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·MANUAL OF
Rheumatic Diseases
by
IV PAUL IIOLBROOK, M.D
DONALD F. HILL, MD.
Tucson, Arizona
with the assistance of
CHARLES A L. STETNENS, JA, MD
y,b
The YEAR BOOK PUBLIS11ERS, Inc
900 EAST ILLINOIS STREET, CHICAGO

·COPYRICHT 1950 BY YEAR BOOK PUBLISHERS, INC. PRINTED NUSA.

·THIS BOOK is respectfully dedicated to the gencral practitioner, for it is he who first sees thesc patients with chronic arthritis and has the opportunity to prevent crippling and deformity This sllustrated manual has been prepared in the belief that it may provide hope and better care for the seven millon victims of chromc thcumatism in the United States.

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·Preface IN TINS nook an attempt has been made to simplify and condense the practical information on rheumatic diseases so that it can be used quickly and easily as a guide to diag.. nosis and treatment by any interested physician Large lab. oratories and well equipped hospitals are not requred to carry out most of the simple basic routine described here Procedures of office and home practice are emphasized No cffort has been made to write a documented scientific treatise It is not intended to cover all aspects of all shenmatic diseases nor to discuss in detail the rare forms. Theories have largely been omitted. The reader seeking more detail or references to orginal articles should consult larger texts on the subject The Rheumatison Review prepared by the American Rheumatism Association usually appears in the Annals of Internal Medicinc every two years It is an excel fent current reference We are indebted to Mrs. Edna McCarthy, physical therapist, for her assistance in developing useful prevention and correction technics and to Il D Voore and F O. White for providing much of the photographic material used in Chapter 9 W.PH D.F.13. 7

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·Table of Contents 11 15 15 36 45 50 53 56 59 1 The Problem of Arthritis and Rheumatism 2 Rheumatoid Arthritis Diagnosis Treatment Cold Therapy 3 Itheumatoid Spondylitis Diagnosis Treatment 4 Degenerative Joint Disease Diagnosis Treatment 5 Fibrositis Trentincnt of Generalized fibrositis 0 Couty Arthritis Diagnosis Treatment 7 Collagen Diseases DugnOSIS Treatment 8 Cortisour and Adrenocorturtropluc llormone (ACTIT) Effects in various Diseases CO 71 79 61 82 60 00 92 103 103 TUT more

·10
RIIEUMATIC DISEASES
109
109
110
.
Dosage
Undesirable Physiologic Effects
Clinical Response
Precautions in Use
9. Prevention and Correction of Deformities
Prevention
Correction
Aids to the Cripple
Index
.
117
117
156
171
• 173

·CHAPTER 1 The Problem of Arthritis and Rheumatism THE TERM "rlicumatism" is as old as medicine and has been used for centuries to designate all forms of painful skeletal disturbances, whether joints, muscles, fibrous tissue or nerves were involved "Rheumatism" is still used and is perhaps the best family name to include all rheumatic diseases Current preference, however, is for the expression "arthritis and rheumatism," which simply means arthritis and the other rheumatic discases. Importance --It is estimated that in the United States approximately seien and one-half million people arc suffering from some form of clironic theumatic discase. There fore, approximately 1 in each 20 of our population is affected If the average family consists of four individuals, then more than thirty million people have one member of their family suffering from chronic rheumatısın. According to public health figures, there are twice the number of patients with chronic rheumatism as there arc with heart disease, 10 times as many as have tuberculosis, 10 times as many as have diabetes, 7 times as many as have all forms of cancers and ·12 RHEUMATIC DISEASES tumors and 40 times as many as have infantile paralysis Arthritis and rheumatism cause more years of disabilty and crippling than all accidents combined. Because arthritis only males cripples for a lifetime bruit does not kill, it has failed until recently to stir the interest of the physician and the public sufficiently to do anything about the problem în 1947, approximately $20,000,000 was collected by public subscription for infantile paralysis, about $18,000,000 for tuberculosis and several millions each for cancer and heart disease. These are worthy causes, but in that year not one cent was raised by public subscription for arthritis and rheumatism One seldom read anything in magazines or newspapers or heard mention over the radio of rheumatism or arthritis In the spring of 1918, the American Rheumatism Association, a group of physicians interested in these diseases, and interested laymen formed the Arthritis and Rheumatism Foundation, a nonprofit organization committed to raise money for research into the cause and cure of these diseases, to provide professional and public education and to do everything possible to improve the knowledge and treatment of these crippling diseases. The Arthritis and Rheumatism Foundation's activities, together with recent advances in research on theumatıc diseases, have created an increased public awareness of the problem. With physician and lay support, the hope for an early solution of many of these -roblems is briglit. Since the newspaper and magazine reports of the miracles chieved with cortisone and ACTH, patients and perhaps me plıysicians are apt to neglect the necessary routine rocedures and wait until the miracle drugs are available.

·THE PROBLEN 13 The ansuers to this line of thinking are simple and blunt. 1. No amount of magic medicine, if it were available, kould restore destroyed joints nor correct deformities. 2. Enough cortisone and ACTII cannot be obtained from present sources to be available for general use, cven if the price were low enough 3 Next to nothing is known about long-time administration or the totic effects that may be produced by administration of these drugs. 4 Nothing is yet known regarding the mechanism of action in relieving rheumatic diseases. 5 Synthetic products offer hope, but not immediately 6. The lightest hope lies in the remarkable and dramatic value of cortisone and ACTI as rescarch tools It is possible with these substances to produce remissions in the disease at will, and when sufficient research work has been done the mechanism of the remission wall undoubtedly le revealed Unfortunately, that may not come this year or next. 7. Each day that crippling arthritis crists, destruction of joints and deformity is slowly progressing It is therefore essential now to do cs erything possible to present deformity, to maintain joint motion and to do the many helpful things that can be done for the patient if he is to lxenefit ultimately from the specific cute ulic it is available CLASSIFICATION This classification of diseases of joints and related structures is taken from the one adopted by the American Rheumalism Association 1 Rheumatoid arthritis a) of peripheral joints ·14 NIEUMATIC DISEASES b) of spine-rheumatoid spondylitis 2. Degenerative joint disease (osteoarthritis, hypertrophic arthritis) a) localized b) generalized 3 Fibrositis a) localized b) generalized 4. Arthritis due to yout 5 Arthritis due to specific infections, es, gonococcic, tuberculous, pneumococcic, syphilitic, brucellar, typhoid, meningo coccic, suppurative, Haverhill (rat bíte) fever, dysenteric, mycotic (coccidioidomycosis) and others 6. Arthritis due to rheumatic fever 7. Arthritis due to trauma 8 Neurogenic arthropathy 9 New growths 10 Hydrarthrosis, intermittent 11. Miscellaneous diseases, e.g., disseminated lupus erythematosus, polyarteritis, scleroderma, drug intoxication, serum sickness, hemophilia, purpura, acromegaly and hystería. This classification may seem quite cumbersome and cona fusing, but actually approximately 9ăxper cent of all chronic rheumatism is covered by the first four headings, i e., rheumatoid arthritis, degenerative joint disease, fibrositis and gout, and it is these four that will receive chief attention in the following pages.

·mopedy CHAPTER 2 Rheumatoid Arthritis OF ALL TIIE RUIEUMATIC DISEASES, rheumatoid arthritis is perhaps the greatest crippler and our most difficult therapeutic problem. It is a constitutional disease which manifests Itself as a profound systemic disturbance and by chronic, deforming, progressive polyarthntis There is no known single cause and no single specific cure DIAGNOSIS Once the discase is well established the diagnosis is usually not difficult. The characteristic picture of chronic polyarthritis, with soft tissue swelling, pain and tenderness in the proximal interphalangeal and metacarpophalangeal joints, the wrists, clbows, knces, ankles and metatarsophalangcal joints, or any combination of these joints, is almost diagnostic. These changes are usually associated with scakness, muscle atrophy, evidences of constitutional illness, flexion deformities, rapid sedimentation rate, demineralization of adjacent bone and cartilage loss The onset of rheunatoid arthritis may be insidious or as acute as that of heumatic feser Diagnostic difficulties usually present them- 13 ·16 RIIEUSTATIC DISEASES selves in the early or minimal stage of the disease process. Diagnostic points in theumatoid arthritis (peripheral) - 1 In 95 per cent of individuals who have theumatoid arthritis it develops after the age of 16 (approximately 5 per cent occurs in children), 2. Onset of rheumatoid arthritis is insidious in approximately 90 per cent and acute or subacute in approximately 10 per cent. 3 Prouimal interphalangeal, metacarpophalangeal, wrists, metatarsophalangcal, knees, elbows and ankles are the joints most likely to be involved and in that approximate order of frequency (Figs. 1--12). However, any joint may be involved. 4. Swelling around the joints is soft and there is usually marked tenderness to firm pressure over the joint. 5. More than one joint is usually affected, and involvement is often symmetrical. Single joint involvement is seen occasionally and occurs in atypical rheumatoid arthritis or in the very slow, insidious form of the disease. 6 Usual constitutional symptoms are fatigue, loss of appetite, low grade fever, loss of weight, nervousness and depression. 7. Weakness is ont of all proportion to pain, joint disease or muscle atrophy Test grip, using two of the examiner's fingers, is often conspicuously reduced even early in the disease (Fig. 13, p. 22). 8 Circulatory disturbances are frequently noted in the form of cold clammy hands and feet and "liver palms." 9. Painful stiffness is present especially after rest and is an almost constant feature of the disease it is more painful and its character is diferent from the stiffness occurring in fibrositis and osteoarthritis, ·7 Fuc 1 ftop left) -Early sheumatoid andsfis. Sote atacarpophalanges! swelling * (trap nghe Early Cus:furt anges in proximal intcrplutangcat Fen 3 (bottom) Alore vivenged stage, with arusts, metacarpophulaogeal and portmal interphalangeal points involved and Irginaing dclorrasty

