Synonyms:—Rheumatic gout; rheumatoid arthritis; osteo-arthritis.
Definition:—A chronic disorder of the joints, characterized by progressive and usually permanent changes in all the structures of the joints, and by deposits around them, resulting in serious deformity. It is to be distinguished from gout and from acute rheumatism, both of which it resembles in some particular.
Etiology:—Heredity has a marked influence in the occurrence of this disease. I have at the present time under observation a family in which the father and his brother died after years of increasing deformity; one son died at thirty, and two sons and one daughter now living have the difficulty in mild form. Another daughter, above forty years of age, has no symptoms of the disease.
The disorder is thought to follow acute rheumatism, and to depend upon the causes which induce that disease. There has been found disease in the spinal cord of many of these patients, such as lesions in the anterior horns, which were degenerative or atrophic in character. It has also been associated with locomotor ataxia, and has seemed to be induced by serious nervous shock or great grief. The trophic changes take place in the structures surrounding the joints, in the skin and muscles, and may be distinctly located in the nerve trunks, closely resembling neuritis, but whether these conditions are primary or secondary is a matter of doubt. An effort is being made at the present time to ascribe the disease to microbic causes, but as yet no progress in this line has been made.
The condition occurs in middle life, only a few cases having been observed in youth. It occurs more frequently in females than in males, in the proportion of four or five to one. Those who are careless in their diet and in their habits of living, who heedlessly expose themselves to abrupt temperature changes, and who do not keep properly clothed, are especially subject to an attack.
Symptomatology:—When a difference is recognized in the mode of onset of this disease, this difference is more theoretical than practical, as it is usually impossible to distinguish between those variations which are designated as acute, sub-acute or chronic.
However, it is possible to distinguish between a class of cases in which there is a slow, progressive deformity of the joints. It may occur first in one joint of the first finger, and later in the same joint on the opposite hand; there may be some slight differences from day to day in the amount of soreness and pain, but there is a uniform, steady progress of all other symptoms. The joints increase in size and in stiffness, or in inability of movement. Occasionally there is no pain in the joints, but the surrounding tissues may be sensitive; at other times there is pain on attempted movement or upon pressure. Occasionally there are no external appearances of redness or swelling of the covering of the joints; later, as the disease involves other joints of the hands and feet, the pain increases, and may be constant.
The other form mentioned is that in which the joints enlarge much more rapidly at certain times than at other times, and this enlargement is accompanied with extreme pain. Upon voluntary or involuntary movement of these joints a sensation of roughness is experienced, and often a crackling—a crepitus—can be heard in the joints. There are evidences of a primary inflammation having occurred in the synovial membranes, as there is hyperemia and local engorgement. Following this, the cartilagenous coverings of the bones are gradually absorbed, there is a development of fibrous tissue, and bony deposits take place from the periosteum which covers the end of the bones, resulting in roughness of the joint primarily, later, of considerable impairment of joint motion, until immobility occurs, and ultimately complete ossification of the joints.
While the disease affects the joints of the extremities only, in most of the cases there are instances, two of which have come under my own observation, in which the gradual progress of the disease through a period of years ultimately involved every joint in the body, producing not only arthritic changes which were plainly apparent in nearly every case, but inducing permanent contractures. In one of these cases the thighs were flexed upon the body until the chin was fixed upon or between the knees, the legs were flexed upon the thighs, and the feet were dislocated at the ankles and stood nearly parallel with the tibia. The articulations between the vertebrae became ultimately ossified, until the movement of the head upon the neck or of any portion of the vertebral column was impossible. The inferior maxillary was solidly fixed, with the teeth separated perhaps one-fourth of an inch; the forearms were flexed upon the arms, and the hands were held together. The pain with this patient was excruciating; it was increased by every motion, and even by a slight jar of the bed. He was under my observation for about a year before his death, with but little change in the condition, which had existed for a year or more previously. No treatment was of the least benefit, and nothing but opium gave him any relief. The opium habit was formed when I was called. He was taking thirty drops of laudanum every two or three hours. In undertaking to cure this habit, so greatly was his distress increased that I desisted, considering it a mercy that his agony could be in part relieved by this remedy.
Heberden's nodes are those small, bony knobs which form around the joints of the fingers, most frequently in women, in the early stage of this disease. Some of these cases never progress beyond this deformity, and a few of the writers consider this a distinct form of the disease. This condition does not influence the general health of the patient in any marked manner. There will ultimately occur those conditions which result from enforced confinement and inactivity, and there is slow muscular atrophy, with corresponding loss of strength, with occasionally a slowly progressive anemia. Disorders of the stomach occur frequently, with chronic constipation. The condition of the kidneys is not early influenced. There is usually a sufficient quantity of rather pale, limpid urine, and occasionally a trace of albumin.
Diagnosis:—This disease is often confused with chronic rheumatism, and occasionally with gout. It must be remembered that chronic rheumatism seldom involves the smaller joints, while gout is paroxysmal, especially in the early stages, at which time both of these diseases are much more painful that this. The bony knobs and the permanently fixed character of the joints, and the progressive character of the disease in the later stages, render the diagnosis unmistakable.
Prognosis:—This disorder is incurable. But little benefit, even in the early stages has been accomplished in any of the cases. However, the progress of the disease may be arrested, more or less permanently, by the rigid adherence to a careful course of treatment.
Treatment:—These patients should be given alterative treatment in a persistent and active form. The use of the old compound syrup of stillingia with corydalis and capsicum, persisted in for a long period, and varied a little according to the judgment of the physician, will influence some cases. I believe that echinacea will be found of some benefit also. It may be given with the sodium iodid, as advised in the treatment of syphilis. The use of potassium acetate and small doses of podophyllum or iris will benefit cases in which there are liver complications. A syrup of hydriodic acid, as advised for gout, may be given under similar circumstances, to these patients. If there seems to be a slowly progressive anemia, the syrup of the iodid of iron should be given in twenty minim doses, every three or four hours. Constipation should be persistently antagonized, and the sewers of the system should be flushed with an abundance of pure water.
Rest to the joints is no advantage in this disease. Joint movement and massage, while they may not decrease the actual condition in the joints, will prevent anchylosis, retard deformity, and contribute to the usefulness of the part, and prevent much ultimate pain.
A free, liberal diet may be prescribed, although an excess of nitrogenous food should be avoided. Vegetarians are less apt to have this disorder than those who partake of meat in its various forms. Coffee and tea should be taken sparingly or be entirely excluded. The use of alcohol does not seem to have much influence in the cause or the development of the disorder, and taken sparingly does not greatly aggravate it.