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Rheumatoid Arthritis

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RHEUMATOID ARTHRITIS (OSTEO-ARTHRITIS, ARTHRITIS Deformans), terms employed to designate a disease or group of diseases characterized by destructive changes in the joints. Though it is only in comparatively recent times that the disease was definitely recognized as separate clinically from either rheumatism or gout, it is certain that it prevailed in ancient times. Characteristic changes in the bones have been found in remains in tombs in Egypt attributed by Petrie to 1300 B.C., and ancient Roman as well as British graves have held bones showing distinct traces of the diseases. Of early medical writers, Paulus Aeginata observed the lesions and seemed to consider them distinctive. Landre Beauvais in 1800 published a description of the disease under the title of Goutte asthenique primitif. The first endeavour, however, to separate rheumatoid arthritis as a distinct disease was made by William Heberden in 1803; while in 1805 John Haygarth recognized the difference between it and rheumatism, and suggested the term "nodosity of the joints." A wide divergence of opinion during the 19th century as to its relation to rheumatism and to gout gave rise to the unfortunate term "rheumatic gout." The name arthritis deformans was suggested by Virchow in 1859. Various causes, such as nervous origin, inherited arthritic diathesis, a relationship to rheumatism or gout, and reflex irritation, have been put foward as giving rise to the disease, but in the present state of medical knowledge two are most favoured. The first ascribes the disease to an infective process arising from micro-organisms. Several observers have found bacteria in the synovial fluid and membranes of affected joints, - Max Schuller finding both bacilli and cocci, while in 1896 Gilbert Bannatyne, Wohlmann and Blaxall isolated a micro-organism, a bacillus with a bipolar staining, which they stated to be almost constantly present in the joints of patients with true rheumatoid arthritis. The second view is that the disease is the result of a chronic toxaemia produced by absorption of toxines from the intestine, with perhaps some error in metabolism. In many cases there seems to be a distinct evidence of a local infection, injury being a determining factor, and some families seem to have joints which are specially liable to degeneration. The disease may begin at any age, for there is no doubt that persistent cases have been met with in quite young children; but it usually begins in early middle-age, and statistics seem to confirm the impression of the greater liability of females. Conditions which tend to lower the general health seem to act as a predisposing cause to rheumatoid arthritis, e.g. mental worry, uterine disorders and various lowering diseases, prominent among which are influenza and tonsillitis. In a number of cases in women the onset occurs about the time of the menopause.

The method of onset varies according to the form. There are four well-marked types - (t) the peri-articular form, in which the most marked changes are in the synovial membrane and peri-articular tissues, and the cartilage may be involved to a lesser degree. In this variety is found every grade of severity. The onset may be acute, resembling an attack of rheumatic fever, for which it may be mistaken; the joints, one or more, are swollen, tender and painful to the touch; the temperature elevated to ioo; 101°; but unlike rheumatic fever, sweating and hyperpyrexia are uncommon. The acute stage may then subside, a slight thickening remaining in the capsule of the joint, and the contours of the limb scarcely regaining the normal; or the attack may gradually develop into the chronic form. The pain varies greatly, and is not necessarily in ratio to the amount of arthritis present. Various joints may be involved, the spinal vertebrae not infrequently sharing in an arthritis; the most usual joints to be attacked, however, are`the knee and shoulder. When the knee is attacked there is commonly effusion into the joint. Muscular atrophy is usually present, but varies greatly in its extent. In most cases it is present to a much greater degree than can be accounted for by disuse of the muscles. The skin has in these cases a curious glossy appearance, and pigmentations may be noticed. In chronic forms the onset is gradual, one joint becoming painful and swelling, and then the others successively; in these slow forms the outlook for the recovery of the joint is not so good as in the acute, and some cases may proceed to extreme deformity with little or no pain. Gradually the shape of the joint is altered; this is in a great measure due to synovial thickening, and partly to the presence of osteophytes in the joint. When the affected joint is moved a distinct crepitation can be felt. The muscles about the joint atrophy often to an extreme degree, and contractures supervene, flexing the leg upon the thigh if the knees should be affected, and the thigh upon the abdomen should the hip be affected. In extreme degrees the patient may become a complete cripple. Later, in many cases a quiescent stage of the disease is reached, the patients cease to suffer pain, and are inconvenienced only by the deformities in the limbs, in which a considerable degree of motion may be retained. Remarkable deformities are seen in hands in which a considerable amount of usefulness still, remains. Dyspepsia and anaemia are frequently associated with arthritis. Monarticular arthritis more particularly affects the aged; and when it affects the hip is known as morbus coxae senilis. (2) The atrophic form of arthritis is not very common. The chief anatomical change is due to atrophy in the bone and cartilage. The disease occurs at an earlier period in life than the peri-articular form, from which the initial symptoms do not markedly differ; but the disorganization in the joint is greater, dislocations frequently occur, and ankylosis of the joints follows. This is the most serious form of arthritis.