·FIG. 4 (top) - Rheumatoid arthritis, with characteristic wrist flexion and
ulnar finger deviation.
FC 5 (bottom left) -Knee involvement, with swelling and atrophy.
FIC 6 (bottom right).-Same case as preceding, showing pronounced
atrophy of the quadriceps muscle.
18

·Fic 7 (top) -Theumatoid arthritis of only a few months' duration, but
with musclo atrophy already deseloped.
Fic. m) -Typical ankle and tarsal involvement
10

·Wrist Fic 9 (top) - Rheumatoid arthritis with conspicuous thickening of the Fic. 10 (bottom) -Advanced arthritic deformity, subluxation and disarticulation of the fingers 20

·ATT
il trpi - Altenutoid arthusts, with churacteristte de foruts of the
metacarpiplalingral prints
Fr. 12 bottomiLong-standing disease, with alreply of the interos
Mak
21

·22 RHEUMATIC DISEASES 10 Muscle atrophy is always present quite early and increases with activity and duration of the disease. It is seen well in the interossei (Fig. 12) and quadriceps muscles (Fig. 6). 11. X-rays made late in the disease are diagnostic but are seldom helpful in early stages. Figures 14–28 show the changes from normal to early disease as compared with ad- Fc 13 - Test grip, a valuable indicator in the early stages of rheumatoid arthritis. Here there is no deformity (the disease is in an early stage), but grip is weak vanced changes. Absence of positive x-ray evidence does not rule out early rheumatoid arthritis. Subcortical cysts or areas having a punched-out appearance are common in rheumatoid arthritis, they are often misdiagnosed as gout (Figs 29 and 30, p. 29). 12 Anemia is nearly always present once the disease is well established. The anemia is microcytic and hypochromic (low color index). Although it resembles an iron deficiency ·REUMATOID ARTHRITIS 23: anemia, the response to iron is not ordinarily satisfactory. 13. The erythrocyte sedimentation rate is almost always increased if the disease is established and active. Rarely, one sees a patient with active rheumatoid arthritis who has a normal sedimentation rate. It is well to ascertain which method is being used to determine the sedimentation rate because the normal value varics with each method. 14. Spontaneous remissions and exacerbations are said by some workers to be the natural course of the disease This statement is misleading It is perfectly true that patients tend to have cycles of Ixeing better and worse, but once rheumatoid arthritis is definitely established, complete, 100 per cent spontaneous remissions are extremely rare Continuous chronic involvement of joints since the onset of the disease, without a single period in which there was 100 per cent recovery, is a strong point in favor of the diagnosis of rheumatoid arthritis. 15 Loss of motion, particularly of the wrists, and loss of full ferion of the fingers may suggest carly rhcumatoid arthritis Differential diagnosis -The following conditions may be confused with and should be distinguished from rheuma. toid arthritis 1 TIETNATIC FEVER -Typical rheumatic fever is a shortterm discase, without joint sequelae Usually in thcumatic fever the carditis, the migratory joint disturbances, the history of a respiratory infection and dramatic response to salıcı lates make the diagnosis relatively easy. Ocrasionally, rheumatoid arthritis of acute onset cannot immediatelt be differentiate with certainty from theumatic fever Close observation, hos escr, for a week or two will almost certainly

·Fig. 14 (left) - Normal hand
Fic 15 (center and right) -Early theumatoid arthntıs, showing
juxta-articular demineralization

·Fr. 16 left) Rs 13 atur sathnt et fimiley established Curtilage de sinucim k 37.95€ s narist in the canals FIL! (irri-lds stage **th xuyuration of the pretui atimahulogeNaints anul alınant teie bucklestity of the canals 1idelt- dameul Telanga and typical otu atas the carpal and beads of these woornals

·FIG 19 (top left) - Normal knee, anteroposterior projection.
F105 20-22.-Early rheumatoid arthritis, showing gradual increase
deaineralization.
28

·Fic. 23 (ton) - Yormal knee, lateral pmjection
FS 24 AND 25 (bottom) - Farly reunatot artlintis, simning dernit
tralization

·Fig. 19 (top left) - Normal knee, anteroposterior projection,
Fics. 20-22.-Early rheumatoid arthritis, showing gradual increase in
demineralization.
20

·i FC 23 (top) - Normal knee, lateral projection Fics 24 AND 25 (bottom) -Early theumatoid arthritis, showing demaneralization 27

·Fics 26-28 - Advanced rheumatoid arthritis, showing obliteration of the
joint space, deformity of articulating surfaces and secondary hyprotrophic
changes
28

