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NOTES, COMMENTS, AND ABSTRACTS

OSTEO-ARTHRITIS.*

BY PHILIP FIGDOR, M.B. GLASG.,PHYSICIAN TO ST. JOHN’S HOSPITAL, LEWISHAM ; ASSISTANT

PHYSICIAN TO THE LONDON TEMPERANCE HOSPITAL.

A GOOD deal of confusion still surrounds the subjectof osteo-arthritis. This is partly because most of thework that has been done has been directed towardsfinding a specific remedy, while the disease itself hasnot yet been adequately studied and described.Different writers attach different meanings to theterm osteo-arthritis, and the result is extremelyconfusing to anyone who consults their text-books.

In 1913 Sir Thomas Horder suggested the classifica-tion of chronic arthritis into two main groups :-

1. Osteo-arthritis, mostly single joint affections affectingelderly people, with early bony changes.

2. Rheumatoid arthritis, mostly a polyarticular diseaseaffecting younger people and with inconspicuous bonychanges.

I find myself in agreement in principle with thisclassification, except that I would divide my twogroups into (1) osteo-arthritis or mono-arthritis, and(2) polyarthritis.The term polyarthritis is becoming increasingly

popular with European writers. There are severaldistinct forms of polyarthritis, and some of themare definitely not what is understood by rheumatoidarthritis. In fact, rheumatoid arthritis is a term whichis not used so much as formerly, and should bediscarded.

Radiological Appearances.Our present state of knowledge of osteo-arthritis

owes a great deal to radiology, which enables us todifferentiate it from other forms of chronic arthritis. Aclinical diagnosis of osteo-arthritis can always beeither confirmed or excluded by X rays.

I regard Thomson’s 2 description of the X ray appear-ances as a standard. He states that cyst-like structuresare seen in all radiograms of osteo-arthritis, and tendto be massed together in localised areas of bone, formingwhat he calls " storm centres of disease." He claimsthat acute clinical symptoms (presumably pain) canalways be shown to be associated with activity of oneor more cyst-like formations on the joint surface. Hegoes further and states that, in joints without acute clinical symptoms, active cyst-like foci are not seen onthe joint surfaces.

Clinical experience shows that there is some basisfor this statement. Every now and again one comesacross a case where it is accidentally discovered thatthe patient has definite, even advanced, osteo-arthritis and denies that he ever felt a twinge of painor stiffness.

A brawny navvy of 50 injured his left knee while diggingin the street. On the following day he had an acutesynovitis and was sent to hospital for X ray examinationto discover if there was any fracture. There was no fracture,but the radiologist reported an advanced degree of osteo-arthritis of the knee-joint. When I saw him, a few dayslater, I put it to him that he must have had pain in thejoint before his accident. This he strenuously denied,pointing out that he had been a labourer, chiefly on roadwork, all his life. He had pain and limitation of movementof the knee-joint, of course, while he had synovitis, butafter a few weeks his synovitis cleared up. Although hehad coarse grating in the joint, he had full and free activemovement of the joint and said he had no pain. He thenreturned to his work and, although he promised to returnto see me if he had any pain or stiffness in the knee, he hasnot done so. Presumably he has remained well, althoughit is now four years since he attended hospital.A somewhat similar case is that of a man, aged 62, a ship’s

rigger, who wrenched his left elbow while at work. Aradiogram taken on the following day showed advancedosteo-arthritis of the elbow-joint. Here again the mandenied previous pain or incapacity, pointing to the fact

* Abridged from a lecture to the Fellowship of Medicine.

that his elbow had to function perfectly as he has to do alot of climbing at his work.Thomson 2 visualises two distinct and separate

radiographic stages : (1) A primary stage, eithercystic or granulomatous in type. This leads to erosionof joint cartilage. (2) A secondary stage of villous andosteophytic changes, which may result from such amechanical erosion. He emphasises the fact that heconsiders the cyst-like formation to be the importantradiographic sign, and almost pathognomonic. Theosteophytic out-growths he believes not to be anessential part of the disease, but a product of thepatient’s reaction, an effort of nature to give extrasupport to or to limit the functions of diseased joints.It is not, radiographically, diagnostic of the disease.R. L. J. Llewellyn 3 also recognises two stages in the

life-history of osteo-arthritis-namely, a primary orpre-osteophytic phase of prolonged duration, thesymptoms being those of villous hypertrophy, and asecondary or terminal stage in which bony and cartil-aginous outgrowths appear. His view is that osteo-arthritis is a generalised and not a localised disorder.He thinks that it can be prevented from developingin the early stages, and says that osteophytes areshown in one knee and not in its fellow.

