reasonably met by Hutchinson's[241] doctrine that there exists a state
of tissue-health which is transmissible by inheritance, which involves
liability to inflammations of joints and fibrous structures, and upon
this arthritic diathesis as a foundation may be built up, under the
influence of special causes, a tendency to gout, rheumatism, or any one
of their various modifications or combinations.
[Footnote 241: _Trans. International Med. Congress_, ii. 95; Guéneau de
Mussy's chap., "De la Diathèse Arthritique," _Clin. Méd._, 1874, t. i.
317-338.]
Hutchinson has demonstrated that gout is often followed by rheumatoid
arthritis, the lesions characteristic of both affections coexisting in
the same joint. Charcot and Cornil had previously observed the same
{90} thing.[242] Acute and perhaps chronic rheumarthritis have
sometimes preceded rheumatoid arthritis. If a predisposition, inherited
or acquired, to rheumatoid arthritis exist, the occurrence of gouty or
rheumatic irritation in the joints may suffice to induce the peculiar
form of disturbance characteristic of the rheumatoid affection, just as
injuries sometimes develop the partial form.
[Footnote 242: _Mémoires de la Société de Biologie_, 1864.]
There is a group of conditions affecting the sexual functions and
organs of women which appear to be specially connected with the general
peripheral form of rheumatoid arthritis. The disease follows pregnancy,
and specially frequent pregnancies, protracted lactation, and various
disorders of menstruation. The latter influence obtained in ten out of
eleven instances of the disease met with in girls under eighteen by
Fuller.[243] The frequency of the disease about the period of the
menopause has been already mentioned. Todd noticed its coincidence with
dysmenorrhoea. Ord in an able and original paper[244] has lately dwelt
upon ovario-uterine disorder or irritation as a frequent active cause
of the disease, having in his opinion met with 33 instances of the
kind. The relationship between these various conditions of the
functions and organs of generation and rheumatoid arthritis cannot be
regarded as settled. Garrod supposed that such conditions, by causing
debility, predisposed to the articular disease. Todd, an ardent
humoralist, held the nexus between the two to be unhealthy secretions
of the uterus, leading to blood impurity; while Ord has ably defended
Remak's view that a direct influence of the nervous system is the real
link of relationship. It seems necessary to remark that mere
coincidence may play a large rôle in the explanation of many of these
cases. In 17 at least of Ord's 33 cases the conditions stated by that
author cannot safely be adduced as anything more; and it is probable
that they would be found present in much the same proportion in any
other chronic painful disease of women.
[Footnote 243: _Loc. cit._, 335.]
[Footnote 244: _Brit. Med. Jour._, i., 1880, 151-153.]
Scrofula and phthisis are regarded by Charcot, Cornil, and Garrod as
frequent antecedents of rheumatoid arthritis: the first had several
times seen white swelling in youth, followed by nodular rheumatism in
later life;[245] and Fuller found that 23 out of 119 victims of
rheumatic gout had lost a parent or one or more brothers and sisters by
consumption.[246] Chlorosis has several times preceded rheumatoid
arthritis. When the prevalence of scrofula, phthisis, and chlorosis is
borne in mind, it will not appear strange that they should frequently
be found amongst the antecedents of rheumatoid arthritis, without
inferring any other relationship between them. Gonorrhoeal rheumatism
has also occasionally preceded rheumatoid arthritis, but Ord and
Hutchinson are probably correct in regarding that affection as a
variety of rheumatoid arthritis.[247]
[Footnote 245: _Loc. cit._, p. 208, foot-note.]
[Footnote 246: _Loc. cit._, p. 334, foot-note.]
[Footnote 247: _Trans. International Med. Congress_, vol. ii. p. 92;
_Brit. Med. Jour._, 1881, p. 158.]
Cold, especially when prolonged and associated with dampness, is
commonly held to be the most common cause of general rheumatoid
arthritis. A protracted residence in low, damp dwellings, deprived of
the sun's rays and of a free circulation of air, is a condition thought
most favorable to the provocation of this disease, perhaps years after
the condition has been done away with.