·들 Foc 29 (left) -Early Theumatoid arthritis, with typical small subcortical cysts FIG 30 (right) --Punched-out areas near the proumal interphalangcal lounts, frequently seen in rheumatord arthritis and often errourously attributed to gout ·80 RULEURIATIC DISEASES settle the diagnosis. In acute rlcumatoid arthritis, fever may be as prominent as in rheumatic fever, ATYPICAL NIEUAIATOID ARTHRITIS.-a) "Palindromic rheumatism" is mentioned here not to establish points of differentiation from rheumatoid arthritis but to emphasize that it is an atypical form of rheumatoid arthritis. Palindromic rheumatism is characterized by suddeirácute attacks of pain and swelling, usually in a single joint, often lasting no longer than 24 hours and ending in complete recovery. These attachs may continue for years without showing any tendency to become chronic, but as a rule the attacks gradually become more frequent until recovery is not complete between the attacks and the disease progresses to chronic arthritis which behaves typically as rheumatoid arthritis. In short, it may be said that palindromic rheumatism is rheumatoid arthritis with a life history much like gout. We have watched a number of such palindromic manifestations progress to typical rheumatoid arthritis. The disease responds to the therapy used for rheumatoid arthritis. b) Intermittent hydrarthrosis. This condition is seen most commonly in the knees, where one or both may become quite swollen without development of any very striking constitutional symptoms and little or no severe pain. These swellings may come and go once or more times a year, with complete recovery between attacks. Again, as in palindromic rheumatism, the swelling usually becomes chronic and may even persist in a chronic form for several years before other joints are affected or the full symptoms of rheumatoid arthritis appear in these patients, if watched for a long enough time, typical rheumatoid arthritis will usually develop, and it is our conviction that this is another form of atypical ·RHEUMATOID ARTHRITIS 31 to rheumatoid arthritis. Therapeutic procedures are identical with those for rheumatoid arthritis. c) There are other bizarre and atypical forms, for rheumatoid arthritis is a constitutional disease, but the diagnosis can usually' bo'made if it is included in the differential diagnosis 3 PSORIATIC ARTHRITIS.-Authorities disagree as whether there is a definite, specific syndrome of psoriatic arthritis or whether there is simply an association of the two diseases. Certainly one sees many patients with rheumatoid arthritis who also have psoriasis. We are convinced that when psoriasis develops around a finger- or toenail, with arthritic involvement of the proximal joint and beyond, we are justified in making a diagnosis of psoriatic arthritis. Figures 31 and 32 illustrate nail and joint involvement. In such cases, clearing of the psoriasis often produces dramatic relief from the arthritis. It is only fair to say, however, that even without this particular type of involvement-when the body is well covered with psoriasis-much improvement of the arthritis often follows the clearing of the psoriasis. It is of no great importance whether one wishes to make the distinction of this type of arthritis or not, as the treatment of the joint problem is identical with that of rheumatoid arthritis. It is certainly true that, in addition to caring for the joints, a special effort should be made to clear the skin lesions 4 COLLAGEN DISEASE (lupus erythematosus disseminatus, periarteritis nodosa, dermatomyositis, scleroderma).--Here we must indeed be wary, for these conditions can and do almost exactly simulate early rheumatoid arthritis. Fortunately they are not common and the differential diagnosis can be made if one is alert to the possibility. Multiple system ·30 RILEUMATIC DISEASES settle the diagnosis In acute rheumatoid arthritis, fever may be as prominent as in Theumatic fever. 2. ATYPICAL NIEUMATOID ARTIINITIS.-a) "Palindromic rheumatism" is mentioned here not to establish points of differentiation from rheumatoid arthritis but to emphasize that it is an atypical form of rheumatoid arthritis. Palindromic rheumatism is characterized by sudden acute attacks of pain and swelling, usually in a single joint, often lasting no longer than 24 hours and ending in complete recovery. These attacks may continue for years without showing any tendency to become chronic, but as a rule the attacks gradually become more frequent until recovery is not complete between the attacks and the disease progresses to chronic arthritis which behaves typically as rheumatoid arthritis In short, it may be said that palindromic rheumatism is rheumatoid arthritis with a life Instory much like gout We have watched a number of such palindromic manifestations progress to typical rheumatoid arthritis. The disease responds to the therapy used for rheumatoid arthritis. b) Intermittent hydrarthrosis. This condition is seen most commonly in the knees, where one or both may become quite swollen without development of any very striking constitutional symptoms and little or no severe pain. These swellings may come and go once or more times a year, with complete recovery between attacks. Again, as in palindromic rheumatism, the swelling usually becomes chronic and may even persist in a chronic form for several years before other joints are affected or the full symptoms of rheumatoid arthritis appear in these patients, if watched for a long enough time, typical rheumatoid arthritis will usually develop, and it is our conviction that this is another form of atypical ·RELEUAIATUL ARTHITIS to rheumatoid arthritis. Therapeutic procedures are identical with those for rheumatoid arthritis c) There are other bizarre and atypical fornis, for theumatoid arthritis is a constitutional disease, but the diagnosis can usually bo nade if it is included in the differential diagnosis 3 PSORIATIC ARTHRITIS.-Authorities disagree as whether there is a definite, specific syndrome of psoriatic arthritis or whether there is simply an association of the two diseases. Certainly one sees many patients with rheumatoid arthritis who also have psoriasis We are convinced that when psoriasis develops around a finger- or toenail, with arthritic involvement of the proximal point and beyond, we are justified in making a diagnosis of psoriatic arthritis Figitres 31 and 32 illustrate nail and joint involvement. In such cases, clearing of the psoriasis often produces dramatic relief from the arthritis it is only fair to say, however, that even without this particular type of involvement-when the body as well covered with psoriasis-much improvement of the arthritis often follows the clearing of the psoriasis It is of no great importance whether one wishes to make the distinction of this type of arthritis or pot, as the treatment of the joint problem is identical with that of rheumatoid arthritis It is certainly true that, in addition to caring for the joints, a special effort should be made to clear the skin lesions 4 COLLAGEN DISEASE (lupus erythematosus disseminatus, periarteritis nodosa, dermatomyositis, scleroderma).-Here we must indeed be wary, for these conditions can and do almost exactly simulate early rheumatoid arthritis Fortunately they are not common and the differential diagnosis can be made if one is alert to the possibility. Multiple system ·Fig 31 (top) --Psoriatic arthritis Note the terminal joint of the fourth finger and extension to the proximal joint-typical of the disease Fic 32 (bottom) -Toenail involvement and extension to the joints 32 ·RIEURIATOID ARTHRITIS 33 volvement is the clue to collagen disease When a patient ith minmal joint changes who is systemically all presents de or more of the followmg changes, suspect collagen distse: (a) multiple system involsement, such as natural nit.. on it pas wwe ordinary arthritis, of new symptoms at related to the joints. (For details see Chapter 7 on colgen disease.) 5 DEGENERATIVE JOINT DISEASE (osteoarthris ) -\hen leumatoid arthritis and degenerative joint disease occur in :latively pure form, there is little possibility of confusion garding the diagnosis because of the pronounced differnces between the diseases (see s. 60 for diagnostic points a degeneratie joint disease) One should remember, howver, that late in rheumatoid arthritis or in the elderly on dividual it is quite possible for rheumatord arthritis and degenerative joint disease to coerist In this situation it is almost always the sheumatoid arthritis chat is disabling and deserves the most attention therapeutically "Afired arthritis" as a poor term but is often used with reference to this condition It is better to diagnose rheumatoid arthritis and degenerative joint disease 6 COUT.-Early intermittent gout is most often confused with atypical rheumatoid arthritis, se, palindromic rheumatism (see p 83 for thifferential diagnosis of gout) Chronic gout is frequentis confused with chronic rheumatoid arthritis Although extremely rare, it is possible for a patient to have both gout and rheumatoid arthritis We have followed several such bona fide cases for a number of years 7 SHOULDER-HAND SYNDROME - This distressing condition ·34 NIEUMATIC DISEASES may exist either unilaterally or bilaterally. It is characterized by pain and limitation of motion in the shoulder and pain and often swelling and limitation of motion in the hand and fingers. Atrophy of the muscles and demineralization of bone occur rapidly. This condition, because of the pain and swelling of the fingers, is frequently diagnosed as rheumatoid arthritis. It is commonly associated with, or follows, one of the following conditions, although it may develop without known cause. (a) myocardial infarction, (b) pulmonary infarction, (c) cervical cord injury or disease, (d) cerebrovascular accident, (c) fractures or trauma. The mechanism of production is not clear, but it is thought to be a reflex nerve disturbance. The course is variable. Patients with mild cases usually recover completely on a program of simple corrective exercises and assistive motion, particularly with regard to restoration of shoulder motion. Severe cases are exceedingly chronic and stubborn problems, but they do not progress as rheumatoid arthritis. The swelling in the hands is usually diffuse and not limited to the joints alone. There is often a tendency to the development of fibrous contractions in the palmar area, similar to Dupuytren's contractions. The sedimentation rate is seldom ele. vated. No treatment has been uniformly successful. In our experience, the most important aspect of treatment is maintenance of shoulder motion with the maximal amount of rest in abduction, which tends to reduce the edema and swelling. There is no substitute for careful, daily, assistive and stretching exercises supervised by a competent physiotherapist. Baking and massage have not been effective jn our with hands. Pervertebral sympathetic nerve or stellate block ivith ·RIIEUMATOID ARTIRITIS joint procaine may be helpful in severe and acute cases. Aspire (60-80 gr. daily), a sleeping tablet and, often, codeine sulfate (5 gr. three to four times daily) will be required during early treatment because the pain is severe. "SUBDELTOID BURSITIS" (subacromial bursitis, periarthratis of the shoulder, supraspinatus tendınıtıs, etc ) -See page 74, for a discussion of this condition 9 GENERALIZED FIBROSITIS.There should be no confusion between this condition and rheumatoid arthritis owing to the absence of joint swelling and the lack of any confirmatory evidence of disease from physical, x-ray and laboratory examinations (See p 77 for discussion of generalized fibrosatis.) 10 SPECIFIC INFECTIONS-a) Conococcic arthritis. Since the advent of sulfonamides and penicillin, the occurrence of gonorrheal arthritis has been tremendously reduced and is now seen quite rarely Postgonorrheal rheumatoid arthri. trs, which is seen not infrequently, is most commonly misdiagnosed as gonorrheal arthritis The dramatic response to penicillin, culture of gonococct from the joint Ruid, the low glucose content of the joint fluid (average approximately 030 mg per 100 cc) and the x-ray appearance' usually permit one to make the diagnosis quite accurately. b) Brucellosis This does not commonly cause persistent swelling in any one joint and seldom should be mistaken for rheumatoid arthritis The history of exposure, the severe sweats, the rising agglutination titer and positive cultures for brucella should define this condition clearly c) Pneumococcic arthritis, tuberculous and other septic joint diseases. These are usually monoarticular and easily differentiated ·30 RIIEUMATIC. DISEASES 11. REITER'S SYNDROME - This name has been attached to the symptom complex of urethritis, conjunctivitis, arthritis and sometimes enteritis. Nothing is known with certainty regarding its etiology. It is largely a self-limited disease with spontaneous recovery in three to six months and few or no joint sequelae It has rarely been reported in civilian practice Streptomycin is said to be sometimes effective. 12 STILL'S DISEASE (JUVENILE RHEUMATOID ARTHRITIS) There is no doubt that the symptom complex spoken of as Still's disease is, in fact, juvenile rheumatoid arthritis. There are two quite striking differences between the prognosis 1 juvenile rheumatoid arthritis and that in adult rheumatoid arthritis Mortality from acute juvenile rheumatoid arthritis is high, whereas that from the adult type is very low. The joint disease usually is not so destructive in juvenile rheumatoid arthritis and frequently, if the full basic routine (p.39) is followed in therapy, the outlook is reasonably good. Spon. taneous remissions often occur at or following puberty. Many children recover almost completely and for years in young adult life without serious sequelae or limitations because of the disease. The prevention of deformity and the maintenance of joint motion and muscle tone are of the ut. most importance in this group. (See Chapter 9 for preven. tion of deformity ) go on TREATMENT Most therapeutic efforts in this unhappy disease have been empiric and have centered about whatever concept of etiology the particular physician happened to hold Theo ries of etiology have come and gone more or less in cycles.

·RILEUMATOID ARTHRITIS 3 The focus of infection theory provided a remarkably wide range for energetic removal of foci Teeth, sinuses, tonsils, gallbladders, appendixes and prostates were attacked with enthusiasm When the supply of removable foci was erhausted and the patient had not improved, vaccines were developed in the hope of producing immunity to those foci which were not removable. Bacterial allergy was then implicated and desensitization tried after failure to produce immunity to the disease by vaccines Circulatory disturbances were investigated and indicted because of certain changes described in the nail capillaries and the common finding of cold and clammy hands and feet This was followed logically by the use of vasodilators, like histamine Intestinal toxemia has long been considered a cause of the disease, and all physicians are familiar with the attempts to reduce the absorption of so-called “toxins" from the gastrointestinal tract by means of colonic irrigations, intestinal antiseptics, purging and the implantation of Bulgarian bacıllus. There are those who believe that neuropsychiatric factors have a major etiologic significance in this disease, and it cannot be denied that treatment directed to this concept has been helpful though not curative Some years ago the endocrine systems came in for a period of enthusiastic attention Jíenopausal arthritis appeared in the literature and every type of hormone known at that time was used therapeutically We are now in a period of revival of interest in the endocrine effects, as indicated by the reports of administration of large doses of sex hormones in the treatment of this disease The metabolic concept of etiology is a tremendously wide field but not too well defined, and worthwhile investigations have been er.

·38 RHEUMATIC DISEASES tremely scanty. Some years ago, because the finger-nails of patients with rheumatoid arthritis were found to contain less sulfur than normal, a deficiency in sulfur was suspected, resulting in the administration of sulfur injections to large groups of people. Carbohydrate metabolism was thought to be faulty, hence the rigidly low starch diets. Considerable increased evidence in recent years has led to the belief that rheumatoid arthritis is essentially a discase of a disordered intrinsic metabolism, and much research work is being donc in this field. Actually, it is a sad commentary that after all these years of guiding our therapeutic efforts along proposed etiologic lines, we must admit that, so far as a single specific etiologic factor is concerned, we are as much in the dark as we ever were. Rheumatoid arthritis thus remains a disease without identification of a specific etiologic agent and without a single specific cure. Ironically enough, as will be seen shortly, the measures known to influence the disease favorably have resulted from more or less accidental observations, and the mechanism by which they act is unknown. Because we have no specific cure, most physicians have either become therapeutic nihilists or have contented themselves with trying one therapeutic procedure after another without recognizing the necessity of a really adequate basic program of management. Regardless of our hopes for a specific cure which may come in the not too distant future, rheumatoid arthritis in the meantime will continue to develop progressive crippling deformity. It therefore seems especially appropriate at this time to emphasize the necessity of establishing every patient with theumatoid arthritis on a basic routine as the first step in the successful management of the disease. Any specific therapy that will be devel.

