Original Communications.

RHEUMATOID DISEASE AS SEEN IN PROVIDENCE.*

By FRANK E. PECKHAM, M.D.

There is a large number of joint conditions, non-tubercular in character which in years gone by have been grouped under the title of rheumatism; this diagnosis being used much as the old fashioned country practitioner made use of the term malaria. You are of course familiar with the terms chronic

rheumatism, arthritis deformans, chronic rheumatic gout, etc. More recently much study has been put into this blind group of cases in an attempt to bring light out of darkness and order out of chaos. Clinically the different types have been pretty thoroughly described but it remained for pathology to enlighten us as regards the actual condition within the joints and so enable us to draw the lines a little finer as regards the different types of disease or of conditions of the same disease. The X-ray has been and is of the utmost value in making a differential diagnosis. The term rheumatoid has been applied more particularly to that type of the disease that has been lately called atrophic arthritis.

Atrophic arthritis is a general disease which manifests itself in joint lesions. Its onset may be gradual or sudden, beginning in one or several joints and gradually advancing until many are involved. At first there is present a swelling which involves the periarticular structures, fusiform in shape and accompanied by muscular atrophy. One joint or several joints may be * first attacked and after weeks, or more likely months, others are involved, the first one attacked not getting entirely well but remaining permanently damaged. The finger joints are early involved although the knees are most commonly affected. As the disease advances muscular contractures take place, the joints become stiff and in aggravated cases the patient may become completely crippled.

The temporo-maxillary joint is affected in many cases and when involved. is considered pathognomonic of the disease and may seriously interfere with mastication. The region of the cervical vertebræ may be affected and the neck may become very stiff for a period of time, when it usually all passes away. Very rarely is the neck permanently stiff, one such case only having come under my observation. The shoulder joints when involved present

*Read at the June Meeting of the Providence Medical Association.

rather characteristic symptoms. There is usually present a severe neuritis extending down the arm even to the finger tips and being especially troublesome at night. In addition, the X-ray plate, as in all the joints, is of great assistance. The knee joints are very commonly affected and present a swollen appearance this swelling being largely due to a condition of villous arthritis. This hyperplastic material may sometimes completely fill a joint, growing thickly from the serous membranes on all sides. There may be some fluid present but there is usually a boggy feeling rather than one of distinct. fluctuation and in depressing the patella, instead of the usual click as it strikes the femur beneath, one gets a sensation much as if it struck a piece of rubber. The cartilage is atrophied and in many places may be very much eroded, the erosions being due to pressure as the villi are caught between the bones in walking. The X-ray plate shows a dimunition of space between the bones due to an atrophy and destruction of the cartilage. These chronic cases may have a slight temperature, 99° or 994°, but never very much and more usually The heart is not ordinarily affected although it may be, at least a valvular lesion may exist.

none.

This form of arthritis may appear in a sudden and acute attack when it may look exactly like an acute attack of rheumatism, with swelled joints and high temperature but after recurring attacks it will be found that the joints are somewhat damaged and that recovery is no longer perfect, then one should reconsider his diagnosis.

The disease with which the above condition is most likely to be confused is that of acute articular rheumatism, but here the onset is always sudden with a high temperature, one joint after another being rapidly involved and as the later joints are affected, the first ones to be attacked have subsided and the recovery is complete, no permanent damage remaining. This process is prone to involve the endocardium and a valvular lesion usually remains as a permanent reminder. In rheumatism the joints are red and extremely tender with effusion present. In atrophic arthritis the swelling is periarticular with absence of redness, no especial tenderness and very little if any effusion. The treatment is also somewhat of a test as the salicylates have a very marked effect on rheumatism, while they do nothing except to somewhat relieve pain in atrophic arthritis.

In contradistinction to the atrophic form is the hypertrophic. Hypertrophic arthritis, or as it has sometimes been called, osteo-arthritis, is an overgrowth of bone. This usually occurs at the sides of the joints in such a manner that the cartilage on one side projects around and partially over the other, forming a sort of lip and hence it has been spoken of as a lipping. It is in this type that Heberden's nodes appear in the terminal phalanges of the fingers. It is this process which is so apt to attack the spine, the overgrowth or encrustation taking place usually more on one side, so that the motion in

Fig. 1. INFECTIOUS ARTHRITIS. Showing bone destruction due to the presence of the organism.

Fig. 3. HYPERTROPHIC ARTHRITIS. Showing lipping of cartilage; also the dense bone; also Heberden's Nodes.

lateral bending is limited on the affected side. The hypertrophied bone pressing on the nerve trunk may cause pain to be referred to the nerve endings, simulating sciatica and various localized neuralgias. One case under my own observation had severe pain referred to the knee and ankle which was very promptly relieved by the application of a tight fitting plaster jacket. Sometimes the overgrowth may be in such a location as to interfere with the function of the joint, when it may be excised with very much benefit.

A process which is perhaps usually present in the atrophic form and may exist in any inflammatory condition of the joint is that of the villous arthritis. This condition is most often seen in the knee joints. In flexing and extending the knee a somewhat softened click will be noticed many times. There is present a laxness of the lining membrane and enough of a fold is formed so that it just catches on motion and thus there results this soft click. There gradually forms more folds and as these are continually catching they get more or less ragged, until the villi thus formed, hang into the joint. One or more may catch between the bones in walking and lock the joint, thus simulating a slipped semilunar or a floating cartilage. These villi may undergo fatty degeneration and thus become fatty tumors projecting into the joints, or the ends may undergo calcification thus forming a small calcareous tumor attached by a fibrous pedicle. The pedicle breaks and then there is produced a floating cartilage. In this manner most of the floating cartilages are formed.

A large class of cases which have also been classed as rheumatism are those of infectious arthritis. Perhaps the most common expression has been gonorrheal rheumatism. This, however, is not rheumatism but an arthritis due either to the gonococcus or to toxin produced by the gonococcus. Infections in joints may follow any of the infectious diseases as typhoid, pneumonia, influenza, etc. Joints may become infected by any organism as the streptococcus or staphylococcus. An arthritis which may at first be traumatic may very rapidly become a virulent infection, usually from the streptococcus or staphylococcus. Any organism may produce an infectious joint, either by its direct presence or by its toxin. When produced directly by the organism there is much more liability to bone destruction, while if due to toxins the process is more liable to be limited to the soft parts. In any infection there seems to be a difference in the virulence of the organism and depending upon this is the amount of damage done, the ease or difficulty with which it is controlled and the duration of the disease. A single joint, many, or all joints may be involved. If the infection be mild, recovery may be complete, if severe much permanent damage may be done. In the other types of disease the onset is usually slow. In any infection it is usually rapid with the joint red, tender, swollen and the pain extending upward as the infection follows the lymphatics. The temperature is high and rapidly ascending with the increase of tension and absorption from the pent up poison and is accom