{91} Poverty and all that it implies are at least frequent antecedents
of the disease (hence one of its epithets, arthritis pauperum), as are
other debilitating influences, such as night-watching, insufficient
food, mental worry, grief, anxiety, etc. Be it remembered, however,
that the disease is frequently observed in the well-to-do, who live in
dry climates and warm houses, are well fed, and want for nothing; so
that the external conditions first mentioned are not essential causes
of the disease, and many of them may act merely as adjuvants.
Direct injury of a joint from a blow, a fracture, a whitlow, etc. may
sometimes induce a local rheumatoid arthritis, which may subsequently
become multiple and involve several articulations more or less
symmetrically.[248]
[Footnote 248: Vide Charcot's and Ord's cases, _loc. cit._]
The partial form presents some peculiarities of causation--thus: it
occurs chiefly in advanced life (senile arthritis), much less
frequently in middle life, very exceptionally in the very young. Men
are much more liable to it than women. It is chiefly this variety which
follows injuries, blows, dislocations, pressure, etc., and the disease
may then be limited to the injured joint and be monoarticular, or it
may extend and become polyarticular, or rarely, as in Ord's case, even
general. This monoarticular form appears to be sometimes induced by
other local irritations of the articular structures than those
following traumatic influences; and as foreign growths in joints and
gouty irritation may respectively induce the lesions indicative of
rheumatoid arthritis, so, it is probable, may simple chronic
rheumatism; and this may be the true relationship existing between
these several affections. It is doubtful at present whether purely
local irritation or injury of a joint can originate the alterations
belonging to rheumatoid arthritis--that is, in the absence of all
predisposition to that disease or of the arthritic diathesis. Cold and
dampness are generally admitted to be causes of the partial form, but
the evidence on this point is not altogether satisfactory. It may be
that chronic articular rheumatism is induced by the prolonged operation
of damp cold, and that the prolonged rheumatic irritation, aggravated
by constant use of the joint and by occasional violence, ultimately
superinduces the profounder alterations characteristic of arthritis
deformans. It appears highly probable that if the predisposition exist,
any long-abiding irritation of a joint, whether the result of violence
or disease, may ultimately originate the alterations of the cartilages
and bones which obtain in rheumatoid arthritis.
As regards the etiology of Heberden's nodosities, and their relation to
other affections of the joints, the following summary must suffice:
They obtain chiefly in advanced life, but do occur rarely in the young;
they are probably somewhat more frequent in women than in men; although
more frequently seen in the upper classes, the poor are not exempt from
them, no doubt because they are specially exposed to slight but
oft-recurring injuries of their digits, such traumatism being an
exciting cause of the disease, especially when confined to a single
joint. The affection is sometimes hereditary; both it and the general
or the partial forms of rheumatoid arthritis may coexist in the same
family and even in the same person. The alterations in the joints are
identical with those found in the general variety of rheumatoid
arthritis, and exist without {92} deposits of urate of soda (Charcot).
It resembles the general form of the disease just mentioned in its
tendency to involve many symmetrical articulations at the same time,
and the partial form in the rarity with which it extends beyond the
joints first attacked. While Heberden's nodosities, as Haygarth taught,
do occur independently of gout and the gouty habit, I believe with
Begbie[249] and Duckworth[250] that in some persons they are evidences
of gout or the gouty diathesis.
[Footnote 249: _Contributions to Practical Med._, 1802, p. 29.]
[Footnote 250: "On Unequivocal Gouty Diseases," _St. Bartholomew's
Hospital Reports_, vol. xvi., 1880, p. 190.]
Quite recently a woman aged forty-eight consulted me with these
nodosities beginning upon the last joint of the fingers, while she was
the subject of vesico-renal irritation and was passing free uric acid
in the urine. Hutchinson has twice seen them in combination with a
peculiar insidious and painless inflammation of the iris and vitreous
body, which occurs in the children of the gouty, yet such children have
no deposits of lithates in their joints, nor any lithiasis, nor acute
paroxysms of true gout, and he considers that "the last joint arthritis
is to be regarded as in part gouty, and in part a kind of articular
chilblain."[251]
[Footnote 251: _Trans. International Med. Cong._, ii. p. 96.]
