RHEUMATOID ARTHRITIS, a disease characterized by destructive changes in the joints. Its origin is unknown but it is probably caused either by micro-organisms themselves affecting the joints or by the absorption of the toxins of micro-organisms in some other site such as the intestine, or mouth. In many cases injury appears to be the determining factor and any condition tending to lower the general health may act as a predisposing cause.
In adults there are two main groups: (I) The Acute or peri-articu'ar type in which the onset is usu ally between 20 and 4o years of age and women are more often affected than men. It is usually acute and many joints may be affected at the outset, the condition being mistaken for acute rheumatism; pain is variable but often severe except at rest. The joints become swollen and fusiform in shape and tender to the touch; those most frequently attacked are (a) hands and feet; (b) wrists; (c) ankles; (d) knees; but any other joint may be affected. The temperature in the acute onset may rise to 103° F but is often less. As the attack subsides the swelling diminishes but there is usually considerable muscular wasting and marked contractures which may result in severe deformity, fixation and loss of function of the joints, the patient becoming a complete cripple.
(2) The Chronic or Osteo-Arthritic Type.—The onset is usually between 4o and 6o years of age, the causes assigned being injury, general ill-health and exposure to cold and wet. Pyorrhoea alveo laris or decayed or deficient teeth are practically always present. The onset is chronic and generally polyarticular; pain is variable and may be slight throughout. The swelling of the joints is nodu lar in shape and practically confined to the joint itself, affection of the periarticular structures being slight. When the condition is polyarticular usually a few large joints are affected, but none are immune ; when monarticular the hip or knee is most likely to be affected. The formation of the new bone occurs and may cause great limitation of movement or even ankylosis ; when this occurs in the spine the condition known as "pokerback" results. In the
later stages the limitation of movement and muscular wasting may render the patient absolutely helpless but the condition is then often quiescent and painless.
(3) A third type of arthritis which occurs in children is known as Still's disease. The onset at about three to six years of age is usually insidious but may be acute. The joints become swollen and fusiform in shape and there is severe muscular wasting and limitation of movement. There is generalized enlargement of glands, sweating is common and the temperature is often persist ently about ioo° F.
The prognosis of all forms is bad, exacerbations and advance being the rule; in children an intercurrent disease is often fatal.
Early diagnosis is essential for successful treatment. Search should be made for a septic focus, which should be removed if found. The general health should be attended to and improved, the diet not being stinted : meat and vegetables may be given freely but indigestible articles avoided. The patient should live on a dry soil. In the acute stage the joints should be given complete rest in a good position and oil of wintergreen applied. In the chronic forms and as the acute stage passes off the joints should not be kept completely at rest, massage and passive movement followed later by active movement up to a moderate amount of exercise being desirable to counteract muscular wasting and con tractures. Spa treatment, radiant heat, hot-air baths and electri cal treatment are also of use, and in recent years radium has been used. If an X-ray photograph shows that bony outgrowth is lim iting movement, an operation for its removal should be consid ered; similarly adhesions may have to be broken down forcibly under an anaesthetic. Whatever the form of treatment adopted it must be persevered with for some weeks before being given up as of no value. (P. L.-B.)