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Chronic Arthritis Deformans





The third type of arthritis deformans is the chronic slow running type
which involves many joints before the process is complete. One form of
this, commonly seen in old men, called osteoarthritis, is often
confined to the hip joint, and often produces considerable deformity.
Another form is more common in women. It begins in middle life by
deformities in the terminal joints of the fingers and the
carpo-metacarpal joints of the thumbs. Bony outgrowth takes place
until the joints become almost or quite useless. It spreads from the
joints primarily affected to the elbows, the knees and occasionally
involves other joints. The disease has no favorable course, but is
progressive, and there is great discomfort, marked disability, aches
and pains particularly in rainy weather and, finally, the patient may
become quite helpless.


Preliminary Stage.--An early symptom associated with arthritis
deformans of chronic character is likely to be a distinct loss of
muscle power, which may be the first symptom in cases that have no
acute beginning. The patient notices that he is unable to hold a
satchel as he did before, or that quite unaccountably it drops from
him. There may be a loss of control over muscles and especially small
muscles that attracts the patient's attention. He finds that he cannot
hold a book as he used to, or that it is difficult to pick up small
objects. He finds it hard to turn a door handle or to pull a cork,
although the pulling action may be perfect, but the ability to insert
the corkscrew is lacking. These symptoms are prone to be intermittent.
They are most noticeable when the patient is tired, or after a damp
day, or a succession of damp days, when he is not feeling well. It
will usually be found that a joint, the affection of which is missed
unless it is carefully looked for, that between the radius and ulna
has become affected, and as a consequence there is a difficulty in
supination. The lesions are different from those which occur in lead
poisoning but at the beginning the symptom complexes may easily be
confused.

This form of arthritis deformans, in its earlier and its later stages,
is a source of unfavorable suggestion as regards other affections. Its
first symptoms may be thought neurasthenic, and if it is so called,
those who hear the diagnosis and see the later developments will
conclude that neurotic symptoms can lead to serious sequelae. On
the other hand, the painful tiredness that is always worse in damp
weather may be termed rheumatism and be a correspondingly unfavorable
suggestion. Patients who develop aches and pains as a consequence of
occupations, or through the relaxation of joint tissues, are most
uneasy because of the confusion of the later stages of this disease
with rheumatism. This must be recalled by the physician if he would be
successful in treating such pains and aches; for not a little of the
discomfort is due to an exaggerated mental impression of their
significance. This of itself often proves sufficient to keep the
patients from the exercise that would relieve many of their secondary
symptoms, at least, and serve to make their discomfort more bearable.


Course of Chronic Arthritis.--The course of chronic arthritis
deformans is always interesting. It is never as serious as the
prognosis at the beginning seems to indicate, and it always has
intermissions which, in most cases, become favorable remissions with
such improvement that the patients feel encouraged, though they never
get entirely well. Six rather typical cases have been under my eyes
for from five to fifteen years. In all of them the course was slow and
the progress of the disease vague at the beginning; and it was
difficult to say how the affection began, or what was its cause, and
apparently nothing would stop its advance. After a time all of them
became discouraged and began to go the rounds. Almost without
exception the physicians told them that they were incurable, and
nearly all of them received unfavorable prognoses either directly from
the physician or from hints sometimes dropped to friends, or from the
attitude of the physician toward them. Much of this discouragement
proved unjustified by the actual progress of the disease for many
years. While they got but scant encouragement from regular physicians,
nearly all of them received hopeful suggestions from irregulars and
were, as a rule, for the time being, somewhat bettered by the
treatments suggested by these, no matter what they were.

Every one of these six cases, as was to be expected under the
circumstances, went through a period of intense discouragement, with
loss of appetite, partly from confinement to the house, partly from
thinking so much about themselves, partly from lack of exercise and,
in general, from their morbid mental condition. As a consequence of
the loss of appetite, or, at least, of failure to eat in the midst of
discouragement, severe constipation developed in five of the six cases
and this further complicated the situation. They ran down very much in
weight, and this emphasized the apparent size of the hypertrophic
nodosities in their joints and weakened their muscles to such an
extent that even under good conditions they found it difficult to
move. After a time, usually many months, sometimes a couple of years,
something happened to make them realize that while they were crippled
and were going to be deformed, they still might find much in life that
was not to be despised. Then they began to pick up in weight, their
muscles got firmer, their nodosities seemed to disappear because the
soft tissues around them filled out, though in most cases some of the
material previously laid down actually was or seemed to be reabsorbed,
perhaps as a consequence of the patient's better metabolism.


Neurotic Additions.--All of these patients are now in much better
physical and, above all, in much better dispositional states than they
were during the first year or two at the beginning of their disease.
While they allowed themselves to run down in weight they were
supremely miserable, with many neurotic pains and aches that were
extremely hard to relieve, they had tendernesses and sorenesses on
rainy days, usually attributed to their rheumatic conditions but
really due to intense depression of the nervous system, with a
constant tendency to exaggerate slight pains and aches into torments,
and in general were invalids, a burden to themselves and others. They
have improved to a noteworthy extent so as to become cheerful,
reasonably happy in their power to help others, interested in many
things and, in at least two of the cases, accomplishing more actual
good for those around them than they probably would if their lives had
continued to be the conventional existences that they had been before
their arthritis came to them. This reminds one of Dean Stanley's
famous expression that life looks different when viewed from a
horizontal position. He used the expression with reference to fatal
illness, but it might well be applied to any ailment that makes people
think seriously and keeps them from occupations only with frivolous
things. One of these patients is a source of consolation to many
friends, who are much better in health than she is, who bring their
troubles to her, and who marvel at her power to make the best of
things.