This is a point to which I would draw attention.I quite agree that one frequently comes across caseswhere the X rays show osteophytes in one knee onlyin the early stages. But my interpretation of thisdiffers from Llewellyn’s in that I hold that the appear-ance or development of osteo-arthritis in the secondknee is a traumatic result of increased strain thrownon that knee when the other is more or less out ofaction.

Etiology.Consideration of this subject almost always begins

with the words " septic focus," and attempts to findan organism and to supply a vaccine. In the last twodecades research has generally been in that direction.As it is only in the last few years that the radiologistshave enabled us to label the disease with accuracy, itseems to me that there is still a great deal to be donein the way of bed-side investigation, as distinct fromthe laboratory. I have investigated 480 cases of osteo-arthritis, all of which have been confirmed by re-dio-graphic diagnosis. The accompanying table shows

Cases of Osteo-arthritis.Age. Male. Female. Total.20-29 ...... - ...... 10 ...... 1030-39 ...... 10 ...... 37 ...... 4740-49 ...... 58 ...... 75 ...... 13350-59 ...... 58 ...... 56 ...... 11460-69 ...... 72 ...... 70 ...... 14270-79 ...... 18 ...... 14 ...... 3280 and over . 2 ......

-

...... 2

218 262 480

that osteo-arthritis is a disease of middle and advancingage and that females are more affected than males ;this is partly, but not wholly, explained by the factthat females live longer. It will be noted from the tablethat I have not come across a case of osteo-arthritis ina man below the age of 30, while I have had ten casesin women between 20 and 30, some of them in the early’twenties.

I believe that osteo-arthritis is traumatic in origin,or rather, that the exciting cause is a trauma. In mycases 267 out of 480 gave a definite history of aninjury, sometimes several years before the onset ofosteo-arthritis. But, in stating that osteo-arthritis istraumatic in origin, I bring in stress and strain asevidence of trauma, as well as injury. Many caseswith no direct history of injury or accident come intothis category.A man of 58 came to hospital with pain in the left shoulder,

going down to the fingers, of three months’ duration. X rayshowed a moderate degree of osteo-arthritis of the shoulder-joint. He had never had an injury, but on inquiry I foundthat he had been an engineer but, owing to inability to getwork at his trade, he had for the last three years been a

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telephone labourer, which meant carrying a 30-lb. bag oftools on his left shoulder.A man, over military age, drove a general in France during

the war for eleven months. The car was a powerful one andhad a very stiff clutch. He said that he used to have painin his back at the end of a day’s driving. When he gaveup driving the car the pain left him. However, severalyears later when I saw him, he had severe pain in his back and an X ray showed advanced osteo-arthritis of his leftsacro-iJiac joint.A man who had been an all-round athlete took up fencing

when he reached the middle ’forties. He entered into it withsuch zest that he became a champion. I saw him when hewas 62, and he had not been able to fence for some yearsbecause he had osteo-arthritis in both hip-joints, more onthe right than on the left. The pathological factor in thiscase is that a strain was put on joints in middle age to whichthey were not accustomed. It is fairly safe to say that, hadhe been a fencer from his youth upwards, he would not havedeveloped osteo-arthritis of his hip-joints.

Osteo-arthritis usually attacks only one joini(excluding the vertebrae). If two or more are affected;close investigation will establish that symptoms beganin one an appreciable time before the second, andX rays will confirm this. The cause of the second jointbeing involved is traumatic—e.g., an osteo-arthritis inone hip-joint will ca,use the patient to put an increasedload or strain on the other hip-joint and will, inuntreated cases, cause osteo-arthritis there.

