been softened by heat and applied limp, or house-flannel which has been dipped in a creamy mixture of plaster-of-Paris and water, and secured by a bandage. Chronic Disease of a Joint may be the tailing off of an acute affection, and under the influence of alternate douchings of hot and cold water, of counter-irritation by blistering or " firing," and of massage, it may eventually clear up, especially if the general health of the individual is looked after. But if chronic disease lingers in the joint of a child or young person, the probability of its being under the influence of tuberculous infection must be considered. In such a case prolonged and absolute rest is the one thing necessary. If the disease be in the hip, knee, ankle or foot, the patient may be fitted with an appropriate Thomas's splint and allowed to walk about, for it is highly important to have these patients out in the fresh air. If the disease be in the shoulder, elbow, wrist or hand, a leather or poro-plastic splint should be moulded on, and the arm worn in a sling. There must be no hurry; convalescence will needs be slow. And if the child can be sent to a bracing sea-side place it will be much in his favour. As the disease clears up, the surface heat, the pains and the tenderness having disappeared, and the joint having so diminished in size as to be scarcely larger than its fellow—though the wasting of the muscles of the limb may cause it still to appear considerably enlarged—the splint may be gradually left off. This remission may be for an hour or two every other day; then every other night; then every other day, and so on, the freedom being gained little by little, and the surgeon watching the case carefully. On the slightest indication of return of trouble, the former restrictive measures must be again resorted to. Massage and gentle exercises may be given day by day, but there must be no thought of "breaking down the stiffness." Many a joint has in such circumstances been wrecked by the manipulations of a " bone-setter." Permanent Stiffness.—During the treatment of a case of chronic disease of a joint, the question naturally arises as to whether the joint will be left permanently stiff. People have the idea that if an in-flamed joint is kept long on a splint, it may eventually be found permanently stiff. And this is quite correct. But it should be clearly understood that it is not the rest of the inflamed joint which causes the stiffness. The matter should be put thus: in tuberculous and other forms of chronic disease stiffness may ensue in spite of long-continued rest. It is the destructive disease, not the enforced rest which causes it; for inflammation of a joint rest is absolutely necessary. The Causes of permanent Stiffness are the destructive changes wrought by the inflammation. In one case it may be that the synovial membrane is so far destroyed by the tuberculous or septic invasion that its future usefulness is lost, and the joint ever after-wards creaks at its work and easily becomes tired and painful. Thus the joint is crippled but not destroyed. In another case the ligaments and the cartilages are implicated as well as the synovial membrane, and when the disease clears up, the bones are more or less locked, only a small range of motion being left, which forcible flexion and other methods of vigorous treatment are unable materially to improve. In another set of cases the inflammatory germs quickly destroy the soft tissues of the joint, and then invade the bones, and, the disease having at last come to an end, the softened ends of the bones solidly join together like the broken fragments in simple fracture. As a result, osseous solidification of the joint (synostosis) ensues without, of course, the possibility of any movement. And, inasmuch as the surgeon cannot tell in any case whether the disease may not advance in this direction, he is careful to place the limb in that position in which it will be most useful if the bony union should occur. Thus, the leg is kept straight, and the elbow bent. In the course of a tuberculous or other chronic disease of a joint, the germs of septic disease may find access to the inflamed area, through a wound or ulceration into the joint, or by the germs being carried thither by the blood-stream. A joint-abscess results, which has to be treated by incision and fomentations. If chronic suppuration continues, it may become necessary to scrape out or to excise the joint, or even to amputate the limb. And if tuberculous disease of the joint is steadily progressing in spite of treatment, vigorous measures may be needed to prevent the fluid from quietly ulcerating its way out and thus inviting the entrance of septic germs. The fluid may need to be drawn off by aspiration, and direct treatment of the diseased synovial membrane may be undertaken by injections of chloride of zinc or some other reagent. Or the joint may need scraping out with a sharp spoon with the view of getting rid of the tuberculous material. Later, excision may be deemed necessary, or In extreme cases, amputation. But before these measures are considered, A. C. G. Bier's method of treatment by passive congestion, and the treatment by serum injection, will probably have been tried. If a joint is left permanently stiff in an awkward and useless position, the limb may be greatly improved by excision of the joint. Thus, if the knee is left bent and the joint is excised a useful, straight limb may be obtained, somewhat shortened, and, of course, permanently stiff. If after disease of the hip-joint the thigh remains fixed in a faulty position, it may be brought down straight by dividing the bone near the upper end. A stiff shoulder or elbow may be converted into a useful, movable joint by excision of the articular ends of the bones. A stiff joint may remain as the result of long continued inflammation; the unused muscles are wasted and the joint in consequence looks large. Careful measurement, however, may show that it is not materially larger than its fellow. And though all tenderness