·UIEUMATOD ARTHRITIS 39 oped will not restore destroyed joints, therefore any help that a future cure may provide your patient will depend on how well you maintain him on a basic program of treatment. Such a basic routine must include specific directions by the pluysician on at least the following eight problems Basic routine - This is to be followed for every patient with rheumatoid arthritis 1 Psychologic adjustment is essential for every patient We do not necessarily refer here to professional psychiatry, but we do urge that when the diagnosis is made the physican tell Ins patient frankly and honestly what is known about the disease and what is not known about it No false hopes should be given and no quick cures can be promised The physician's failure to place honestly and thoroughly before the patient the problem he is facing with rheumatoid arthritis is responsible for more patients consulting quacks and quick cures than any other single factor Adjustments with family, children, business and economic status are also essential. Instead of having the problem explained and a full basic program outlined, patients are too frequently told either that nothing can be done for the disease, or "We will try these new injections for a while and see if they help 2. Rest and activity should be carefully balanced on the basis of fatigabılıy and pain Moderate activity is helpful provided the patient is not attempting to walk on beat and painful joints and provided the activity is followed by adequate rest (See Chapter 9 for details) 3. Diet and bowel management must be understood by the patient and presenbed accurately by the physican This is essential not because there are special diets which will cure arthritis but to make certain that the patient is on ·40 RHEUMATIC DISEASES a highly nutritious, well balanced diet; and unless one is prescribed for him he will most certainly at one time or another cmbark on one of the fad diets. Diets in general, so far as caloric intake is concerned, should be adjusted to improve nutrition and weight if malnutrition is present and to achieve a more nearly normal weight if the patient is overweight 4, Correction of ancmia is essential. The anemia of rheumatoid arthritis is the hypochromic microcytic type and is often stubborn in its response to the ordinary treatment with iron, liver, folic acid or vitamin B. When these agents fail to restore a moderately satisfactory blood picture, transfer sions should be resorted to in an effort to maintain the de sired blood level. 5. Cautious removal of foci of infection should be undertaken, not with the promise of curing the disease but to im. prove the patient's general health. Foci of infection in a patient with active acute rheumatoid arthritis should be removed only after careful preparation and preferably after one or two blood transfusions. It is also well to give prophylactic doses of a sulfonamide or penicillin before and after removal of the foci because occasionally removal of foc! without these precautions produces a violent exacerbation of the disease. 6 Corrective and group muscle postural exercises should fye taught carefully and carried out meticulously because they offer both the ambulatory and the bedfast patient an opportunity to maintain muscle tone and joint motion (See the list of exercises, p 145). 7. Relief of pain is usually quite easily accomplished by the administration of aspirin, salicylates, gentle warmth, ·RHEUMATOID ARTHRITIS splinting and support of painful joints and other simple cedures. If opiates are required, the diagnosis should questioned. 8 Prevention and correction of deformity are essent. In every patient with rheumatoid arthritis, the probabila of residual deformity in all involved joints should be antic pated and prevented This problem is so important tha Chapter 9 has been devoted to it. Elective procedures. Once the patient on the basic pro gram of management is established, one is justified m looking about for additional measures that may influence the arthritis favorably The list of so-called cures for rheumatism and arthritis runs into the thousands, and their very numbers are good evidence of the lack of specificity. Among the more commonly used agents which in our experience have been of doubtful value or worthless are vaccines, neostigmine, procaine intravenously, fever therapy, ACS (Bogomolets' serum) and gadget physiotherapy Short wave diathermy, whirlpool baths, paraffin packs, ionization and many other so-called physiotherapy methods are expensive and for the most part worthless in the treatment of rheumatoid arhritis It is our deep conviction that the most valuable hysiotherapy for the patient with rheumatoid arthritis is the raining of his own muscles through carefully directed everses (see Chapter 9) These exercises may be done in ater or on the bed, but trained personnel is required to ich and supervise the patient's own activities He must be taught to use his own muscles Warmth is sometimes helpful, but the intensive bakıng and massage that are so popular, though perhaps comforting at the moment, will keep the disease active and do more ultimate harm than good ·42 PUHEUMATIC DISEASES The basic program already described is essential for every patient with rheumatoid arthritis. The following elective procedures unfortunately are not applicable all at once or to all patients, but may be selected when suitable and should be given consideration from the standpoint of newer concepts in etiology and the possibility that they will ultimately prove the ideal treatment. 1. TRANSFUSIONS.-Patients with acute or subacute theumatoid arthritis often respond well and sometimes dramatically to repeated transfusions of ordinary blood. Transfusions are, of course, also valuable in correcting anemias. We have used in excess of 100 pregnant blood transfusions in patients with active rheumatoid arthritis. The results were vanable. A few patients who had failed to improve materially after usual blood transfusions made rather spectacular improvement after transfusions of pregnant blood. There were, however, failures with the pregnancy transfusions as well Obviously, transfusion of pregnant blood is not a practical method of therapy and has been done by us only as a research problem in studying the mechanism of the remission when it occurs. Our practice is to prescribe ordinary blood transfusions, one weekly, preferably approximately 300 cc, for three to five or six weeks in acute or subacute cases. 2. GOLD THERAPY – The use of gold therapy for rheumatoid arthritis dates back approximately 20 years and, despite the hazards, has increased during this period. There is no question that 40-60 per cent of patients who can take adequate gold therapy will show improvement. A smaller percentage may show a complete remission of the disease. Much is written about the therapy of rheumatoid arthritis with gold, but it must be remembered that theumatoid arthritis ·MEUMATOID ARTIKITIS 43 of peripheral joints is the only form of rheumatism in which It should be used Rheumatoid spondylitis is not usually benefited. Cold may be toxic, and the most careful supervision is required for successful administration. (For details of gold therapy, see pp 45f) 3 CLIMATE.-A small percentage of patients with rheumatoid arthritis experience dramatic improvement with a change to a warm dry climate The majority have no striking change, but are usually more comfortable and with equally good medical care are apt to improve more rapidly than they would in less favorable clsmatic surroundings The chance, however, that a change of climate will help does not warrant disruption of the economic security of a family Climate consists in complex meteorologie factors such as stability of barometric pressure, humidity, altitude, amais concentration - temperat wave found it impossib.. predict which patients with rheumatoid arthritis will be clearly benefited by climate. If a change of climate is to be considered, three to sur months should be planned as a minimal trial period Patients need medical supervision at at times. The advice frequently given patients, "Just go out and bake in the sun," is extremely dangerous Each year patients are seen in deluium from following this advice A systemic reaction on exposure to the sun in dry desert regions can occur without skin burn to guide the length of exposure. A change nate may also entail other considerations: absence from home and business, a scheduled routine of living, time available to make a job of getting well, etc Many of these are important in recovery. I LU ·44 RHEUMATIC DISEASES 4. X-RAY THERAPY,- This is undoubtedly of value is treatment of rheumatoid spondylitis but does not af to be beneficial in the peripheral form of arthritis. 5. PREGNANCY,-Although some would doubt the a ability of including pregnancy among the therapeutic ag for rheumatoid arthritis, it nevertheless has a profounfluence on the disease. Of 96 women with active rheum arthritis observed during pregnancy by us and other per cent showed a remission of the disease during the nancy. We have in a number of instances advised pregn in women with active progressive arthritis which had been altered by other available therapeutic aids. The di is apt to recur following childbirth, but if special ca given the patient and includes rest, small doses of thy extract and a few small blood transfusions, remissions often maintained for several years. Pregnancy is menti not sa much because of its practical applicability but cause, like jaundice, of its strong antirheumatic action. 6. JAUNDICE.-This is not available by clinical pres tion, but it is well known that an adequate attack of jaun may produce a striking reversal of rheumatoid arthritis. 7. CORTISONE AND ACTEL.-Cortisone is a steroid horn produced by the adrenal cortex. It is at present manufact in very small quantities and by a long series of cher processes from the steroid nucleus in bile. ACTH (adre corticotrophic hormone) is produced by the anterior pa tary gland and regulates the activity of the adrenal com This substance is secured at present in very small quant from the pituitaries of hogs. These two substances are newest and most powerful antirheumatic agents so far served. Since the initial dramatic report of Hench, Kent ·RIEURCATOID ARTIRITIS 45 Slocumb and Polley, of the Nayo Clinic, indicating that these substances were capable of reversing the process of theumatoid arthritis, it has been clearly established by us and others that these substances do produce a striking remission and a reversal of the active disease in patients with active rheumatoid arthritis. (See Chapter 8 ) These very observations that rheumatoid arthritis, our most cripplug disease, can be completely reversed and the patient returned to normal under the circumstances of pregnancy, jaundice, gold, cortisone, ACTH therapy, and sometimes transfusions, offer as the brightest possible hope that we shall discover the mechanism of the remission and that further research will uncover a certain and specific treatment and perhaps preventive for rheumatoid arthritis Contrast this with the present irreverssbility of cancer, infantsle paralysis and chronic heart disease Advances are being made in research in all the rheumatic diseases The greatest danger lies in our tendency to put off doing the basic things required for the patient while waiting for the quick cure. The entire field of rheumatic diseases can be understood and reasonably accurate diagnosis can be made hy any physician who will make the effort and spend a reasonable amount of time on the problem Treatment of rheumatoid arthritis has not yet been reduced to specific therapy, but an honest attempt to treat adequately one's patients with this disease will yield a far greater degree of success than is generally supposed. GOLD THERAPY Indications.~Gold therapy is much more successful in early rheumatoid arthritis without much joint destruction ·46 RHEUMATIC DISEASES than in the late stages with destroyed joints. After the basic routine (p. 39) is established, if progress is not made in the first month or two, one may consider the advisability of gold therapy. When the patient's organic status is suitable, except for the arthritis, the risk of gold therapy may be less than that of progressive, uncontrolled joint damage, and gold therapy may be indicated. Results in more than 2,000 cases, collected from the literature and our own experience, indicate that one may expect about 60 per cent of the patients who can take gold without having toxic reactions to show definite improvement. A smaller percentage may show complete remission, Preparations.-There are six or more gold compounds on the market, including gold sodium thiosulfate (Sanocrysin), gold sodium thiomalate (Myochrisyne), gold thioglucose (Solganol-B oleosum), gold sadium succinimide and gold thioglycoanilid (Lauron) Of these products, gold sodium thuomalate and gold thioglucose have been most widely used in this country The gold content of the various salts varies from approximately 37 to 54 per cent. Their solubility also varies, gold sodium thiomalate being insoluble and gold thioglucose soluble in water; our experience has been largely with gold thioglucose and gold sodium thiomalate. Dosage - The routine is 10 mg. of the soluble salt twice the first week and 25 mg. weekly for three weeks thereafter. If the patient is small, the dosage will remain at 25 mg. once weekly. If the patient weighs over 120 lb., it is our custom after three weeks at 25 mg, to increase the dose to 50 mg. weekly. When deciding to use gold therapy one must weigh the possible hazards of toxicity against the serious outlook of the disease.