In my series there are 12 cases where both hip- andknee-joints were affected ; in six the hip-jointwas affected first and in the other six the knee-joint. It is noteworthy that osteo-arthritis occurs inthe women who have a rapid and heavy increase inbody-weight before or at the time of the menopause.In my series of 100 cases of osteo-arthritis of the knee-joints in women onlv 28 gave a history of injury.The type of direct injury that causes osteo-arthritis

is more obvious. A young man dislocates his shoulder.The dislocation is reduced and he has no furthertrouble. A middle-aged or elderly man has hisdislocation reduced and in a variable number ofmonths or a year or two he develops an osteo-arthritisof the shoulder-joint. A similar result frequentlyfollows a fracture of the upper end of the humerus.A workman has a fall, or is struck on the back. Heis taken to hospital and is X rayed, with negativeresults as regards fracture. In many of these casesosteo-arthritis of the spine develops later.

It is trauma in the middle-aged and elderly thatproduces osteo-arthritis. Similar traumata in theyoung do not.

In my series of lumbar and sacro-iliac osteo-arthritisin women, 36 out of 46 had no history of injury, but26 had had gynaecological operations and two had hadhaemorrhoid operations. Eight of these 28 had hadpain in the back before the operation, but the othershad not, and in all the other 20 pain in the back cameon within a few months of operation, and the X rayshowed sacro-iliac osteo-arthritis. I incline to theview that this was due to injury to the sacro-iliacjoints at the time of operation, in placing the patientinto position for operation, or in letting the legs downafterwards.

" Malignant Arthritis."Osteo-arthritis, like cancer, attacks the middle-aged

and elderly-i.e., the physiologically dying. Traumain this state produces a pathological change. Whatis this change ? Thomson and other radiologistsare emphatic that the process is degenerative and notmalignant. But though the radiologists may beemphatic, their task is not always easy.A few months ago I saw a woman, aged 51, who was

clinically a well-established case of osteo-arthritis of theright shoulder-joint. I sent her for a X ray examinationto confirm the diagnosis. The radiologist’s report was asfollows : " The bone of the upper third of shaft and head ofthe humerus and of scapula in region of shoulder-jointshows areas of rarefaction. P Cystic degeneration. Isthere any question of secondary deposits in this case ? "

In this case there was no question of any pre-existingmalignant disease and yet that was the radiologist’s report.Every now and again one gets these reports, particularlyfrom young and inexperienced radiologists.

That the disease does not kill is no criterion. Itcauses such severe pain and is often so resistant toany treatment that one is almost justified in labellingit " malignant arthritis."To those who still think in terms of oral sepsis, it

can be pointed out that the disease attacks people whohave reached the age of double dentures, and, in thosewho have teeth, extraction of the remaining teethseems to make very little difference. As a matter offact, osteo-arthritis seems to attack mainly peoplewho have led healthy, active, temperate, and evenabstemious lives. The intemperate form a very smallproportion of these cases. These people deserve a gooddeal more sympathy than they receive. The pain ofosteo-arthritis is one of the most severe that anydisease produces, yet the victims, because, as they say," they have nothing to show for it," are enjoined bytheir friends (and often by their doctors) to exercisethe joints or they will get stiff and have more pain,Of course, the more they exercise the worse the pain.

Diagnosis of Osteo-arthritis.It is, of course, very important to diagnose the

condition as early as possible, for the prognosis dependsvery largely on that. Now, particularly in the caseof the shoulder- and hip-joints, the first symptom isgenerally a pain, not located at or near the joint itselfbut in the muscles below the joint-i.e., a referredpain. A good proportion of these cases come to thehospital with a diagnosis of " neuritis."

In my series 128 out of 145 cases of osteo-arthritisin the shoulder-joint had referred pain down the arm,mostly pain from the shoulder to the elbow; andin the hip-joint 54 out of 64 had pain down thethigh, sometimes to the knee, and a few had painin the knee-joint only. This referred pain is notonly an early symptom, but it is the main symptomthroughout the history of the case until, in fact, thedisease is arrested. In the knee-joint pain is generallyconfined to the knee. Only a small minority complainof pain radiating down the shins. In sacro-iliac andlumbar osteo-arthritis, the pain is generally confinedto the lower back, but some cases reach hospitaldiagnosed as sciatica.