may have passed away, and though the neighbouring skin is no longer hot, still the joint remains stiff and useless. No progress being made under the influence of massage, or of gentle exercises, the surgeon may advise that the lingering adhesion be broken down under an anaesthetic, after which the function of the joint ma) quickly return. There are the cases over which the " bone-setter " secures his greatest triumphs. A qualified practitioner may have been for months judiciously treating an inflamed joint by rest, and then feels a hesitation with regard to suddenly flexing the stiffened limb. The " bone-setter," however, has no such qualms, and when the case passes out of the hands of the perhaps over-careful surgeon, the unqualified practitioner (because he, from a scientific point of view, knows nothing) fears nothing, and, breaking down inflammatory adhesions, sets the joint free. And his manipulations prove triumphantly successful. But, knowing nothing and fearing nothing, he is apt to do grievous harm in carrying out his rough treatment in other cases. Malignant disease at the end of a bone (sarcoma), tuberculosis of a .joint, and a joint stiffened by old inflammation are to him the same thing. " A small bone is out of place," or, " The bone is out of its socket; it has never been put in," and a breaking down of everything that resists his force is the result of the case being taken to him. For the " bone-setter " has only one line of treatment. Of the improvement which he often effects as if by magic the public are told much. Of the cases over which the doctor has been too long devoting skill and care, and which are set free by the " bone-setter," everybody hears—and sometimes to the discomfiture of the medical man. But of the cases in which irreparable damage follows his vigorous manipulation nothing is said—of his rough usage of a tuberculous hip, or of a sarcomatous shoulder-joint, and of the inevitable disaster and disappointment, those most concerned are least inclined to talk ! A practical surgeon with common-sense has nothing to learn from the " bone-setter." Rheumatoid Arthritis, or chronic Osteo-arthritis, is generally found in persons beyond middle age; but it is not rare in young people, though with them it need not be the progressive disease which it too often is in their elders. It is an obscure affection of the cartilage covering the joint surfaces of the bones, and it eventually involves the bones and the ligaments. A favourite joint for it is the knee or hip, and when one large joint is thus affected the other joints may escape. But when the hands or feet are implicated pretty nearly all the small joints are apt to suffer. Whether the joint is large or small, the cartilages wear away and new bone is developed about the ends of the bones, so that the joint is large and mis-shapen, the fingers being knotted and the hands deformed. When the spine is affected it becomes bowed and stiff. This is the disease which has crippled the old people in the workhouses and almshouses, and with them it is steadily progressive. Its early signs are stiffness and creaking or cracking in the joints, with discomfort and pain after exercise, and with a little effusion into the capsule of the joint. As regards treatment, medicines are of no great value. Wet, cold and damp being bad for the patient, he should be, if possible, got into a dry, bright, sunny place, and he should dress warmly. Perhaps there is no better place for him in the winter than Assuan. Cairo is not so suitable as it used to be before the dam was made, when its climate was drier. For the spring and summer certain British and Continental watering-places serve well. But if this luxury cannot be afforded, the patient must make himself as happy as he can with such hot'douchings and massage as he can obtain, keeping himself warm, and his joints covered by flannel bandages and rubbed with stimulating liniments. In people advanced or advancing in years, the disease, as a rule, gets slowly worse, sometimes very slowly, but sometimes rapidly, especially when its makes its appearance in the hip, shoulder or knee as the result of an injury. In young people, however, its course may be cut short by attention being given to the principles stated above. Charcot's Disease resembles osteo-arthritis in that it causes destruction of a joint and greatly deforms it. The deformity, however, comes on rapidly and without pain or tenderness. It is usually associated with the symptoms of locomotor ataxy, and depends upon disease of the nerves which preside over the nutrition of the joints. It is incurable. A Loose Cartilage, or a Displaced Cartilage in the Knee Joint is apt to become caught in the hinge between the thigh bone and the leg bone, and by causing a sudden stretching of the ligaments of the joint to give rise to intense pain. When this happens the individual is apt to be thrown down as he walks, for it comes on with great suddenness. And thus he feels himself to be in a condition of perpetual insecurity. After the joint has thus gone wrong, bleeding and serous effusion take place into it, and it becomes greatly swollen. And if the cartilage still remains in the grip of the•bones he is unable to straighten or bend his knee. But the surgeon by suddenly flexing and twisting the leg may manage to unhitch the cartilage and restore comfort and usefulness to the limb. As a rule, the slipping of a cartilage first occurs as the result of a serious fall or of a sudden and violent action—often it happens when the man is " dodging " at football, the foot being firmly fixed on the ground and the body being violently twisted at the knee. After the slipping has occurred many times, the amount of swelling, distress and lameness may diminish with each subsequent slipping, and the individual may become somewhat reconciled to his condition. As regards treatment, a tightly fitting steel cage-like splint, which, gripping the thigh and leg, limits the movements of the knee to flexion and extension, may prove useful. But