(RHEUMATOID ARTHRITIS)
=Definition.=—A chronic affection of the joints, characterized by
progressive changes in the cartilages and synovial membranes, and by
new osseous formations restricting the motion of the joint and causing
deformity.
=Osteopathic Etiology= and =Pathology=.—It is due to lesions of the
spinal column affecting the spinal and sympathetic nerves as well as
disturbing the circulation to the cord. Lesions of the spinal column
and ribs are found corresponding to the innervation of the diseased
joints. The osteopath has been able in every case to demonstrate
clinically important osteopathic lesions. In addition the symmetry of
joint involvement, muscular atrophy, sweating, etc., point to nervous
lesions. Falli found upon autopsy that the anterior horns had undergone
atrophic changes. Nervous lesions are probably of a predisposing
character while some infection is the exciting cause. A thorough search
of the entire body should be made for foci of infection. Malnutrition,
traumatism, exposure to cold, and pelvic diseases are important
causative factors. In all cases lesions will be found disturbing the
organs of digestion. Females are more frequently affected than males.
The disease is frequently seen in women suffering from ovarian and
uterine troubles, especially at the menopause. Hereditary influence may
be a factor, also auto-intoxication. The disease is most common between
the ages of twenty and thirty. Mental worry, anxiety, grief and injury
are also predisposing factors.
=Pathologically=, in one class of cases, the cells of the cartilages
and of the synovial membrane proliferate. The cartilages undergo
atrophy, or may become soft, degenerate, and are absorbed, leaving the
ends of the bone bare. The bones naturally atrophy and become smooth.
In another class the edges of the cartilages where the pressure is
slight, thicken and form outgrowths which ossify and enlarge the heads
of the bones, forming osteophytes which greatly impair the motion;
true ankylosis is rare. The synovial membrane becomes thickened, also
the capsule and ligaments, thus greatly restricting the movements of
the joints. The muscles around the joints atrophy. In the spinal cord
atrophic and degenerative lesions are found. In Still’s disease there
is an enlarged spleen and marked changes in the joint.
=Symptoms.=—Pain and swelling of the joints and fever and enlargement
of the lymphatics near the joint are characteristic. The spleen
is congested and later on there is gastro-intestinal disturbance.
=Multiple arthritis deformans=, also known as Heberden’s nodosites,
is characterized by nodules developing at the sides of the distal
phalanges. It occurs most frequently in women between the ages of
thirty and forty, and gradually increases with age. At first the joints
are swollen, tender and painful and then apparently become better.
These attacks may appear at different intervals while the nodules at
the sides of the joints gradually increase in size. The larger joints
are rarely affected. The progressive form may be either acute or
chronic. The acute form at the onset may resemble articular rheumatism.
It is more common in women between the ages of twenty and thirty, but
may occur in children. Pregnancy, recent delivery, lactation, the
menopause, and rapid child bearing are common antecedents. There is
swelling and tenderness of the joints and slight fever. Several joints
are usually involved. The =chronic form= is most common. Symmetrical
joints are usually involved. The affected joints slowly enlarge and are
painful and red. Usually the hand is first affected; then the wrists,
knees, toes, jaws and spine; in extreme cases every joint is affected.
The vertebræ, =spondylitis deformans=, may be attacked. The cervical
spine may be alone involved, in which case the head cannot be moved
up or down, although rotation usually remains. In some instances the
entire spinal column is affected and may become perfectly rigid. In
some cases there is hardly if any pain, while in others the pain is
agonizing and is almost constant. The joints gradually become deformed,
stiff and creak when moved; later they become completely ankylosed.
This deformity is due partly to the thickening of the capsule, to
the presence of osteophytes, and to the contraction of the muscles.
These contractures flex the leg upon the thigh and the thigh upon the
abdomen. Muscular atrophy increases the deformity. Numbness, tingling,
pigmentation and glossiness of the skin, and local sweating may be
present and are of trophic origin.
The =monoarthritic form= affects old persons chiefly, and women more
frequently than men. It affects particularly the hips, the knees, the
shoulders, and the vertebral articulations. This is often caused by an
injury. The muscles waste away and the knee-jerk is usually increased
upon the affected side.
=Diagnosis.=—Care has to be taken in not confusing it with rheumatic
fever or gout. Radiographs should be made.
=Prognosis.=—If treated early there is a fair chance for curing
the disease. Advanced cases usually improve under treatment. The
osteopathic treatment should be persistent for at least several months.
=Treatment.=—Osteopathic treatment, if long continued in rheumatoid
arthritis, has given satisfactory results, although owing to the
extent of the deformity, a cure in advanced cases cannot be expected.
An important cause of the disease is probably a trophic or vasomotor
disturbance to the tissues of the joint. Osteopathically, there
is never any difficulty to locate disorders in the spinal column
corresponding to the innervation of the involved joints. The fact that
many of the joints are affected symmetrically indicates that the lesion
is a spinal one involving the nerve center. During the incipiency
marked improvement is the rule.
A thorough attempt should be made in every case to discover the source
of infection and remove it, though this does not preclude the essential
osteopathic adjustment.
The treatment consists of attempts to correct the spinal derangement
and careful manipulation of the diseased joints to restore vitality and
motion in them. The preceding simple, but effective treatment, must be
continued two or three times per week for months or even years in order
to be of particular value. Coupled with the specific treatment should
be a careful consideration of the general health. The emunctories
should be kept active and the food of the patient be nutritious. The
osteopath should require the patient to take considerable physical
exercise at regular intervals, warm baths and plenty of fresh air.
Massage and friction of the diseased joints will be of aid in absorbing
effusions and in restoring the tone of atrophied muscles. Hot
compresses are a help. The baths at various hot springs are sometimes
of benefit, and change of climate is invigorating.
O. J. Snyder[69] has this to say: “I must be very emphatic, however,
to here advise exceptional caution in your manipulative procedure.
* * * You cannot attempt to move the joint, for, if you do you will
cause excruciating pain and do irreparable harm in that you will cause
breaking down of the cartilage and cancellous bone tissue. Your first
endeavor should be to reduce inflammation and to mitigate pain. * * *
Osteopathically much comfort and reduction of pain can be accomplished
by inhibition in the proper spinal areas. A little friction and very
gentle extension or traction of the joint can be attempted as soon
as the condition of the joint, by the foregoing treatment, has been
made possible. At no time should rotation or sidebending, or any other
manipulation that produces irritation of tissue be attempted.”
In stout adult women a villous arthritis of the knees may develop owing
to faulty posture and poor elimination. These conditions are often
amenable to treatment.