Alexis Thomson

“ In cases in which there has been recurrent attacks of locking, the ligaments become slack, the joint is wobbly, and the quadriceps is wasted. The patient himself, or the surgeon, may discover the loose body and feel it roll beneath his fingers, especially if it is lodged in the supra-patellar pouch in the knee, or on one or other side of the olecranon in the elbow. In most instances the patient has carefully observed his own symptoms, and is aware not only of the existence of the loose body, but of its erratic appearance at different parts of the joint. ”

“ The patient complains of increasing disability of the limb, movements of the joint becoming more and more restricted and painful. There is swelling corresponding to the distended capsule of the joint, and on palpation the bodies moving under the fingers yield a sensation as of grains of rice shifting in a bag. If the bodies are so numerous as to be tightly packed together, the impression is that of a plastic mass having the shape of the synovial sac. The stiffness and the cracking on movement may suggest arthritis deformans, but the X-ray appearances make the diagnosis an easy one. ”

“ This estimate, so far as the actual frequency of bone lesions is concerned, has been generally accepted, but recent observers, notably John Fraser, do not accept the presence of bone lesions as necessarily proving that the disease commenced in the bones; he maintains, and we think with good grounds, that in many cases the disease having commenced in the synovial membrane, slowly spreads to the bone by way of the blood vessels and lymphatics, and gives rise to lesions in the marrow. ”

“ The changes in the joints involve almost exclusively the synovial membrane and the ligaments; they consist in cellular infiltration and exudation, resulting in the formation of new connective tissue which encroaches on the cavity of the joint and gives rise to adhesions, and by contracting causes stiffness and deformity. The articular cartilages may subsequently be transformed into connective tissue, with consequent fibrous ankylosis and obliteration of the joint. ”

“ Conditions of Impaired Mobility of Joints.#--There are four conditions of impaired mobility in joints: rigidity, contracture, ankylosis, and locking. _Rigidity_ is the fixation of a joint by involuntary contraction of muscles, and is of value as a sign of disease in deep-seated joints, such as the hip. ”

“ In the larger joints the subjective symptoms usually precede any palpable evidence of disease, the patient complaining of stiffness, crackings, and aching, aggravated by changes in the weather. The roughness due to fibrillation of the articular cartilages causes coarse friction on moving the joint, or, in the knee, on moving the patella on the condyles of the femur. It may be months or even years before the lipping and other hypertrophic changes in the ends of the bones are recognisable, and before the joint assumes the deformed features which the name of the disease suggests. ”

“ The _ankylosing type_ of chronic arthritis is fortunately much rarer than those described above, and is chiefly met with in the joints of the fingers and toes and in those of the vertebral column. The synovial membrane proliferates, grows over the cartilage, and replaces it, and when two such articular surfaces are in contact they tend to adhere, thus obliterating the joint, cavity, and resulting in fibrous or bony ankylosis. ”

“ Stiffness is a variable feature--in some cases amounting to absolute rigidity, so that no ordinary force will elicit movement. It is characteristic of this, as of other neuroses, that the symptoms come and go without sufficient cause. When the patient's attention is diverted, the pain and stiffness may disappear. There is no actual swelling of the joint, although there may be an appearance of this from wasting of the muscles above and below. If the joint is kept rigid for long periods, secondary contracture may occur--in the knee with flexion, in the hip with flexion and adduction. ”

“ The course of the disease as met with in persons past middle life is more chronic; it begins insidiously, and many years may pass before there is pronounced disability. The earliest symptom is stiffness, especially in the morning after rest, which passes off temporarily with use of the limb. As time goes on, the range of movement becomes restricted, and crackings occur. This stage of the disease may be prolonged indefinitely; if it progresses, stiffness becomes more pronounced, certain movements are lost, others develop in abnormal directions, and deformed attitudes add to the disablement. ”

“ It is characteristic that the symptoms develop abruptly without satisfactory cause, that they are exaggerated and wanting in harmony with one another, and that they do not correspond with the features of any of the known forms of organic disease. In some cases the only complaint is of severe pain; more often this is associated with excessive tenderness and with impairment of the functions of the joint. On examination the joint presents a normal appearance, but the skin over it is remarkably sensitive. A light touch is more likely to excite pain than deep and firm pressure. ”

“ In others, the joints, although stiff, can be moved but exhibit pronounced crackings. When there is much connective tissue formed in relation to the synovial membrane, the joint is swollen, and as the muscles waste above and below, the swelling is spindle-shaped. Subacute exacerbations occur from time to time, with fever and aggravation of the local symptoms and implication of other joints. After repeated recurrences, there is ankylosis with deformity, the patient becoming a helpless cripple. On account of the tendency to visceral complications, the tenure of life is uncertain. ”

“ Recovery is apt to be attended with impairment of movement due to adhesions, ankylosis, or contracture of the peri-articular structures. Caseous foci in the interior of the bones may become encapsulated, and a cure be thus effected, or they may be the cause of a relapse of the disease at a later date. Interference with growth is comparatively common, and may involve only the epiphysial junctions in the immediate vicinity of the joint affected, or those of all the bones of the limb. ”

