Joints: Keeping ’em close, yet a little apart

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A few structures in our body, set us apart from our closest primates. Most animals need all fours, but we can balance, walk and run on our twos. This makes our hands free, and allow us to manage many fine movements. Our rigid bones make these actions sturdy, and our joints keep our bones together. Joints, a physical interface between two bones, are made up of soft cartilages, tough ligaments, and a tiny bit of fluid. All these supports also keep two bones a bit apart from each other. Like all human relations, a little space gives flexibility for our flawless actions.

“Rheum” in Greek means to flow. Rheumatology – A name for science that deals with joints, embodies similar flexibility or flow. We also use the word arthritis, for a painful inflamed joint. This word also has a Greek origin.

There are about 360 joints in our body, and 27 of them are in each of our hands. Hand-joints, help with most of our manual chores. However, when diseases makes them stiff, painful, or swollen, it leads to a considerable disability. It’s no wonder that many rheumatology images and postage stamps focus on our hands. Further, two common joint diseases, Rheumatoid arthritis and Osteoarthritis, both disproportionately affect our hands-joints.

Rheumatoid Arthritis – A Signature rheumatic disease

Rheumatoid arthritis (RA) is a painful affection of multiple joints, mostly in young women. Landré-Beauvais a French Physician in 1800s, was the first to distinguish it in from Gout -which was then its more famous cousin. Gout was more common in men, and in wealthy, while RA occurred mostly in women, most of whom were poor. In fact Landre identified this disease as Goutte Asthénique Primitive, or “Primary Asthenic Gout”. In 1859 Alfred Garrod, an English Physician named it Rheumatic Gout. It was Archibald Garrod, Alfred’s son, who in 1890 gave the disease its present name – Rheumatoid Arthritis.

It is still a matter of debate, if RA is a more recent disease from the modern period, or has its secrets buried in antiquity. Many medieval paintings show women with deformed hands, while Egyptian mummies do not. Maybe, this disease remained hidden due to its gender predilection, or due to its cosmetic disfigurations.

Osteoarthritis – the other hand disease

William Heberden, a British Physician, in 1782, first noticed finger nodules. He called them digitorum nodi. This finding was first published in 1802, and these nodes were named after Heberden.

By 1850s, various other physicians could identify these nodules, and their relationship to destroyed worn out joints. Such joint destruction would affect both men and women in their later ages. It was not merely confined to hands, but also seen in hip and knees. What previously was just a feature of ageing, was now recognised as a disease.

Initially this joint disease or arthritis was named as “partial rheumatic arthritis” or “arthritis mutilans”. Archibald Garrod, the same physician who named Rheumatoid arthritis, also gave the disease its current name – Osteoarthritis (OA). We know Rheumatoid arthritis as a disease of young with more pain, swelling and inflammation. In contrast, its sibling Osteoarthritis is more a disease of wear-and tear, and only a low grade of inflammation.

Gout – the original joint disease

Unlike RA and OA, Gout was well known to the ancient Egyptians and Greeks. Gout is typically recognised as “a sudden severe pain in great toe, that would often awaken one from sleep.” Previously known as Podagra, a Dominican monk Randolphus (1197-1257) gave the name Gout. Word Gout is derived from Gutta – which in Latin means “drop”. Ancient physicians thought of it as a bad humour, that had dropped in a joint.

Till 19th century, all joint diseases were just variants of Gout. Other joint diseases such as OA and RA gained wider recognition only in early 1900s. Till 1950’s, Gout was considered as a disease of the intemperate, and the affluent. As healthcare became more accessible, this disease also got a wider recognition. In 1964, English magazine Punch noted “In keeping with the spirit of more democratic times, gout is becoming less upper-class and is now open to all …“

Affection of the spine – Spondylosis

Our spinal cord is protected by 33 vertebral bones. Each bone is separated from the other by vertebral joints and cartilage discs. Word “spondylosis” is derived from latin – “spondy” for spine and “losis” for problem.

Ankylosing (which means fused) spondylosis (problem of the spine) is a particular painful disease of the vertebral joints and ligaments, that mostly affects young-men. While this disease was known for a long time, It was first described as a separate entity in 1893, by Vladimir Bekhterev – a Russian neurologist. Later Adolph Strümpell in 1897 and Pierre Marie in 1898, also separately described this disease. For this reason, this disease was also known as Bekhterev disease, Marie–Strümpell disease. First X-rays of patients with disease were taken only after 1897. X-ray appearance led to its name.

The Beginnings of Orthopedics

The science of setting broken bones, is known since the ancient times. Till 18th century, war-injuries, that also led to broken bones, and amputed legs, were mostly treated by surgeons. Orthopedics of today, was not a separate science. In 1740s Nicolas Andry, and later in 1780 Jean-André Venel started treating bone deformities in children. Jean opened a first hospital for such diseases in Paris . They were the first orthopedicians (derived from French word orthopédie – orthos (right or straight) and paideia (children)).

About a century later, Antonius Mathijsen, a Dutch military surgeon, invented the plaster of Paris cast in 1851, and use of this innovation is now universal. Many surgeons including Adolf Lorenz (1854-1946) used casts and splints to treat congenital dislocation of hip, and club-foot in children.

From surgeries of bone to the surgeries of joints

However, it was advent of X-rays in 1895, that led to growth of orthopedics. Bones, their fractures and types could now be better described. Over next 50 years, many surgeons gave their names to different types of fractures.

X-rays also improved our understanding of hip and knee joints. By 1950s we had cobalt chrome alloys and stainless steel, as materials that were both inert and strong. In the 1960s, Sir John Charnley, a British Surgeon used stainless steel alloy to perform the first successful hip replacement for osteoarthritis. Subsequently more alloys and designs for hip, and later for knee were developed. In 1968 Emile Letournel in France, improved on both knee replacement and hip-acetabular surgeries.

Advances in our understanding of Rheumatic diseases

By 1940s, we had realised that most diseases of joints and ligaments are not infections. These are diseases of our own hyperactive immune system. Salicylic acid, or Aspirin had become popular in 1900s, and it was the only medicine available for relief of pain till 1950s. In 1948, we discovered Rheumatoid factor (used in diagnosis of RA) as well as corticosteroids (used in treatment of RA). Use of corticosteroids dramatically relieved symptoms in patients with Rheumatoid Arthritis (RA). More better medicines, such as disease modifying drugs such as methotrexate, were still two decades away.

We discovered lupus anticoagulant, in 1952, antinuclear antibodies, in 1958, and association of HLA B27 with ankylosing spondylitis, in 1970. These new discoveries led to better identification, of a variety of rheumatic diseases such as SLE and Sjorgen’s. In last two decades, we have also identified many more immune molecules, that have a role in different rheumatic diseases. Today we have many designer drugs or biologics, that target culprit molecules. These developments have opened newer doors in how we treat these diseases.

Bridge the gap

Our understanding of disease and joints, ligaments, cartilages and other structures is rapidly expanding. We also have newer diagnostic tests, medicines, and improved surgical devices and techniques. As this field expands, we also need to improve awareness and access to medical developments. We need to be better aware about our joints.

Joints are not merely a bridge between the two bones. In fact they our our wheels. While our mind generates thought and drive, our joints convert it into a visible action. So next time we eat, write, walk, run or jump with joy, let’s remember our tireless joints.