·RHEUALATOID ARTIRRITIS We do not use the large doses of 100 mg. weekly because of the pronounced increase in toxic symptoms experienced The dosage of 50 mg. weekly should be continued for three to five months at least, provided no touc symptoms appear, before deciding that gold will not be effective If remission or striking improvement occurs and the sedimentation rate drops during this penod, the interval of dosage is increased so that the patient will receive 50 mg. each two weeks With satisfactory improvement in the clinical and blood pictures on this routine, the interval may be increased to once in three weeks Because of the hazards of exacerbations and recurrences of the disease when gold therapy is interrupted, we no longer give gold in courses and stop when a specified amount has been given Many patients who have had excellent remissions on gold may have severe exacerbations a few months after therapy is stopped, and these patients often do not respond so readily to retreatment with gold. Our experience suggests that, once having attained an excellent result and a remission of the disease, maintenance doses every two to three weeks should be continued for at least a year or two and perhaps longer Toric reactions. The mortality rate calculated in over 2,000 cases was 0 39 per cent. Toric reactions of some kind occurred in 32 per cent of this group. The higher the weekly dosage, the more apt the patient is to show toxic effects. The toric reaction most frequently encountered is dermatitis. This may be of any degree, from a mild rash to a severe exfoliative type of dermatitis. Other toxic reactions include ulcerative stomatitis, hepatitis, nephritis, ulcerative colitis, thrombocytopenic purpura, agranulocytosis, aplastic anemia, cerebral involvement and bronchitis. Such ·18 RHEUMATIC DISEASES toxic reactions usually are encountered after several hundred milligrams of the drug have been given, but occasionally they are seen following the initial small dose. Toxic reactions may also manifest themselves weeks after the treatment is completed There is no definite, sure way of preventing sucla reactions. It is possible that liver injections and administration of the vitamin B complex, vitamin C and antihistamines and other general measures are helpful, but they are in no way specific for prevention of toxic reactions to gald. Treatment of toxic reactions.--Because of the overwhelm ing evidence that British anti-lewisite (BAL) was effective in treatment of arsenical and mercurial poisoning, it has been tried in the treatment of gold toxicity by a number of investigators. Many of the toxic reactions to gold are extremely mild and self-limiting on discontinuance of the gold. BAL is an effective antidote to the gold toxicity, if given early. If the gold reaction is severe, either a severe dermatitis or one of the other serious evidences of toxicity, BAL should be given early and in adequate doses. One hundred milligrams should be given intramuscularly as the initial dose and, if there is no unfavorable reaction, followed four hours later with 200 mg, and, again if no serious reaction occurs, repeated to a total of 800–1,000 mg. during the first 24 hours, The duration of treatment depends on how rapidly the evidence of toxicity clears. BAL itself may produce some toxic reactions, occasionally causing urticaria, abscesses at the site of injection and nausea and vomiting. We have found ACTII highly effective in blocking or relieving the skin manifestations of gold toxicity; so, if available, it is the treatment of choice. Contraindications to gold therapy.-Gold therapy should ·RHEUMATOID ARTTIRITIS 49 be avoided in the presence of severe diabetes, nephritis, ulcerative colitis, hepatic insufficiency, blood dyscrasias, a history of exfoliative dermatitis, rheumatic fever and dissem. inated lupus There are undoubtedly other contraindications Precautions in use of gold.-Before giving each injectron, look for rash, purpuric spots, stomatitis, albuminuria, microscopic hematuna and any unusual symptom which the patient may report 2 Check every two or three wecks for leukopenia, low platelet count and changes in the hemoglobin content and differental count 3 Do not give gold unless you are familiar with the bad results it is our conviction that this is one injection which the physician should give and not delegate to 2 nurse.

·CHAPTER 3 Rheumatoid Spondylitis RIIEUMATOID SPONDYLITIS is also known as Marie-Strümpell disease, spondylitis ossificans, spondylitis ligamentosa, anky. losing spondylitis and spondylitis rhizomelica. This form rheumatism is important because it is the most frequently misdiagnosed condition among the rheumatic diseases. The failure to diagnose it properly is due almost entirely to failure to consider it as a possibility, because the diagnosis is quite easy once it is thought of. There is wide difference of opin. ion as to whether rheumatoid spondylitis is actually rheumatoid arthntis with a predilection for the spine or whether it has some additional variant and should be considered a separate disease. There are three arguments for considering it a separate disease. (1) The sex incidence is approximately 9 males to 1 female, whereas peripheral rheumatoid arthritis roughly involves 3 females to 1 male. (2) Gold therapy is not effective, whereas in peripheral rheumatoid arthritis it may be effective. (3) X-ray therapy is effective, whereas in peripheral rheumatoid arthritis it is not. Two arguments favor its classification as theumatoid arthritis. (1) In approvímately 25 per cent of the patients peripheral joint changes develop that arc indistinguishable from those of rheumatoid 50 ·RHEUMATOID SPONDYLITIS 51 arthritis. (2) The pathologic changes in the lateral articulations of the spine in rheumatoid spondylitis are similar if not identical to those in the peripheral joints in theumatoid arthritis. In its late stages rheumatoid spondylitis us so characterzstic that the diagnosis is obvious. The young man with a stiff back who tends to protrude the head and develop wagon-wheel deformity, walking with a waddling gait, often with hip and shoulder limitation, sometimes with fixed distortions of the pelvis or spine, presents the late picture of this disease (Figs. 33–35). The onset may be acute (15 per cent) or insidious (85 per cent) The early symptoms are nearly always misdiagnosed Frequently fibrositis, lumbago, lumbosacral strain, sciatica or muscular rheumatism is diagnosed in the early insidious type of onset. In a high percentage of cases the first complaints are referred to the lower part of the back and consist of periods of aching or stiffness, transient sciatica and difficulty in bending forward to pick up objects from the floor In some cases these symptoms are intermittent, with complete freedom between attacks for a number of months or years In others the symptoms continue to increase slowly and the patient begins to notice that coughing, sneezing, turning himself in bed being jarred during a ride over a rough road produces pain, often low in the back and frequently in the nb cage General constitutional symptoms develop, of which weight loss is the most constant and dramatic. Many patients lose from 20 to 60 lb, in a few months or a year. There are fatigability, loss of appetite, sometimes low grade fever. During this stage ordinary anteroposterior and lateral x-rays of the lumbar region of the spine usually reveal no evidence of or

·water
Fics 33-35 – Rheumatoid spondylitis. Late effects, with peripheral joint
involvement, malnutrition, flexion deformity of the spine, fired nb cage and
striking muscle atrophy.
52

·RHEUMATOID SPONDYLITIS 53 disease, but x-rays of the sacroiliac joints will almost always reveal changes that are characteristic of the disease (Figs 42-45, p. 57). As the disease progresses upward from the lumbar region to the dorsal and cervical areas, flattening of the chest and fixation of the costal cage occur Vital capacity is markedly diminished. Because of the collapse and fixation of the costal cage, the head tends to pull forward and the neck develops a characteristic deformity and loses motion The deformity may start in flexion and often goes into hyperextension, compensating for the flexion in the dorsal region of the spine The shoulders and hips are frequently involved, with gradual decrease in motion, and flexion deformity is hkely to develop in the hips Early diagnosis is essential, for it is only then that treatment can prevent these deformities DIAGNOSIS The following obserwilons should Icad to correct diagnosis 1. Rheumatoid spondylitis should be suspected in any young man who has recurrent low back pain, sciatica or lumbago 2 Excessive loss of weight with vague symptoms of muscle or joint pain should suggest rheumatoid spondylıtıs 3 Pain low in the back or in the chest on coughing or sneezing and difficulty in turning over in bed are typical symptoms of rheumatoid spondylitis 4. Limitation of motion of the lumbar spine and flattening of the lumbar curve usually occur early (Figs. 36-39) There may also be limited chest expansion (Fig 40) Tenderness and spasm of lumbar muscles are usually present ·Fics. 36 AND 37 (left top and bottom) - Rheumatoid spondyltis, early stage. Appearance is normal until flexion of the spine is attempted, when straight back is easily poted Fics 38 AND 39 (right top and bottom) -Moderately advanced stage Some deformity is apparent in upright position; the lumbar curve is flattened on flerion. 54 ·Fic 40 (top) - Rheumatoid spondylites The chest looks normal, but Datual change from forced expiation to forced inspiration was only k in. ndicating fuzation of the nb cage Fic, 41 (bottom) -Chest compression sign It is positive when dorsal ertebrae are involved It may be eliested easly, before there is much imita. en of the rib cage 53

