Uterine authors ascribe to uterine disorders a prominent, if not the most prominent part in the causation of multi ple arthritis deformans, and if their views are correct, an explanation is supplied of the excessive liability of the female sex. The influence of the menopause as a predisposing cause has already been discussed, and frequent and rapid child-bearing as well as excessive and pro longed lactation must be ranked among the conditions which cause exhaustion and so predispose to the disease. Of the 411 female cases of my series the condition of the menstrual function was noted in 176. In 105 cases the catamenia were regular and normal, and they were irregular in period or in amount in 71.
Two hundred and sixty-seven of the female patients were married and 144 were single.
The size of the family was noted in the case of 132 patients, and of these 92 had less than six children, and 40 had more ; 2 had had. thirteen, 1 fifteen, and 1 seventeen children.
In 5 cases the onset of the disease was said to have occurred after a confinement, in 3 after a miscarriage, and in 3 during preg nancy. Five patients had suffered from uterine or ovarian tumors. Dr. Ord" states that of a series of thirty-eight patients under his care no less than thirty had some uterine derangement or disease, either slight or severe, and be has observed that in some cases the menstrual periods are attended with an increase of the pain in the joints. In some cases pregnancy seems to hasten the progress of the disease, but occasionally the patients suffer less at such periods than at other times.
Worry and the most interesting of the exciting causes of arthritis deformaus are certain which can only be supposed to act through the nervous system, and which may be roughly classed as worry and care. The potency of such causes has been asserted by a number of observers, and histories of this kind are far too fre quently volunteered by the patients to allow of any serious doubt upon the subject.
In the series of 500 eases there were 34 in which such causes were mentioned, and among such were included sudden losses by bank failures and sick nursing of near friends.
Nor are the pernicious effects of worry and care confined to the original causation of the disease, for such influences further tend to increase the patients' sufferings when the disease is already estab lished, and the statement is not infrequently volunteered by them that any depression of spirits or anxiety always tends to make the pains worse.
Some cases have been recorded in which a violent mental shock or fright instead of prolonged worry has preceded the onset. Two cases are mentioned by Kohts" in which arthritis deformans followed the shock of a shell bursting close to the patient, and Leyden" states that in Strasburg many cases date their origin from the bombard ment of that city during the Franco-German war. Here, however, the other conditions prevailing in a besieged city may have been partly responsible.
_Tojm..—The influence of injuries is more marked in the causation of the localized than of the multiple variety of the disease. Never theless eases are occasionally met with in which the characteristic changes have been developed in a single joint which has been the seat of an injury, and have afterward extended to other articulations. I have myself met with several cases in which this was stated to have been the course of events.
Lastly there remains a considerable proportion of cases in which none of the exciting causes mentioned above appears to have been at work, nor indeed can any definite cause for the onset of the disease be traced.