Lastly, in some instances they are no doubt the hybrid offspring of an
inherited tendency to both gout and rheumatoid arthritis.
No more important principle in pathology exists than has been of late
years insisted upon, especially by Jonathan Hutchinson and in his
recent lecture by Sir James Paget[252]--to wit, that "by inherited
dispositions, accumulating and combining or converging in definite
proportions, new diseases may be developed and old ones be variously
modified."
[Footnote 252: _Lancet_, ii., 1882, 1017-1021.]
The pathogenesis of rheumatoid arthritis is the subject of differences
of opinion very like those existing in regard to acute articular
rheumatism. The weight of evidence is in favor of its diathetic
relationship to rheumatism; and the doctrine of an arthritic diathesis
and of the operation of the causes of the disease through the nervous
system appears to be specially applicable to it, with less difficulty
than to acute rheumatism, and the probability of a specific germ being
its true cause is very remote. What seems to be necessary in addition
to the preceding is, that the causes shall be more persisting and
oft-recurring, so as to maintain a prolonged local irritation of the
articular tissues, or that the neuro-arthritic diathesis shall be
highly developed. Under these conditions the prolonged or oft-repeated
application of cold and damp to the peripheral nerves, severe or
oft-repeated slight injuries to joints, urethral or ovario-uterine
irritation, chronic gout or rheumatism, or even, exceptionally, an
attack of the acute form of these diseases, may originate rheumatoid
arthritis; and all wearing influences, such as anæmia, excessive
menstruation, prolonged lactation, innutrition, failing health, mental
anxiety, or shock, etc., act as adjuvants in the development,
aggravation, and maintenance of the articular disease.
DIAGNOSIS.--It is perhaps not possible to distinguish with certainty
either the acute or the chronic form of rheumatoid arthritis from
subacute or chronic rheumarthritis respectively before the
characteristic deformities of the former affections have appeared.
Acute rheumatoid arthritis, which is comparatively rare, may be said to
exist, rather than subacute {93} articular rheumatism, if the disease
affect early and chiefly the smaller joints of the hands and feet alone
or along with some of the larger articulations, especially the
sterno-clavicular or the temporo-maxillary; if the effusion into the
joints be abundant; if inflammation persist in the articulations first
involved, notwithstanding the invasion of other joints; if the heart
escape; if the patient be a female who is constitutionally delicate, or
has borne children rapidly, or is the subject of disordered
menstruation, or has been attacked soon after childbirth or during
lactation;--finally, if, on cessation of the attack, one or more of the
joints remain swollen and permanently enlarged and impaired in
function. The coexistence of iritis, or a history of a previous attack
of that disease not attributable to syphilis or gout, would strengthen
the above view.
Precisely the same considerations serve to distinguish chronic general
or polyarticular rheumatoid arthritis from chronic articular
rheumatism, with the following qualifications: endo- or pericarditis is
not of frequent occurrence in chronic rheumatism, so that this
distinction is not available, and chronic rheumarthritis of long
standing does sometimes impair the movements of the joints, and even
produce slight alterations in them. However, it does not, as a rule,
involve so many joints as rheumatoid arthritis; it is less symmetrical
in its distribution, and much less prone to implicate the
sterno-clavicular, the temporo-maxillary, or the vertebral
articulations. Nor does it cause removal of the articular cartilage,
enlargement of the heads of the bones, and the formation of osteophytes
around them, and of loose bodies in the articulations, together with
marked deformities and luxations of the joints. A history of a remote
or recent attack of acute rheumarthritis or of chorea, or the presence
of chronic valvular disease, would strongly indicate the simple
rheumatic nature of the case.
The partial form of rheumatoid arthritis can with even less certainty
than the general be distinguished from chronic articular rheumatism
before the characteristic alterations of the joints have been
developed, more especially as it is sometimes a consequence of gouty
irritation and probably of chronic rheumatism. Chronic arthritis
following a traumatic cause, and persisting obstinately in the injured
joint is probably rheumatoid, if not strumous, gouty, or periarthritic.
