Joints and Ligaments

The symptoms of synovitis include stiffness and tenderness in the joint. Movements cause pain. Effusion of fluid takes place, and there is fullness in the neighbourhood. If the inflammation is advancing, and particularly if it is going on to suppuration, the skin over the joint is flushed and 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 splint, padding and bandages. Slight compression of the joint by a bandage aids absorption of the fluid. If the inflammation is extremely acute a warm fomentation or an ice-bag or an evaporating lotion will often give relief. As the inflammation is passing off, massage of the limb and of the joint will prove useful.

Chronic Disease of a Joint.

This may be the tailing off of an acute affection, and may eventually clear up. But if chronic disease lingers in the joint of a child or young person, the proba bility of its being tuberculous must be considered. In such a case prolonged and absolute rest with sunlight treatment (see HELIO THERAPY) is necessary. As the disease clears up, the splint, if it has been used, may be gradually left off, but on the slightest indi cation 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, as yet, 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 chronic joint disease, the question arises whether the joint will be left perma nently stiff. If an inflamed joint is kept long on a splint it may eventually be found permanently stiff ; but except from disuse and shortening of muscles, 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 destructive changes wrought by the inflammation. In one case the synovial membrane is so far destroyed that the joint ever afterwards creaks at its work and easily becomes tired and painful. It is crippled but not

destroyed. In another case the ligaments and cartilages are im plicated as well as the synovial membrane, and when the disease clears up, only a small range of motion is left, which forcible flexion and other methods of vigorous treatment are unable ma terially to improve. In yet another case 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, with or without an intervening period of abscess formation, the softened ends of the bones unite like the broken fragments in simple frac ture. For this reason the surgeon places 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. If a joint is left stiff in an awkward and useless position its excision may be desirable. The cut ends of the bones are then treated as a fracture.

A stiff joint may remain as the result of long continued inflam mation ; the unused muscles are wasted and the joint in conse quence looks large. Careful measurement, however, may show that it is not materially larger than its fellow. No progress being made under massage or gentle exercises, the surgeon may advise that the lingering adhesion be broken down under an anaesthetic, after which the function of the joint may quickly return.

These 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 hesi tates to flex suddenly the stiffened limb. The "bone-setter" does not, and his manipulation here proves successful. But such vigor ous treatment in other cases works irreparable damage and it is only instructed knowledge that can determine whether forcible movement of a stiff joint should or should not be undertaken.

Charcot's Disease.

This resembles rheumatoid arthritis (q.v.) 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 loco motor ataxy, and depends upon disease of the nerves which preside over the nutrition of the joints. It is incurable.