Elements of Surgery

by Robert Liston

Such affections advance slowly; all the articulations are liable to them; but those which are most subject to the disease are the hip, knee, ankle, and elbow. Of these, the knee-joint is most frequently affected, probably from the greater extent of cancellated and articulating surface. In young persons of unhealthy constitutions, the joints not unfrequently become affected one after another, and superficial abscesses form, terminating in open sores. I was obliged to amputate the upper extremity of a young lady a few days ago, in which a metacarpal bone and its articulation, the entire chain of carpal bones, the wrist and elbow joints, were all thoroughly involved in disease.

NEURALGIC AFFECTIONS OF JOINTS.

The joints, like other parts of the body, are very often the seat of painful affections, without organic disease existing. These neuralgic affections are often connected with, or followed by, hysterical symptoms. They frequently also depend upon derangement of the digestive organs,—upon the lodgement of irritating matters, sordes, or worms in the intestinal tube; and when we reflect upon the extent of the lining membrane, the expansion of nervous filaments, and upon the sympathy which they hold with the whole system, we cannot be astonished at the circumstance. Many cases of supposed hip-disease in children, with the symptoms and some of the signs of it, have come under my notice, which have yielded at once to the expulsion of offending matters or worms. Some affections of joints seem to depend upon gouty diathesis; others are intermittent: at one time the joint complained of is hot, and somewhat swollen; at another cold, and bluish on the surface. In these affections of joints the pain, indeed, is seldom constant: the patient’s rest is not broken; there are none of the violent spasms during sleep, which attend upon certain alterations of structure. The pain is equally complained of when the part is touched with the utmost gentleness, or when a thorough and searching examination is made, when the joint is freely moved, and the articulating surfaces of the bones are forcibly squeezed against each other. The pinching of the skin causes pain. There is seldom throbbing, or heat, or swelling; though, after long continuance of the diseased state, these may supervene to a slight extent. The pain complained of is seldom referred to one point, but to a large extent of the limb; and if the attention is diverted, the examination may be carried to any extent, without complaint being made.

Sir B. Brodie, who has done a great service to the profession by directing attention to these nervous affections in his excellent work, and in his lectures, notices that the knee, when the seat of pain, is generally kept in the extended position, and this is very different from what has been stated to be the position of one affected by organic disease. The tumefaction following upon local treatment, and especially when leeching and counter-irritants have been employed, is sometimes, as he remarks, very perplexing.

This class of diseases generally affects females of delicate organisation about the age of puberty, and in whom the menstruation is irregular. Males in delicate health are also subject to similar affections.

ON GROWTHS FROM THE SYNOVIAL MEMBRANE, AND LOOSE SUBSTANCES IN THE JOINTS.

The synovial membrane is sometimes studded on its inner aspect with loose fleshy or semicartilaginous substances projecting into the cavity of the joint. The entire surface of the membrane is occasionally covered with these bodies, which are of a white or yellowish colour, and very variable in size and shape; the smallest presenting the form of villi not much larger than those of the jejunum, the largest having somewhat the magnitude and appearance of the appendices epiploicæ of the large intestine, while many of an intermediate size approach in appearance to a lemon-seed. In some instances the membrane is only partially pervaded by them, and they are not unfrequently arranged like a fringe around the edge of the articular surfaces. They are generally very smooth on the surface, which appears to be perfectly continuous, if not identical, with the synovial membrane. Their attachment is frequently broad, and occasionally very narrow and pedunculated, often merely filamentous, so that a little further thinning of the part, or slight force acting on the body, would remove it from the capsule, and throw it loose into the cavity of the articulation. The disease has been most frequently seen in the knee, and sometimes in the elbow.

The affection is obscure in its nature; it is slow in its progress; the joint is the seat of pain after and during exercise, probably from the morbid processes interfering with the motions of the articular surfaces. As the disease advances, the joint becomes swelled and elastic, unattended generally by ulceration of the tissues within or around it. In examining the part, when the articular surfaces are moved on each other, it will be found that their motion is more or less interfered with; and considerable irregularity in their action may be felt by the hand placed firmly on the joint during the procedure.

Loose bodies may be found in the articulations, particularly in the knee and elbow, under the circumstances just described; but we often find others of a different structure loose within the capsule, which may be throughout smooth and apparently healthy. These bodies are extremely variable in size, generally rounded or oval, with a polished surface; many of the smallest present the character of fibro-cartilage or cartilage; the larger are often more or less modulated, very firm and gristly, and sometimes contain a considerable nucleus of bony matter. The articular ends of the bones are occasionally more or less misshapen by the formation around them of knobs of adventitious osseous substance.

The disease is common in the knee; and patients frequently go about for years, who will tell you that they have something rolling within the joint, which will often be found on examination to be actually the case. It is obvious that loose bodies in the joint must prove an obstacle to easy progression; and the smaller ones seem to be particularly so, probably from becoming easily entangled by different parts of the articular apparatus.