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 intra-uterine 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 not 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 courses open: 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. Sometimes 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. O.*)
JOINTS, in engineering, may be classed either (a) according to
their material, as in stone or brick, wood or metal; or (b) according
to their object, to prevent leakage of air, steam or water, or
to transmit force, which may be thrust, pull or shear; or (c) according
as they are stationary or moving (“working” in technical
language). Many joints, like those of ship-plates and boiler-plates,
have simultaneously to fulfil both objects mentioned
under (b).
All stone joints of any consequence are stationary. It being uneconomical to dress the surfaces of the stones resting on each other smoothly and so as to be accurately flat, a layer of mortar or other cementing material is laid between them. This hardens and serves to transmit the pressure from stone to stone without its being concentrated at the “high places.” If the ingredients of the cement are chosen so that when hard the cement has about the same coefficient of compressibility as the stone or brick, the pressure will be nearly uniformly distributed. The cement also adheres to the surfaces of the stone or brick, and allows a certain amount of tension to be borne by the joint. It likewise prevents the stones from slipping one on the other, i.e. it gives the joint very considerable shearing strength. The composition of the cement is chosen according as it has to “set” in air or water. The joints are made impervious to air or water by “pointing” their outer edges with a superior quality of cement.
Wood joints are also nearly all stationary. They are made partially fluid-tight by “grooving and tenoning,” and by “caulking” with oakum or similar material. If the wood is saturated with water, it swells, the edges of the joints press closer together, and the joints become tighter the greater the water-pressure is which tends to produce leakage. Relatively to its weaker general strength, wood is a better material than iron so far as regards the transmission of a thrust past a joint. So soon as a heavy pressure comes on the joint all the small irregularities of the surfaces in contact are crushed up, and there results an approximately uniform distribution of the pressure over the whole area (i.e. if there be no bending forces), so that no part of the material is unduly stressed. To attain this result the abutting surfaces should be well fitted together, and the bolts binding the pieces together should be arranged so as to ensure that they will not interfere with the timber surfaces coming into this close contact. Owing to its weak shearing strength on sections parallel to the fibre, timber is peculiarly unfitted for tension joints. If the pieces exerting the pull are simply bolted together with wooden or iron bolts, the joint cannot be trusted to transmit any considerable force with safety. The stresses become intensely localized in the immediate neighborhood of the bolts. A tolerably strong timber tension-joint can, however, be made by making the two pieces abut, and connecting them by means of iron plates covering the joint and bolted to the sides of the timbers by bolts passing through the wood. These plates should have their surfaces which lie against the wood ribbed in a direction transverse to the pull. The bolts should fit their holes slackly, and should be well tightened up so as to make the ribs sink into the surface of the timber. There will then be very little localized shearing stress brought upon the interior portions of the wood.
Iron and the other commonly used metals possess in variously