“ The morbid changes in the joints present a remarkable combination of atrophy and degeneration on the one hand and overgrowth on the other, indicating a profound disturbance of nutrition in the joint structures. ”

“ As a rule these attacks are repeated; the pain attending them diminishes, but the joint becomes the seat of permanent changes: the synovial membrane is thickened, abnormally vascular, and coloured brown from the deposit of blood pigment; on its surface, and in parts of the articular cartilage, there is a deposit of rust-coloured fibrin; there may be extensive adhesions, and in some cases changes occur like those observed in arthritis deformans with erosion and ulceration of the cartilage and a form of dry caries of the articular surfaces, which may terminate in ankylosis. ”

“ The complaint may be of vague pains, of occasional cracking on moving the joint, or of impairment of function--usually an inability to extend or flex the joint completely. In many cases a clear account is given of the symptoms which arise when the body is impacted between the articular surfaces, namely, sudden onset of intense sickening pain, loss of power in the limb and locking of the joint, followed by effusion and other accompaniments of a severe sprain. On some particular movement, the body is disengaged, the locking disappears, and recovery takes place. ”

“ Hydrops may occur apart from disease--for example, in the knee-joint from repeated sprains, or when there is a loose body in the joint--but is met with chiefly in the chronic forms of synovitis which result from gonorrhoea, tuberculosis, syphilis, arthritis deformans, or arthropathies of nerve origin. ”

“ If the articular surface is extensively diseased, a thin slice of bone should be removed, and if foci in the marrow are then revealed, it is better to gouge them out than to remove further slices of bone, as this involves sacrifice of the cortex and periosteum. ”

“ The occurrence of joint lesions in _locomotor ataxia_ (tabes dorsalis) was first described by Charcot in 1868--hence the term "Charcot's disease" applied to them. Although they usually develop in the ataxic stage, one or more years after the initial spinal symptoms, they may appear before there is any evidence of tabes. The onset is frequently determined by some injury. The joints of the lower extremity are most commonly affected, and the disease is bilateral in a considerable proportion of cases--both knees or both hips, for instance, being implicated. ”

“ The capsular ligament, except in hydrops, is the seat of connective-tissue overgrowth, and tends to become contracted and rigid. Intra-articular ligaments, such as the ligamentum teres in the hip, are usually worn away and disappear. The surrounding muscles undergo atrophy, tendons become adherent to their sheaths and may be ossified, and the sheaths of nerves may be involved by the cicatricial changes in the surrounding tissues.
_The X-ray appearances of arthritis deformans_ necessarily vary with the type of the disease and the joint affected ”

“ When bony ankylosis has occurred with the joint in an undesirable attitude--for example flexion at the hip or knee--it can sometimes be remedied by osteotomy or by a wedge-shaped resection of the bone, with or without such additional division of the contracted soft parts as will permit of the limb being placed in the attitude desired. ”

“ The best possible result being rigid ankylosis in a good position, it may be advisable to bring this about artificially by arthrodesis or resection. Operation is indicated when only one joint is affected and when the cord lesion is such as will permit of the patient using the limb. The wounds heal well, but the victims of tabes are unfavourable subjects for operative interference, on account of their liability to intercurrent complications. When the limb is quite useless, amputation may be the best course. ”

“ In arthritis deformans a rarer type of loose body is met with, a portion of the lipping of one of the articular margins being detached by injury. In Charcot's disease, bodies composed of bone are formed in relation to the capsular and other ligaments, and may be made to grate upon one another. ”

“ The abscess may develop so insidiously that it does not attract attention until it has attained considerable size, especially when associated with disease of the spine, pelvis, or hip. The position of the abscess in relation to different joints is fairly constant and is determined by the anatomical relationships of the capsule and synovial membrane to the surrounding tissues. The bursae and tendon sheaths in the vicinity may influence the direction of spread of the abscess and the situation of resulting sinuses. ”

“ The state of the general health may necessitate operation as the most rapid method of removing the disease. The social status of the patient must also be taken into account; the bread-winner, under existing social conditions, may be unable to give up his work for a sufficient time to give conservative measures a fair trial. ”

“ When arthroplasty is impracticable, and a movable joint is desired--for example at the elbow--a considerable amount of bone, and it may be also of periosteum and capsular ligament, is resected to allow of the formation of a false joint. ”

“ 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. ”

“ 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 ”

“ Although most frequently met with in young women with an impressionable nervous system, and especially among those in good social circumstances, it occurs occasionally in men. The onset may be referred to injury or exposure to cold, or may be associated with some disturbance of the emotions or of the generative organs; or the condition may be an involuntary imitation of the symptoms of organic joint disease presented by a relative or friend. ”

“ 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. ”

“ Locking of joints is more often met with as a result of injuries, especially in fractures occurring in the region of the elbow. In certain injuries of the semilunar menisci of the knee, also, the joint is liable to a variety of locking, which differs, however, in many respects from that described above. ”