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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