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·CHAPTER 4 Degenerative Joint Disease DEGENENATIVE JOINT DISEASE, or osteoarthritis or hypertrophic arthritis, is actually not so much a discase as it is a wearing out of tissue. The mamfestations may be observed in either of two forms. 1 The localized form may occur at any age and is sec ondary to major trauma, faulty structure or previous joint infection. The symptoms are localized and usually the diagnosis is easily made on the basis of the history and clinical examination and roentgenographic studies of the affected joint. 2 Generalized degenerative joint disease often involves the spine, knees and hips or other weight-bearing joints Ileberden's nodes (enlargement of the end finger joints) oc. cur frequently; they have been shown to have a familial tendency. This type of arthritis occurs usually in older people and has been called "old folk's rheumatism" The exact cause of the degenerative process is not known; however, some of the chief contributing factors are overweight, faulty posture and weak muscle tone, all of which produce constant "minor trauma" and inevitably lead to extra stress and strain on the joints 39 ·60 RIIEUMATIC DISEASES DIAGNOSIS The diagnosis of generalized degenerative joint disease is not difficult. The following points are helpful in arriving at the diagnosis. 1. The spine and weight-bearing joints are usually involved. 2 The end joints of the fingers are often enlarged (Heberden's nodes) (Figs. 46–18). 3. Onset is insidious 4 Symptoms first appear in persons past middle age. 5 The patient is often overweight and has a low basal metabolic rate 6. There is seldom much soft tissue swelling such as is present with rheumatoid arthritis The swelling in degenerative joint disease usually feels hard and firm in contrast to the soft flud swelling of rheumatoid arthritis. 7 Usually x-ray studies show increased mineral deposits with sharpened articular margins Figures 49-56 show normal joints and joints affected by degenerative disease. There may be eburnation of subchondral bone and joint cartilage destruction. When narrowing occurs in the disk spaces between the vertebrae, lipping of vertebral margins is common. 8. The disease seldom affects the wrists, feet or metacarpophalangeal and proximal interphalangeal joints, which are so often involved in rheumatoid arthritis, 9. The sedimentation rate is normal or slightly elevated 10. The patient usually is not systemically ill, 11. Symptoms chiefly complained of are pain on motion of or weight-bearing by the involved joints, stiffness of the back or knees on getting up from a chair and pain or swelling in the end finger joints

·M
M
FIC 46 (top) -Degeneratre point disease (osteoarthritis) Xote enlarged
end konts (Heberden's nodes)
Fc 47 (bottom left) -Jleberden's node
FIC 49 (bottom right) - V-ray of same joint
61

·FIG. 49 (left) - Normal lumbar region of the spine. Fia 50 (right) - Normal lumbosacral joint.

·--- Fics 51 and 52 --Degenerative joint disease of the lumbar region of the spine, showing urregular narrowing of the inter ertebral spaces and compensatory bridging between the vertebrae 83 ·FIC 53 (top left) - Normal knee, anteroposterior projection Fic 54 (top right) - Degenerative joint disease (ostetsarthritis of the knee, anteroposterior projection Note sharpening of the spines of the tibia. in contrast with the normal FIG 55 (bottom left) --Normal knee, Literal projection FIC 56 (bottom right) -Osteoarthritic knee, lateral projection Note good mera nation and patelar spurs 61 ·65 DEGENERATIVE JOINT DISEASE Three types of degenerative joint disease deserie special mention 1. Incolvement of the hup (malum corac) may be extremely disabling Pam in the hip may be the first symptom, often with early loss of extremes of motion. There are cartilage destruction, with narrowing of the joint space, and deformity of the head of the femur, and the disease is progressive, with increasing limitation of hip motion and severe pain on weight-bearing One or both hips may be involved Symptoms may be limited to the hups or the hip involvement may be only a part of widespread joint disease The x-ray picture is characteristic (Figs 57-59) Treatment is the same as that outlined for generalized degenerative joint disease (pp 71 ff) 2 Osteoarthritis of the spine is the second type of degenerative joint disease worthy of special mention This diagnosis is frequently made to account for low back pain Many such diagnoses are made only because of low back pain and x-ray evidence of lipping or spurring of the vertebral margins Osteoarthritis of the spine is not as common a cause of pain as the frequency of this dugnosis would sug. gest X-ray evidence of spurs or hooks (osteophytes) on the anterior margins of the vertebral bodies is not uncommon in patients who have no pain or symptoms (Figs 51 and 52) These spurs can and do occur as well in patients who complain of back pain The osteophytes are merely calcified annular ligaments and represent in a sense the tombstones which mark the site of loss of disk substance It is true that loss of outline of disk material may result from degeneratie joint disease of the spine (osteoarthritis) or from unrelated ctrologic factors such as trauma and infection The sole pa- ·FiG 57 (top) -- Unilateral malum coxae, with loss of hip joint cartilage and deformity of the femoral head Fic 58 (bottom left) -Early malum coxae, showing loss of lp funt cartilage but little demineralization, cyst formation or deformity of ferrat head Fic 59 (bottom right) - Far-advanced malum corae, showing almost complete obliteration of the joint space with are as of demineralization, and of condensation with deformity of the femoral head 66

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·Fic 60 - Degenerative joint disease of cervical vertebrae, with narrow. ing of the intervertebral spaces and hypertrophic marginal changes 88 ·69 DEGENERATIVE JOINT DISEASE tain percentage of cases of low back pain. It is well to remember that backache and neck pain occur far more frequently from soft tissue (muscle and tendon) disturbances than from osteoarthritis. The single observation that degenerative joint disease (osteoarthritis) is present should seldom be accepted as an adequate explanation for symptoms Pain in the neck associated with occipital headache is often ascribed to osteoarthritis of the cervical vertebrae Such a condition can, of course, cause pain, but the symptoms are far more frequently due to fibrositis of the neck muscles (see p 76) 3 Senile ostcoporosis (Figs. 61-63) is often not diagnosed There is marked decalcification which, in the spine, frequently results in the collapse of one or more vertebrae The patient may note a loss of several inches in height. Nerve root involvement with radicular pain is common The cord may, of course, be injured if vertebral disintegration is sufficient The treatment includes corrective exercises, back brace, if needed, and administration of male and female hormones. It is our practice to give women (usually over 60) methyl testosterone in 5-10 mg doses daily, in the form of sublingual or buccal tablets It is given for three weeks, followed by one week of diethylstılbestrol in doses of 0 25 05 mg daily If side-effects of the methyl testosterone (SCHnal awareness, slight edema, weight gain and husky voice) become unpleasant, the drug should be discontinued before the three week course is completed and the one week course of diethy Istılbestrol begun The methyl testosterone should he started again at the end of the week's treatment with Prethvishlbestrol and continued for three weeks, or until ede-effects become unpleasant, thus alternating the two

·70
Fic 61-Normal lumbar region
of the spine
FIG, 62-Early tenile ostenporosis
FIG 63 - Well established seule
osteoporsis

·71 DECESERATIVE JOINT DISEASE medications for six months or more Occasionally even quite elderly women have slight vaginal bleeding while taking the female hormone. The patient should be warned of this possibility and instructed to stop the female hormone and return to the methyl testosterone should bleeding occur We prefer to administer the hormones separately rather than together because we wish to give the minimal amount of female hormone to these elderly women, who are in the cancer age TREATMENT OF GENERALIZED DEGENERATIVE JOINT DISEASE A positive diagnosis, intelligent advice and assurance that the disease is not crippling will do much to dispel the antiety of the patient (especially a woman) with IIeberden's nodes and painful knees Reassurance is one of the most effective aspects of therapy of this disease Treatment in general should be directed toward relieving the excessive stress and strain resulting from constant minor trauma to the joints and alleviating the "wear and tear” factors The following suggestions will be helpful I After the patient has been reassured, insist on the estabhishment of a routine, depending on the degree of the simptoms Dismissal of the patient with the mere assurance that the disease is not serious or crippling will result in his going elsewhere for relief of lus discomfort 2 Weight reduction of the patient is overweight 3 Correction of posture 4 Routine daily correctnc exercises for strengthening the supporting muscles (See the list for rheumatoid arthritis, p 145, and select suitable ones ) ·72 RHEUMATIC DISEASES 5. Shoe correction, for better weight-bearing angle. 6. Achieve a balance between rest and erercise which the patient can tolerate, and gradually increase the activity as weight is reduced, posture is improved and muscle strength is increased. 7. Prescribe aspirin, which is the most helpful drug generally for the relief of pain and stiffness. It should be used in adequate dosage (30-60 gr. daily). 8 Short periods of warming and light massage of the muscles are soothing but not essential. 9. Application of Ace bandages for support of a painful knee until muscle tone can be improved is often helpful in walking (sce pp. 131 and 135). 10. Insist on the use of crutches whenever there is hip involvement or severe knec pam. Correct crutch walking should be taught (Figs 100 and 101, p. 132). This maintains correct posture and balance and prevents excessive stress on the painful weight-bearing joints. 11 Intravenous or local injection of procaine, curare, X-ray therapy, sex hormone therapy and many other prom cedures are occasionally helpful but usually not essential 12 General maintenance of warmth and protection, use of electric blankets, etc., add much to the patient's comfort 13 Head traction with a Sayre head sling for 20-30 minutes, combined with heat and gentle rotation of the head, is helpful when the cervical spine is involved Weight should not be over 20 lb. to start and is gradually increased as tolerated With the exception of degenerative joint disease of the hips (malum coxae), this condition is essentially benign and can be described as not the "crippling kind” of arthritis. Pa-

·DEGENERATIVE JOINT DISEASE
tients will in general respond satisfactorily to an adequate
treatment program such as that described here, which is
neither complicated nor expensie
73