for a muscular, athletic individual the wearing of this apparatus may prove vexatious and disappointing. The only alternative is to open the joint and remove the loose cartilage. The cartilage may be found on operation to be split, torn or crumpled, and lying right across between the joint-surfaces of the bones, from which nothing but an operation could possibly have removed it. The operation is almost sure to give complete and permanent relief to the condition, the individual being able to resume his old exercises and amusements without fear of the knee playing him false. It is, however, one that should not be undertaken without due consideration and circumspection, and the details of the operation should be carried out with the utmost care and cleanliness. An accidental wound of a joint, as from the blade of a knife, or a spike, entering the knee is a very serious affair, because of the risk of septic germs entering the synovial cavity either at the time of the injury or later. If the joint becomes thus infected there is great swelling of the part, with redness of the skin, and with the escape of blood-stained or purulent synovia. Absorption takes place of the poisonous substances produced by the action of the germs, and, as a result, great constitutional disturbance arises. Blood-poisoning may thus threaten life, and in many cases life is saved only by amputation. The best treatment is freely to open the joint, to wash it out with a strong antiseptic fluid, and to make arrangement for thorough drainage, the limb being fixed on a splint. Help may also be obtained by increasing the patient's power of resistance to the effect of the poisoning by injections of a serum prepared by cultivation of the septic germs in question. If the limb is saved, there is a great chance of the knee being permanently stiff. Dislocation.—The ease with which the joint-end of a bone is dislocated varies with its form and structure, and with the position in which it happens to be placed when the violence is applied. The relative frequency of fracture of the bone and dislocation of the joint depends on the strength of the bones above and below the joint relatively to the strength of the joint itself. The strength of the various joints in the body is dependent upon either ligament or muscle, or upon the shape of the bones. In the hip, for instance, all three sources of strength are present; therefore, considering the great leverage of the long thigh bone, the hip is rarely dislocated. The shoulder, in order to allow of extensive movement, has no osseus or ligamentous strength; it is, therefore, frequently dislocated. The wrist and ankle are rarely dislocated; as the result of violence at the wrist the radius gives way, at the ankle the fibula, these bones being relatively weaker than the respective joints. The wrist owes its strength to ligaments, the elbow and the ankle to the shape of the bones. The symptoms of a dislocation are distortion and limited movement, with absence of the grating sensation felt in fracture when the broken ends of the bone are rubbed together. The treatment consists in reducing the dislocation, and the sooner this replacement is effected the better—the longer the delay the more difficult it becomes to put things right. After a variable period, depending on the nature of the joint and the age of the person, it may be impossible to replace the bones. The result will be a more or less useless joint. The administration of an anaesthetic, by relaxing the muscles, greatly assists the operation of reduction. The length of time that a joint has to be kept quiet after it has been restored to its normal shape depends on its form, but, as a rule, early movement is advisable. But when by the formation of the bones a joint is weak, as at the outer end of the collar-bone, and at the elbow-end of the radius, prolonged rest for the joint is necessary or dislocation may recur. Congenital Dislocation at the Hip.—Possibly as a result of faulty position of the subject during intrauterine life, the head of the thigh-bone leaves, or fails throughout to occupy, its normal situation on the haunch-bone The defect, which is a very serious one, is probably nut discovered until the child begins to walk, when its peculiar rolling gait attracts attention. The want of fixation at the joint permits of the surgeon thrusting up the thigh-bone, or drawing it down in a painless, characteristic manner. The first thing to be done is to find out by means of the X-rays whether a socket exists into which, under an anaesthetic, the surgeon may fortunately be enabled to lodge the end of the thigh-bone. If this offers no prospect of success, there are three coursesopen: First, to try under an anaesthetic to manipulate the limb until the head of the thigh-bone rests as nearly as possible in its normal position, and then to endeavour to fix it there by splints, weights and bandaging until a new joint is formed; second, to cut down upon the site of the joint, to scoop out a new socket in the haunch-bone, and thrust the end of the thigh-bone into it, keeping it fixed there as just described; and third, to allow the child to run about as it pleases, merely raising the sole of the foot of the short leg by a thick boot, so as to keep the lower part of the trunk fairly level, lest secondary curvature of the spine ensue. The first and second methods demand many months of careful treatment in bed. The ultimate result of the second is so often disappointing that the surgeon now rarely advises its adoption. But, if under an anaesthetic, as the result of skilful manipulation the head of the thigh-bone can be made to enter a more or less rudimentary socket, the case is worth all the time, care and attention bestowed upon it. Some-times the results of prolonged treatment are so good that the child eventually is able to walk with scarce a limp. But a vigorous attempt at placing the head of the bone in its proper position should be made in every case. (E. 0.*)
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