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Rh a few leeches, followed by a fomentation, will give relief; or an icebag 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 inflamed 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 afterwards 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 may 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