·CHAPTER 5 Fibrositis FivnosITIS, OR “muscular rheumatism," is said to be the most common form of chronic rheumatism. There are two general types. 1 Localized fibrositis may result from injury, infection or exposure or exist in association with arthritis around a joint This type is usually not difficult to diagnose and is ordinarily quite easily and successfully treated. Treatment should be directed to protection of the injured part, removal of infection, avoidance of exposure, use of selected exercises, compresses, intermittent heat and, in the late stages, massage In many instances, the infiltration of 10 cc. of 1 per cent procaine into the painful area permits increased inotion, relieves pain and hastens recovery. There are several special types of localized fibrositis that deserve mention a) "SUBDELTOID BURSITIS” (periarthritis of the shoulder, subacromial bursitis, supraspinatus tendinitis, painful shoulder, etc ) - This condition is the cause of approximately 90 per cent of painful shoulders. It is frequently encountered, is the cause of excriciating pain and may result in a “frozen shoulder" (Figs. 64 and 65). It is generally believed that the process starts in the tendon of the supraspinatus muscle 74 ·FIBROSITIS 75 and extends to the bursa, This painful condition is almost always due to minor or major trauma, exposure, foci of infection or any combination of these factors It is usually unilateral The severe pain in the shoulder produces acute discomfort, particularly on abduction and rotation Occa- CA FIGS 64 AND 63 -Neglected subdeltoid bursitis with completely frozen shoulder Note musck atropliy and rather normal x-ray appearance of the joint sionally x-rays disclose a calcified area in the region of the bursa If untreated, this condition may result in a so-called "Frozen shoulder“ with motion limuted to a few degrees There may be secondary discomfort in the hand, Irut usually not with the swellig, marked atrophy and hand pain is so common in the shoulder-hand syndrome (p. 33) ·76 NIEUMATIC DISEASES During the acute attack, rest, x-ray therapy to the shoulder (usually 50 r at 30 cm. distance daily for four days, then once weekly for two additional treatments) and the maintenance of shoulder motion by a gentle and wise physical therapist will often result in a painless shoulder with free motion. Additional x-ray therapy of the acute attack is seldom helpful if there has been no improvement with the first course. Aspirin (60-80 gr. daily), codeine sulfate ($ gr. three or four times daily) and a night sedative may be required if pain is severe. If the condition is seen late when there is already pronounced shoulder limitation, short wave diathermy followed by patient and skilful assistive and stretching exercises to restore the shoulder motion will usually over a period of weeks or months restore a painless shoulder and secure normal motion. Occasionally, late in the disease, very gentle manipulation under anesthesia is necessary to break adhesions that limit the shoulder motion b) YERNIATED FATPAD.-This condition occurs most frequently in the back, in the lumbar and lumbosacral areas. Distended lobules of fat, when confined in the normal fibrous integument, may produce pain. A distended lobule may herniate through the fibrous covering and often is easily felt on palpation. Simple heat and massage combined with procaine injection is usually successful. Unless the pain is intractable, surgical removal should not be undertaken. c) FIBROSITIS OF THE NECK. Pain in the neck, often associated with headache, is a frequently encountered type of discomfort caused by fibrositis in the neck structures. The lymph nodes are usually enlarged and tender, the muscles tight and spastic, and the headache and neck discomfort can be severe enough to be disabling. The condition is usually ·FIBROSITIS 177 associated with foci of infection in the sinuses, nasopharynx or mouth. The patients are extremely sensitive to cold, drafts, exposure and fatigue. On the basis of x-ray findings, such patients often go on for years, receiving treatment for osteoarthritis of the cervical spine, without discovering the true cause of the disability, Figure 66 shows striking osteoarthritis of the cervical spine in a woman, aged 5), who had had severe neck pain and occipital headaches for three years. She had been treated for osteoarthritis with head traction, procaine injections and all the usual remedies, none of which had relieved her. Complete relef from all symptoms followed the cleanng up of chronically infected adenoid tissue in the nasopharynx by means of radum application Osteoarthritis was present, but was not responsible for the symptoms. Figure 67 shows early osteoarthritis that caused severe symptoms. If the librositis is of long standing, a long course of heat therapy and vigorous massage may be required These measures should be undertaken only after a careful survey and removal of infected foci in the head 2 Generalized fibrositis, on the other hand, is an elusive ill-defined term. There are no certain diagnostic critcria. The diagnosis of generalızed fibrositis is often used as a "catch basket" for patients who complain of generalızed joint or muscle pain, usually without any substantiation from laboratory, x-ray and physical examinations. It is perfectly truc that tenderness on pressure will be found in many arcas, although no specific pathologic process is identifiable with regularity It is quite probable that most cases of general. ized fibrositis belong in the classification better described as "antiety state or "psychonrurosis with skeletal symptoms Recently the condition in some patients of this group, who ·78 RHEUMATIC DISEASES show quite typical psychoneurotic symptoms of the conversion hysterical type with fixed patterns, lias been termed "psychogenic rheumatism” These patients should be recognized and given psychiatric treatment. Instead of using the FIC 66 (left) - Pronounced ostenarthritis of the cervical partson of the spine, but not the cause of the patient's symptoms F1c 67 (nght) -Early osteoarthritis of the cervical portion of the spine Changes appear to be less extensive than those in Figure 66, set the patient's symptoms were due to the arthritis term “psychoneurosis with skeletal manifestations" or "anira iety state” for the balance of this group, we have adopted the expression “tension pain” and find that the patient understands this term quite well. These patients sit in the office or lic on the examining ·FIBROSITIS 79 table with every muscle held tense. If the patient's anxiety; ofton unconscious, results in constant muscle tension, the pain may be very real, for continuous tension in the same muscle group will produce pain in a normal person. The typical patient in this category generally complains of pain and aching in the muscles and joints, usually widely distnbuted, worse in the morning on awakening and improved with exercisc. Physical examination usually gives negative results except for tenderness on pressure over many different points and soreness of the muscles. X-ray and laboratory examinations do not add any positive findings Atroply, swellsng, limitation of motion and evidence of constitutional 11- ness are seldom present such a patient is usually anxious, tense and frightened at the thought of having arthritis It is not uncommon, when one sees them in consultation, to find these patients taking five or six linds of physiotherapy, numerous injections and oral medications TREATMENT OF GENERALIZED FIBROSITIS Thc patient cannot be dismissed with the assurance that nothing can be found flis emotional and tension problems are often obscure, and a little time spent in listening to the patient's story will often pa great dividends in thernpentic results The patient must be given a careful explanation that will satisfactorily account for luis pain and the assurance that hic can do something about rehesing it Regardless of etioloyv, we are convinced that, guru an adeqnate explanation of their problem and guidance in the use of reiving and stretching exercises list, p 151), together with active cicrcise, these patients will show gratifying improve- ·80 REUMATIC DISEASES ment. Many patients will gladly accept such an interpretation of their problem and with sympathetic encouragement will often pour out their anxieties and fears. This mental catharsis in itself has often been strikingly beneficial. Certainly, if an understanding of anxiety and tension pain together with the most superficial psychiatric aid and simple self-help measures will succeed in relieving symptoms, this is a method of treatment to be preferred over the usual gamut of vitamins, vaccines, ionizations and gadget physiotherapy that is usually so unsuccessfully employed in these problem cases. These patients, though lacking in positive physical signs and evidence of organic disease, are usually just as all and miserable as those who have definite changes They deserve advice on a definite routine of living, wise periodic guidance and an understanding of their problems. Such a course of management will often transform what are known as “office pests” or “crocks” into grateful and happy patients. .

·CHAPTER 6 Gouty Arthritis GOUTY ARTHRITIS is an intrinsic disorder of uric acid metabolism. Ilyperuricemia appears to be hereditary, but all mditise in 50-75 per cent of cases The typical lite story of a patient with gouty arthritis may show hyperuncemia for years before an attack of arthritis First attacks usually occur in a man at about the age of 45, though they may occur in the twenties and through the sixties. First attacks are usually acute, with joint swelling and pain, often in a single joint, lasting a few days to a few weeks, with complete recovery The attack is usually dramatic and severe and often occurs at night The period of remission of freedom after the first attack may vary from a few uccks to several years Gradu. ally, houerer, attacks may hecome more frequent and of longer duration If this cycle continues, chronic gouty ar. thritis becomes established and there will be no periods of complete remission (Fig 6%). This may require 10 years or longer Multiple joints liccome inı nlied, and the disease may lxccome as crippling as rheumatoid arthritis 81 ·82 RHEUMATIC DISEASES ATTACKS Stogo of chronic gout TIME IN YEARS Fic 68 - Typical life history of gouty arthritis. The exact mechanism of uric acid disturbance associated with the acute attack is not known. Recent investigations suggest that it may be related to a faulty androgen produced by the adrenal cortex. DIAGNOSIS The diagnosis of gouty arthritis is not based on the blood uric acid level owing to difficulties in the accuracy of methods and to the fact that many individuals may have a high blood uric acid level without having gouty arthritis. It is quite probable that if all patients with gout were examined frequently by accurate methods, most of them sooner or ·GOUTY ANTHRITIS 83 later would be found to have elevated blood (tric acid levels. Patients may be seen, lowever, in an acute attack of gout with normal blood uric acid levels. The diagnosis usually can be made quite easily by using the following diagnostic lunts, 1. Ilistory of acute attacks of arthritis, ordinarily limited to one area, subsiding promptly with complete recovery, usually in a man. The ratio is about 97 men to 3 women. The big toe, commonly thought of as the gouty joint, is involved intally in only 60 per cent of cases. Gout does, however, tend to insolve peripheral joints-seldom the hips, shoulders or spine 2. Striking remission by the use of colchicine (sec p. 87), given until duarrhea occurs, during or at the onset of an acute attack 3 A tendency for the acute attack to occur after surgery and after trauma (as after a hunting trip). 4 Demonstration of uric acid in the joints (Figs 69 and 71) and in the toptı on biopsy 5. Occurrence of renal colic or the demonstration of Tenai calculi as corroliorative evidence 6 X-rays not diagnostic until the late stages (Figs 70 and 72) Differential diagnosis -Gout may be confused early in its course with acute rheumatic fever, atypical rheumatoid arthritis, 1c., palindromic rheumatisın, traumatic arthritis, osteoarthritis and certain rather rare conditions 1. The initial attack of rheumatic fever usually occurs ixclore age 40, whereas the imtial attack of gout occurs after ago 10. In rheumatic fever there is a ingratory arthritis, wuch is rare in got, and there is no scaling or pecling of the skin over the joint, as is seen in gout. The colchicine ·82 RIIEUMATIC DISEASES ATTACKS Slage of chronic gout TIME IN YEARS FIC 68 - Typical life history of gouty arthritis The exact mechanism of uric acid disturbance associated with the acute attack is not known. Recent investigations suggest that it may be related to a faulty androgen produced by the adrenal cortex. DIAGNOSIS The diagnosis of gouty arthritis is not based on the blood uric acid level owing to difficulties in the accuracy of methods and to the fact that many individuals may have a high blood uric acid level without having gouty arthritis It is quite probable that if all patients with gout were examined frequently by accurate methods, most of them sooner or