(3) In the hypertrophic form the anatomical changes include the formation of new bone as well as changes in the cartilage. This new-bone formation may lead to progressive ankylosis in the joints. Should the vertebral column be affected a rigid condition of the spine known as spondylitis deformans (" poker back") may ensue. What are termed "Heberden's nodes" are small hard knobs about the size of a pea frequently found upon the fingers near the terminal phalangeal joints; they rarely give rise to symptoms. Popularly ascribed to gout, these nodes are in reality a manifestation of arthritis.

(4) A variety of arthritis occurring in children is known as Still's disease; in which the swelling of the joints is associated with swelling of the lymph glands and of the spleen. The onset is often acute, with fever and rigors; sweating is profuse and the joints are enlarged and painful. There may be much muscular wasting and limitation of movement in the joints, and anaemia is associated with the disease.

The treatment of rheumatoid arthritis is rarely curative, once the disease has been permanently established; and it is therefore important to begin treatment before destructive changes have taken place in the joints. In the acute febrile form, which is frequently taken for rheumatism, the essential treatment is rest to the affected joints, with the application of oil of wintergreen; the joint should not be fixed but supported. In the more chronic forms medicinal treatments are usually of little value. Potassium iodide is useful in some cases by promoting absorption of the hypertrophied fibrous tissue, and guaiacol if administered for a sufficiently long time is said to be capable of arresting the disease, diminishing the size of the joint and helping movement. Where anaemia accompanies the disease iron and arsenic are of value. The general health of a patient suffering from rheumatoid arthritis must be maintained, and he should live upon a dry soil. Visits to Aix-les-Bains, Buxton, Bath or Droitwich, with their baths and shampooings, often prove useful, particularly when combined with gentle massage. It is a mistake to keep the joints entirely at rest in the chronic forms, as this tends to the formation of contractures and ankylosis. Moderate exercise without undue fatigue is desirable. Patients should go early to bed and have plenty of rest, sunshine and fresh air. It is important that the diet should be nourishing and plentiful, and should there be intestinal putrefaction fermented milk is useful. As regards the local treatment, it will be well in the majority of cases to determine by the X-rays the exact state of the affected joints. Radiant heat, vibration and hot-air baths are among the best treatments. The active hyperaemia induced by hot air favours restoration of movement and alleviates pain, but where there is pronounced destruction of bone and cartilage full restoration of a joint cannot take place. Systematic exercises of the joints tend to prevent the atrophy of the adjacent muscles, .,nd Bier's passive hyperaemia induced by the temporary use of an elastic bandage has the same results. Should an X-ray photograph reveal the presence of spurs or loose bodies in the joints interfering with free movement their removal is called for. Sometimes the breaking down of adhesions under an anaesthetic is necessary, and gentle passive and later active movements of the joints should follow if freedom of use is to be gained. Recently treatment by radium has taken a definite place in the therapeutics of chronic arthritis, its analgesic properties seeming of great benefit. (H. L. H.)