But before definitely deciding it will be prudent to await the
development of some of the characteristic alterations of structure
appertaining to rheumatoid arthritis. An affection of the shoulder
frequently occurs which resembles in many respects rheumatoid
arthritis, and has been well described by Simon Duplay[253] and W.
Pepper.[254] It usually follows an injury, such as contusion, sprain,
etc., of the joint, but may be spontaneous; it is unattended by
swelling or deformity. Its early symptoms are pain on pressure of the
shoulder a little below the outer border of the acromion, and
especially behind it and at the coracoid process, also about the
insertion of the deltoid and below the acromion during movements of the
joint, especially when the arm is raised from the side or rotated
inwardly; early restriction of these movements, which increases till a
fibrous ankylosis becomes established and scapula and humerus move
together as one piece, motion between those bones no longer existing,
and forcible attempts to produce it giving great pain, and sometimes
producing {94} crepitus in or about the articulation; sometimes early
numbness and pain down the member to the hand in the course of the
ulnar, internal cutaneous, or the radial nerve; vicious and painful
semiflexion of the elbow; after a time wasting of the group of muscles
which move the shoulder-joint. Although usually monoarticular and of
traumatic origin, I have seen it affect first one and then the other
shoulder in the absence of any known injury, and beginning like a
neuritis or a neuralgia of the scapulo-humeral nerves. Duplay, however,
regards it as a periarthritis. It may be distinguished from the
rheumatoid arthritis by the absence of effusion into or enlargement of
the articulation, and of deformity of the bones; by the early
restriction of the movements and the rapid development of adhesions
which fix the articulation; and by the curability of the disease.
[Footnote 253: _Archives Générales de Méd._, Nov., 1872, pp. 512-542.]
[Footnote 254: _Archives of Med._, Oct., 1880.]
The articular affection of locomotor ataxia sometimes closely resembles
monoarticular rheumatoid arthritis,[255] but may be distinguished by
its sudden invasion, often without pain or fever; the prompt
development of a general and often enormous tumefaction of the entire
member, with copious effusion into the joint; the early destruction of
the articular cartilages, the rapid wearing away of the heads of the
bones, and the proneness to spontaneous fracture of their brittle
shafts; the prompt absorption of the articular effusion, followed by a
relaxed state of the ligaments and a facility of dislocation; the early
occurrence of the articular affection, when motor inco-ordination is
scarcely developed, and its frequent association with the crises of
ataxia or the presence of some of the other symptoms of that disease.
The importance of these facts will be especially evident in those
examples of ataxic articular disease in which, at an advanced stage,
eburnation and deformity of the articular surfaces, with the formation
of loose bodies and osteophytes, are observed, just as they are in
arthritis deformans.
[Footnote 255: Charcot's _Lectures on Diseases of the Nervous System_,
Syd. Soc., 1877; _Archives de Physiologie_, t. i., p. 161, 1868;
_ibid._, xi., 1869.]
Articular disease closely allied to what occurs in locomotor ataxia is
now and then observed in the early stages of progressive muscular
atrophy,[256] but while the large joints, more particularly the knee
and the shoulder, suffer in the former affection, the phalangeal
chiefly and the larger articulations more rarely are attacked in the
latter. Of course the peculiar symptoms of progressive muscular atrophy
coexisting with those of the articular affection would serve to
distinguish the latter from rheumatoid arthritis.
[Footnote 256: Remak, _Allgem. Med. Central. Zeitung_, March, 1862;
Rosenthal, _Clinical Treatise on Diseases of the Nervous System_,
translated by L. Putzel, M.D., 1879, p. 286.]
It is often very difficult to say whether a given case is one of
chronic rheumatoid arthritis or of chronic gout; and there is no doubt
that in England, where gout prevails, it is not unfrequently associated
with rheumatoid arthritis, sometimes preceding and even causing it,
much more often following it, for the one does not exclude the other.