Limitation of movement of the joint is usuallyearly. In the hip-joint and shoulder-joint abductionis the chief restriction. As the disease progresses,there is a functional ankylosis. I have come across anoccasional bony ankylosis in the hip-joint, but mostauthorities deny that this ever happens.

Gra.ting occurs in the knee-joints, but is not diag-nostic, because it also occurs commonly in healthy,joints. The same remark can apply to the early stagesin the shoulder-joint. The knee-joint, however, doesbecome definitely enlarged, particularly—judging byits appearance-the lower end of the femur, giving theknee a characteristic look.The gait of a person with osteo-arthritis of the hip-

joint is a characteristic waddling, with almost nothingto distinguish it from that of a case of congenitaldouble dislocation of the hip-joint. Muscular wastingoccurs, but it is seldom a gross wasting and sometimesis not very apparent.

A PATHOGNOMONIC SIGN.

In observations previously published I have notedwhat I believe to be a pathognomonic sign of osteo-arthritis in the lumbo-sacral region, including, ofcourse, the sacro-iliac joints. When the patient lieson his face and the lumbo-sacrum is palpated with theflat of the fingers, there is a characteristic flabby," penetrating " feel of the wasted lumbar and sacralmuscles, giving one almost the impression that oneis palpating the bare bone. There is no tendernesson palpation. It is difficult to describe the tactilesensation one receives, but I believe it to be pathog-nomonic. Of the 86 cases in my series every one hadthis sign.

Treatment.

I have elsewhere 5 defined a specific therapeuticagent as one which, used in a particular, definite, and

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specified form—-e.g., in a drug of a definite chemicalcomposition-and applied in a particular, definite, andspecified way to a particular, definite, and specifieddisease or pathological condition, secures a relief fromsymptoms and a return to normal and active functionof the body or part, excluding permanent tissuedamage." According to that definition, there is no

specific remedy for osteo-arthritis.Claims have been made that particular micro-

organisms are the cause of osteo-arthritis, but Koch’spostulates have not been fulfilled.Warren Crowe 6 believes in the view, advanced by

many workers in the last two decades or so, thatstreptococci are the cause of osteo-arthritis and non-articular rheumatism. He stresses the numerousvarieties of streptococci and the difficulty in dif-ferentiating them. In treatment, therefore, in orderto make certain that the several streptococci infectingany given patient are included, he advocates the useof a stock’ streptococcus vaccine, containing thegreatest possible number of different streptococci.My own view, and one that I take care to emphasise

to patients, is that the most important part of treat-ment is rest. The affected joint must be rested. Futurerestoration of function of the joint is, in my belief, asecondary consideration to getting rid of the pain.The first object of treatment must be to ease thepatient of the sometimes intolerable pain he suffers.I am against any forcible movement of the joint, as itsometimes lights up the disease again. Some caseswhere the pain has entirely ceased but where there isalmost an ankylosis of the joint, in the course of a yearor two (sometimes a few months), with freedom frompain, achieve an almost complete restoration offunction of the joint by the patient’s own naturalefforts.

In osteo-arthritis of the shoulder-joint, the armshould be placed in a complete sling, with the elbowwell supported, so that all weight is taken off theshoulder-joint. It is surprising what relief this simpleprocedure often gives. It is not easy to achieve restof the hip- or knee-joints while the patient is goingabout. In some cases a walking calliper is the onlything that will ease the pain.

I believe that osteo-arthritis is a local and not ageneral condition, and that local treatment in the formof rest is essential. The application of liniments andpastes to the seat of pain or to the joint is useless.Massage, also, is not only useless but is contra-indicated, as it often increases the pain.Diathermy is the most valuable form of treatment.