The prognosis for cure is extremely unfavorable, but the prognosis for
a reasonable amount of happiness and a large amount of usefulness is,
in my experience, excellent and though, of course, new habits will
have to be formed and new ways of looking at life assumed, if this can
be quietly and persuasively made clear to the patient early in the
case, much of the more or less inevitable suffering that the patient
will have to endure may be lessened.

The older the patient, as a rule, the better the prognosis in these
cases. As with regard to diabetes, tuberculosis and many another
affection, every year after fifty adds to the prospect that the
patient's ordinary span of life will not be much shortened and that
the symptoms will not be severe. Occasionally the disease develops in
patients who have been extremely healthy until they were well past
sixty. I have in mind particularly a patient who did not begin
seriously to suffer from the disease until she was sixty-eight. Then
for two or three years she was very miserable, mainly because she had
been very active and she feared that the disease would cripple her. It
did bring about a considerable limitation of her activity. Ten years
have passed, however, and she is still able to be about, and, though
now well on the way to eighty, in good weather she still attends to
various duties that take her outside of her home and occupies herself
with many interests.

I was never able to tell her that she would be better. I assured her
from the beginning, however, that she would never be so much worse as
she imagined, and that she would never be actually crippled. During
the early stages of the disease, her discouragement and, above all,
the diminution of activity, the lack of exercise and occupation of
mind and the over-occupation with herself, made her not only mentally
miserable but seriously interfered with many bodily functions.


TREATMENT

In the treatment of arthritis deformans the most important object is
the general health of the patient. Owing to the confinement, the
pains, which are often worse at night, cause disturbance of
sleep which reacts upon the general health. As a result of depression
and discouragement, patients are prone to loss of appetite. This is
sometimes looked upon as a symptom of the disease, but it is not a
direct symptom except during the acute stage when there is fever, and
is due rather to the changed conditions in which the patients live and
the mental influences that surround them. If the patient loses in
weight, as is so often the case, the effects are likely to be more
serious, for the remission is delayed and is less complete in its
consequences. Above all, it is important not to disturb the diet of
the patient in such a way as to interfere with nutrition. Owing to the
supposed rheumatic element, meat, or at least red meat, is
occasionally taken out of the diet by the recommendation of the
physician. Whenever this is done, harm results. There is a definite
tendency to anemia, which will be emphasized by an exclusively
vegetable diet, especially in those accustomed to eat meat freely. As
a rule, there is much more need to encourage the patient to eat than
to limit the diet in any way. Patients must rather be advised to take
a generous mixed diet and to consume about as much meat and the same
varieties as before. Tinkering with the diet has never been known to
do any good for arthritis deformans and often does harm. The drinking
of large quantities of water seems to do more than almost anything
else to help these patients into a better frame of body and mind.
Their neurotic symptoms are, as a rule, even more important than their
joint symptoms, and if the neurotic symptoms can be cured, as they
usually can without much difficulty, the patients feel much better.


Systematic Exercises.--As soon as the acute stage has passed patients
should be encouraged to take some systematic exercise in spite of the
discomfort that is associated with it. Unless muscles are moved
regularly deformities in bad position will result and there will be
crippling which can be avoided in most cases. It is sometimes
difficult to secure exercises for the small muscles that are involved
and definite occupations are better than artificial exercises. For the
fingers, for instance, I find that the best thing is knitting. By this
I mean using the old-fashioned knitting needles for the making of
stockings, wristlets, jackets, and the like. Crocheting is also of
some use, but it does not give employment to as many of the small
muscles as knitting. If the knitting is done with old-fashioned yarn
from which the lanolin has not all been extracted, some of this
substance comes off on the fingers during the movements associated
with knitting. This seems to do good by rendering the joints more
supple and the muscles more easy of movement. At least the suggestion
is very helpful to the patients.


Electricity and Mechano-therapy.--Electricity has been much praised,
but whatever good it accomplished has always seemed to me to be
confined to the exercise afforded the muscles. Its use, however,
serves to keep up the patient's hope.

Mechano-therapy often does good and some of the Zander machines are
likely to be useful. Pulleys and weights for the shoulders and arms
have their place and resisted movements serve to restore muscles to
function which they had lost during the time when the joints were
worst. Their use helps to bring the joint into the most available
conditions.

Something that has distinct hope in it must always be done for these
patients. For this local treatment means more than anything else.
Unfavorable suggestions keep flowing in upon him from the
failure of medicine, and serve to concentrate his attention on his
condition and make him think that nothing can benefit him. Often the
physician finds that his patient has been to someone else, who did
some simple thing that brought relief of symptoms, at least for a
time, and restored his confidence to such a degree that he felt much
better for a time at least. These ailments are emphasized by advancing
years and, though we cannot prevent decay of tissue, we can keep the
patient's mind from inhibiting still further the functions of the
impaired tissue.


General Condition.--The patient's general condition must be made as
good as possible. For this outdoor air is the most important factor.
It increases impaired appetite, makes sleep more restful and easy, and
gives one of the best occupations of mind that can be obtained. Of
course, changes in the weather will bring discomfort. Where it is
possible, such patients must be sent to climates as equable as
possible. Such a change of climate during December, January and
February will often make them very comfortable, and the distraction of
mind, with the possibility of getting out in the mild climate, will
diminish their sensitiveness and be more powerful factors in the
dissipation of their aches and pains than the climate itself. Where
people cannot be sent away from home, the securing of corresponding
distractions means a great deal. The one thing necessary for the
physician is to keep the patient from brooding upon himself and his
ills and to find other occupations of mind for him.





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