While rheumatoid arthritis most frequently begins in the hand, and is
usually symmetrical and bilateral, gout commonly begins in the lower
extremities, and especially in the metatarsal joint of the great toe,
and of one foot only. Chronic gout is far more frequently preceded by
attacks of acute gout than chronic rheumatoid arthritis is by the acute
form of that affection; a history of inherited predisposition, of
indulgence in the {95} use of wine, ale, porter, and of animal food, of
deficient bodily exercise, with perhaps great mental occupation or
anxiety, of recurring gouty dyspepsia or of a tendency to lithiasis,
would indicate gout, while the absence of these and a history of
frequent exposure to cold and wet, of injury to the joint, of previous
exhausting disease or drain, of impaired health, debility, or poverty,
would strongly imply rheumatoid arthritis. Gout is especially observed
in males over thirty, and very rarely in children; general rheumatoid
arthritis is chiefly a disease of females during menstrual life, and
occasionally occurs in children of either sex.
The partial form is, like gout, chiefly a disease of men, but occurs
generally at a more advanced age than gout. Even chronic gout is more
or less paroxysmal, with distinct intermissions; chronic rheumatoid
arthritis is more or less abiding and progressive, with only remissions
in its course and severity; the former is frequently associated with
chronic renal disease, the latter is not. The urate-of-soda deposits
about the articulations in gout appear as more or less round or ovoid
swellings in the close vicinity of the joints, but not observing their
exact level or their general form; softish when recent, they never
acquire a bony hardness, and are nearly always capable of slight
lateral movement. The skin covering them is frequently stretched and
glossy, and may exhibit white spots of urate of soda. The articular
nodosities in chronic rheumatoid arthritis are actual osseous
enlargements of, or outgrowths from, the articular surfaces, forming
part of them, immovable and conserving more or less their form. The
integument covering the nodosities is not glossy or dotted with
chalk-like specks. The several types of deformity of the fingers
previously described, and mainly produced in rheumatoid arthritis by
muscular contractions and altered shape of the articular surfaces, are
not seen in gout. Finally, if chalk-like concretions are visible in the
ears, joints, or finger-ends, or if the blood contain uric acid, gout
is present. While rheumatoid arthritis and chronic gout occasionally
coexist in the same patient in England, in Canada, where the latter
disease is comparatively rare and the former quite common, the writer
does not remember to have observed such coexistence.
Besides the acute syphilitic disease of the joints already alluded to
as occurring in children (inherited), a chronic arthritis is observed
in the adult amongst the very late lesions of syphilis. It is usually
monoarticular, affects the larger joints, especially the knee, and may
originate either in the synovial membrane or in the bone and
periosteum. In syphilitic synovitis the history of the case, the
existence occasionally of soft gummy tumors in the periarticular
tissues and of hydrarthrosis, the trivial degree of pain and
tenderness, the insidious invasion and chronic course of the affection,
and its prompt relief by antisyphilitic remedies, will indicate the
nature of the case.
When it originates in the bone and periosteum, although the invasion
may be prompt and the pain at first severe, the latter usually
moderates greatly and becomes nocturnal, and the articular surfaces
present localized rather than general enlargement (hyperostosis); nodes
often coexist; effusion is moderate, unless the synovial membrane is
also involved, and full doses of iodide of potassium will soon afford
relief.
PROGNOSIS.--In the polyarticular form the course varies much more than
is commonly believed, and the disease must not be regarded as
necessarily {96} progressive and incurable. When it occurs in young
persons, and in children more especially, although it may suffer
exacerbations and remissions for a few years, yet arrest of the disease
and recovery of the functions of the joints, sometimes with very little
deformity, now and then take place under suitable management. Quite
recently a man of thirty-two consulted me about a vesical affection who
from the age of eight had suffered every winter for twenty years from
rheumatoid arthritis in his hands and feet, and finally in the knees.
Yet when seen by me he had been free from pain in his joints for three
years, and, although they were somewhat deformed, their movements were
remarkably free and painless.