When there is much effusion into the joints the absorbed toxic products cause the serious constitutional symptoms. Surgical interference is warranted when an obstinate effusion is inducing toxaemia, or a chronic effusion endangers the use fulness of the affected joint, without causing much systemic disturbance, while early drainage lessens the chances of heart lesions. O'Conor, of Buenos Ayres, has abandoned medication in such cases, and opens and drains a joint as soon as the diagnosis is made. While this is too radical, surgical interference is indicated in cases in which it is more dangerous to wait than to operate, and in chronic cases in which the patient's earning ca pacity is interfered with to a material extent. A. T. Bristow (Brooklyn Med. Jour., June, 1900).
Chronic Articular Rheumatism, or Rheumatoid Arthritis. Synonyms.—Rheumatic gout, rhuma tisnie cltronique infeclieux, polyarthritis deformans.
Definition.—A chronic polyarticular disease allied in some respects to matism and due, in all probability, to the invasion of micro-organisms.
In osteoarthritis or rheumatoid arthri tis there are three types: (1) an acute polyarticular disease; (2) a chronic polyarticular disease of primary and sec ondary forms; (3) a monarticular dis ease. There is no connection between the acute polyarticular and the monarticular affection, or between the latter and the chronic polyarticular condition. G. A. Bannatyne (Practitioner, May, 1900).
S ympt oms.— Rheumatoid arthritis presents few or perhaps no premonitory symptoms, although some patients claim that they have felt pains in the ball of the thumb or in the wrist a short time before the appearance of the affection in the joints. The disease itself begins with swelling of one or more joints, the latter assuming a spindle shape. The skin becomes reddened or bluish; the local temperature is raised one or two degrees. In some cases the affected joints present an elastic swelling with distinct fluctuation; in other cases a soft, flabby enlargement is witnessed, or crepitation may be elicited from the start by passive movements. Pain is al most constantly complained of, caused particularly by motions of the joint; but in the more acute form of the disease it is also present during rest. Synovial pouches are sometimes found in the proximity of the joint which insinuate themselves between the muscles and ten dons. This is especially observed in the small joints of the fingers.
The affection usually begins at the fingers, but from there it spreads upward to the larger articulations; and the el bow, shoulder, knee, and even the hip may successively be attacked. In the
larger joints an effusion of fluid, some times quite profuse, is often observed. The affection ordinarily spreads from the periphery toward the centre and a certain degree of symmetry is commonly noticed with regard to the joints affected and to the time of their invasion.
All joints are liable to be attacked by the disease, even those of the spine, the ribs, and the jaws. The different articu lations are involved with varying fre quency, as shown by the following statistics of Garrod and Bannatyne:— Ankylosis either from fibrous changes or from interlocking of the osteophytic outgrowths (often observed in the jaws) frequently results. Another frequent sequel of the disease is deformity of the articulations, due to dislocation of the bones; this is particularly observed in the hands and in the knees. In the hands there may be deflection to the ulnar side, or, more rarely, to the radial side. Flexion and hyperextension may also be observed and every possible com bination of these deformities may occur.
While these deformities develop, the knuckles and the wrist become enlarged and nodular and the muscles of the fingers atrophy; as a rule, the thumb escapes in the less severe cases, but is affected when the disease is more gen eral. The deformity of the knee ordi narily consists in flexion and some rota tion of the foot outward; in some cases there is much fluid distending the knee, in others the ligaments surrounding the joint present a pulpy softening which may easily be confounded with effusion in the joint. In a third type we only find enlargement and immobility of the heads of the bones. The deformities of the joints are caused by the weakness of one set of muscles, these being over come by the greater strength of other muscles and by the diminished power of the softened ligaments. Pain is present in almost all cases, but its intensity varies according to the severity of the case and the stage of development.
Cardiac symptoms are present in a certain portion of cases (7.9 per cent., Bannatyne); the lesions of the heart are, however, not so severe or so extensive as in the acute articular variety. In a considerable number of cases there is enlargement and tenderness of glands, corresponding to the affected joints. The skin shows small fibrous nodules, as in acute articular rheumatism. In all acute cases atrophy of the muscles espe cially of the extensors and the interossei is observed; the tendon-reflexes are often slightly increased.