The current should be directed to and concentrated onthe affected joint and nowhere else, and should begiven three times a week for 15 to 20 minutes. Wherethe patient reacts to this treatment, sometimes as fewas half a dozen treatments will give relief from painof some months’ duration, but generally the durationof treatment should be reckoned as many weeks upto several months. I believe that diathermy is thenearest approach we have to a specific remedy forosteo-arthritis. The patient generally finds the treat-ment very soothing, and it frequently banishes thepain for the time being, even in the early days. Pre-cisely how it acts one cannot determine. Certainlyin the majority of cases it seems to arrest the diseaseprocess, whatever that may be. The large majorityof my cases have done very well with diathermy andrequire no other form of local treatment.Every now and again one comes across cases that do

not respond to diathermy, but do well with radiant heator chlorine ionisation, provided that the patient hashad a course of diathermy first.

There is one form of general treatment which mustbe given in all cases, and that is an analgesic or asedative of some kind until the local treatment has hadtime to take effect. I generally advise grs. 10 or grs. 15bromide mixture thrice daily. If the pain disturbs thepatient’s rest I do not hesitate to give a soporificnightly for several weeks if necessary. The mostimportant point of all is the necessity for as completerest to the joint as it is possible to obtain.

REFERENCES.

1. Horder, T. H. : Clin. Jour., 1913, lii., 325.

2. Thomson, J. A. : Proc. Roy. Soc. Med., 1929, p, 1119.3. Llewellyn, R. L. J. : Proc. Bath Conference, 1928, p. 120,

et seq.4. Figdor, P. : Clin. Jour., 1929, lviii., 152.5. Same author : Med. World, 1925, xxiii., 44.6. Crowe, H. W. : Bacteriology and Surgery of Chronic Arthritis

and Rheumatism, London, 1927.

THE TREATMENT OF FRACTURES.A CONCISE and valuable account of the treatment

of fractures and its underlying principles has been,prepared by the Fracture Committee of the American,College of Surgeons 1 and published in the quarterlyBulletin of the College (1931, xv., No. 1). In 30 pages,-copiously illustrated, a description is given of thenormal processes of bone repair, the conditions..favouring them, the functions of practitioner andsurgeon in promoting them, and the management of

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many particular varieties of fracture. No attempthas been made to describe operative procedure, thetechnique of skeletal traction, or methods of local.anaesthesia, and the summary is written with an eyeto the requirements of general rather than hospital’practice. Emphasis is laid especially on the import-ance of the "emergency initial treatment," the-dangers of delay, and the importance of functionalrestoration. " The treatment of difficult fractures"requires the care of experienced surgeons."The outline concludes with the following series of-

aphorisms :-APHORISMS..

Always use gentleness and care in handling any-broken limb. Roughness is inexcusable.Use only the simplest methods of examination for-

the diagnosis of fracture.Eliminate all unnecessary handling of the injured:

limb.Definite localised tenderness over an injured bone-

usually is satisfactory evidence of fracture.Never attempt to elicit crepitus.Disturb the patient and the injured part as little-

as possible.Do not be deceived by the absence of deformity

and disability ; in many cases of fracture some-

ability to use the limb persists. Sufficient examina--tion is one which includes a short history, a brief-inspection and palpation limited to the localisation.of the point of greatest tenderness, coupled with aslight test for false motion.Do not overlook the responsibility of making a’

diagnosis. Look for more than one fracture.An exact diagnosis is absolutely essential to proper

treatment and requires suitable X ray films taken in.two planes.Make it a duty to see that the patient has an early-

suitable X ray examination and, competent treatment-.thereafter.Keep the axes of the ankle- and knee-joints abso-

lutely transverse. When the sole of the foot rests-flat on the ground, the top surface of the astragalus-should be parallel with the ground.A stiff shoulder following a fracture of the fore-

arm usually may be prevented. The functionalutility of the limb as a whole is a good measure ofsuccessful treatment.

Following fracture, the damage of the injury-per se must always be reckoned with and deducted’from the normal attainable by treatment.

Passive movements affect bone and joint surfaces,.often injuring them both. Active movements affectmuscles and mind, usually strengthening both..Guided muscular contractions are of primary import--ance in causing bony union provided, of course,.motion of the bone fragments is avoided. Doctorsand the public have been taught for ages to keepbroken limbs at absolute rest for many weeks.Apply traction in such a way as to tire the muscles

and not produce irritation ; that is, make the pullslow, steady, and if necessary increase its force, until;

1 40, East Erie-street, Chicago, Illinois.