Neuroses or Neuralgia of Joints are affections in which great pain is present in the joints either on movement or at rest, though no pathological anatomical foundation can be discovered. Of late years many cases of what was formerly considered pure neuralgia have been found to be cases of interstitial and parenchymatous neuritis, and in the same way neuralgia of the joints is not so wide a term nowadays as when used by Brodie, and the number of cases has considerably diminished since we have gained further knowledge of certain conditions. These conditions consist of actual changes in the joint, e.g., dislocated semi-lunar cartilage, or the small, but from the clinical point of view often important, circumscribed infiltrations in the capsule, which give rise to striking subjective symptoms (see p. 382). It is clear that these cases cannot be considered as neuralgia of the joint, and it is equally wrong to consider as such those cases in which pain is felt in the joint after inflammation, for the pain is certainly due to infiltrations, adhesions, etc., though these are not easy to show.

True cases of neuralgia in joints are rare and occur in more or less neurotic and psychopathic individuals. In these cases it is as difficult to distinguish between fully conscious simulation and real sensations of pain, which latter may be so severe as to occasion disarticulation of the hip (Pitha and Billroth), as it is to give an opinion as to the value of the different kinds of therapy. These are many, varying from hypnotic suggestion to massage, and may succeed or fail on grounds of which we are, and perhaps always shall be, absolutely ignorant. Let me remind my readers of the variable and mysterious hysterical symptoms other than those affecting joints. One hysterical patient frightened the neighbourhood for years with violent epileptiform attacks, which never failed to yield to a solemnly performed subcutaneous injection of aqua destillata purissima. Another patient who for years was dumb or could only whisper found the muscles of her larynx and her vocal cords in good condition as soon as she felt electrodes touching her skin, whether they happened to be in connection with the battery at the time or not, and cried out distinctly during the stage of excitement when under chloroform. A third hysterical patient, one of Dr. Bum's, stayed in bed from pain in the knee, suffered intense pain if the joint was merely touched, but could stand energetic massage if she was allowed a trace of chloroform, and was cured in this way. There are many cases of this sort which are healed by pictures of the Madonna or by holy water of different kinds. Massage is not worse than holy water, hypnotism, or the suggestion of personal influence, or pictures of the Madonna, but it depends entirely on the patient's opinions whether it is better than these.

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The masseur-gymnast has in most cases to deal with the larger joints. The knees and ankles are the most commonly affected. The shoulder, elbow, and wrist each provide a considerable number of cases. The hip is more protected, and except for tuberculosis is not so often the seat of pathological processes or so exposed to trauma. Apart from deformities, especially scoliosis and flat-foot, other joints than those above mentioned comparatively seldom come under treatment.

Apart from the examination of fractures already referred to, a concise reminder as to how an examination should be conducted is necessary for a considerable number of my readers.

After hearing the history of the illness and the subjective symptoms one proceeds with inspection, and one should make a rule of never neglecting to compare the affected with the corresponding healthy joint. The colour of the skin may at once give some clue, e.g., in cases of trauma or of acute, especially purulent, inflammation, such as "white swelling." The position of the joint often throws light on dislocations or fractures, and is also characteristic for the different joints when inflamed. Special care is taken to observe the deviations in form which are peculiar to each joint when the contents of the joint cavity are increased, and also those produced by thickenings in the articular and peri-articular parts. These deviations in form vary enormously. We all know how obvious, even to the most inexperienced eye, are the alterations in form which appear as the result of a severe wrench, or of fluid in the joint after serofibrinous and purulent, or during tubercular, deforming, and other affections of joints, or after long fixation. On the other hand, every masseur knows how easily the most experienced doctor may overlook the inconspicuous local swelling, which in many cases may denote a circumscribed simple synovitis without exudation in the joint cavity, a so-called "capsulitis," which, especially if it occurs in the knee, is of such extraordinary importance from a practical point of view This condition was in reality little known or thought of before Mezger enlightened us on the subject. By measuring the circumference with a tape measure, or the most variable diameters with compasses, a more accurate idea of the changes of volume may be gained. It is of the first importance to note whether and to what degree active movements are limited. After this one proceeds with palpation, the most important part of the examination, which as far as possible completes and makes clear the diagnosis. One then tries to gain some idea as to the contents of the joint cavity, chiefly by examining for fluctuation in the way which every medical student knows, and which need not be described in detail. By means of pressure and slow frictions, during which it is well to apply a lubricant to the patient's skin, and if need be by constantly comparing with the corresponding joint of the other side, and by observing any tenderness, the most accurate knowledge possible is gained with regard to the changes in the soft parts of the joint, especially the capsule. When the capsule is protected by thick coverings this examination is difficult, and necessarily gives less certain results, but in those places which are thinly covered, and especially where the capsule may be pressed against a smooth bony surface, as, for example, a great part of the front of the knee, very small changes and thickenings can be detected.