·Fic 71 (top)-Chronic tophaceous gout of the knee
Fic 72 (bottom)-Same case 1-ray of the left knee
83

·Fic 69 (top) -Far-advanced tophaceous gout.
Fic 70 (right) -X-ray of the same foot
84

·-
Fic 71 (top)-Chronic tophaceous gout of the knee.
Fic. 12 (bottom) -Same case, 2-tay of the left knee.
85

·FIC 69 (top).-Far-advanced tophaceous gout
Fic 70 (right).-X-ray of the same foot
84

·GOUTY ARTHRITIS 87 2. Protection of joints with cradle, footboard or cotton batting 3 Colchicine (1/100 gr.) every two to three hours, as tolerated, untıl diarrhea occurs. The diarrhea, if not selflimiting, may be controlled quickly with paregoric. The diarrhea, or therapeutic point, may develop within 24 hours but may be delayed as long as three days If nausea develops before the diarrhea, reduce the frequency of the colchicine administration. Definite diarrhea (three or four watery stools) is the best guide to adequate dosage An acute attack of arthritis not relieved by this routine almost certainly not gout The relief in acute gout, when it occurs, is dramatic and there can be no doubt of a positive response to the test, 4 Massage or physiotherapy, other than application of hot or cold compresses, is not indicated and may produce an exacerbation of the attack 5 Adrenocorticotrophic hormone (ACTH) relieves the acute attack (see Chapter 8 for a discussion of ACTH) Interval management (between attacks) - Interval treatment is prescribed on the basis of the frequency and severity of attacks 1 Every patient who has had an attack of acute gouty arthritis should carry 1/100 gr colchicine tablets with him, just as the patient with angina carries nitroglycerin At the first sign of discomfort he should begin takıng 1 tablet every two or three hours until relieved or until diarrhea occurs It is often possible by this simple means to abort or reduce the severity and duration of the gouty attack 2 Any patient subject to acute gouty arthritis who requres surgery should be especially prepared by use of a low purine diet and administration of salicylates and/or col.

·86 NHIEUMATIC DISEASES therapeutic test (paragraph 3 below) is negative in rheu matic fever and positive in early gout attacks. 2. The palindromic type of rheumatoid arthritis is apt to behave clinically very much as gout. Sudden acute attacks in joints of the upper extremities with complete or almost complete recovery are apt to be atypical rheumatoid ar. thritis and, in a woman, almost certainly so. Such attacks occurring in the lower extremities of a man may he esther gout or atypical rheumatoid arthritis. The skin over the joint involved by acute gout tends to discolor and to scale as the attack subsides, although this is not invariably true. One needs to be wary with this problem as the attacks of atypical rheumatoid arthritis, i.c., palindromic rheumatism, may be so brief that a false positive result of the colchicine therapy test may be recorded Sometimes a period of observation and trial treatment may be necessary to differentiate with certainty between atypical rheumatoid arthritis, i.c, paliwa dromic rheumatism, and gout. Differentiation is especially difficult in the presence of acute intermittent arthritis of the lower extremities in a man. Fortunately one does not often meet this problem 3 Traumatic arthritis and osteoarthritis do not respond to the colchicine therapy test and should offer no serious problem in differential diagnosis (see the points in diagnosis of osteoarthritis, p 60). TREATMENT Treatment of the acute attack.-The routine to be tollowed during the attack is well established. 2. Absolute bed rest.

·GOVTY ARTIRITIS 2. Protection of joints with cradle, footboard or cottbatting 3 Colchicine (1/100 gr ) every two to three hours, a tolerated, until diarrhea occurs. The diarrhea, if not self limiting, may be controlled quickly with paregoric The diarrhea, or therapeutic point, may develop within 24 hours but may be delayed as long as three days If nausea develops before the diarrhea, reduce the frequency of the colchicine administration Definite diarrhea (three or four watery stools) is the best guide to adequate dosage An acute attack of arthritis not relieved by this routine is almost certainly not gout The relief in acute gout, when it occurs, is dramatic and there can be no doubt of a positive response to the test 4 Massage or physiotherapy, other than application of hot or cold compresses, is not indicated and may produce an exacerbation of the attack 5 Adrenocorticotrophic hormone (ACTH) relieves the acute attack (see Chapter 8 for a discussion of ACTH) Interval management (between attacks) - Interval treatment is prescnbed on the basis of the frequency and severity of attachs 1 Every patient who has had an attack of acute gouty arthritis should carry 1/100 gr colchicine tablets with him, just as the patient with angina carries nitroglycerin At the first sign of discomfort he should begin taking 1 tablet every two or three hours until relieved or until diarrhea occurs It is often possible by this simple means to abort or reduce the severity and duration of the gouty attack 2 Any patient subject to acute gouty arthritis who requires surgery should be especially prepared by use of a low purine diet and administration of salicylates and/or col- ·88 RILEUMATIC DISEASES Low FAT, MODERATELY LOW PURINE, HICH CARBOHYDRATE DIET FOR COLT Foods OT ALLOWED Foods ALLOWED Sweethreads Lean beef Anchovics Lean lamb Liver Whitefish Kidneys Baked fowl Brains Eggs Sardines Mild cheese Gravy Sauces Vegetables other than those of Fat meat allowed Butter and fats (only as specified) White bread ALL spices and condiments Skimmed milk Vegetables Spinach Cauliflower Weak coffee Asparagus Onions Weak tea Peas Mushrooms Dry beans Fruits Sugar BREAKFAST I serving of fruit 1 egg 1 slice white bread 1 teaspoon butter Weak coffee or tea, as desired SAMPLE MENU FOR Gour DIET LACR DINNER 2 eggs or 2 oz mild 1 serving (2 oz) lean, cheese plan meat, fish or 2 servings of allowed fowl, 3 days a week, Vegetables other 4 days use 2 1 salad eggs or oz mild I serving fruit chcese I slice white bread or 2 soda crackers 2 servings of allowed vegetables 1 teaspoon butter or I salad mayonnaise 1 serving frunt 1 glass skin milk or I slice white bread buttermilk Weah tea or coffee, 1 teaspoon butter or mayonnaise as desired 1 glass skim milk or buttermilk Weal tea or coffee, as desired • Total calories should be adjusted to reduce weight of the patient as overweight ·COUTY ARTHRITIS 89 chicme for three to five days before surgery takes place 3. A patient subject to gouty arthritis should make every attempt to protect himself against undue trauma or injury Footwear and socks should be carefully selected and unnecessary stresses and strains to weight-bearing joints avoided 4. For patients having one mild attach or less yearly, the interval treatment is confined to routines 1, 2 and 3. 5 For patients having one or two severe attacks yearly, routines 1, 2 and 3 are followed and, in addition: a) A low fat, moderately low purine, high carbohydrate diet b) Aspırın, 60-80 gr daily for three days cach neek, hecause it increases uric acid ercrction c) If this routine does not provide satisfactory results, cinchophen may be substituted for aspırın, in doses of 71 gr. three times a day for three days each wcek In gout, liver toxicity from cinchophen is extremely low or absent Nevertheless, patients taking cinchophen should be watched for evidence of toxicity (nausea, pruritus, jaundice, etc ). 6 Patients who have repeated severc attacks yearly should follow routines 1, 2, 3, 5a, 55 and 5c, and add a) Colchicine, 1/100 gr. three times daily for three days weekly, not on the same day that aspırın or cinchophen is taken ·CHAPTER 7 Collagen Diseases THE COLLAGEN HISEASES, strictly speaking, include all diseases in which there is characteristic fibrinoid degeneration of collagen. Collagen is a product of fibroblasts. Fibrinoid degeneration consists of swelling of the mucoid ground substance, together with proliferation, degeneration and necrosis of fibroblasts. Inasmuch as these changes occur in connective tissue, diffuse collagen disease may involve many different areas of the body. Just as fibrinoid degeneration is the common denominator of these diseases pathologically, multiple system involvement is the signboard pointing to the clinical diagnosis. The following disease syndromes are usually classified as Jiffuse collagen diseases. 1. Periarterites nodosa (polyarteritis, necrotizing tascale litis) -The fibrinoid degeneration in this disease tends to localize in the media and intima of the medium-sized and small arteries The lumen of the artery may be obliterated and thrombosis or hemorrhage may occur. The blood vessels of the heart, kidneys, brain or any other part of the body may be involved. Clinically the disease resembles a severe progressive infection, with fever, weakness, loss of weight, ·COLLAGEN DISEASES 91 muscle and joint pains and, usually, an intermittent downhill course Laboratory studies reveal a rapid sedimentation rate, usually albumin and red cells in the urine, often eosinophilia with leukocytosis. The diagnosis may often be established by muscle biopsy. lfultiple system incolvement, including joints, kidneys, heart, etc., should suggest the diagnosis 2 Lupus erythematosus disseminatus This too is a disease of connective tissue due to collagen necrosis. The necrosis may be very widespread, involving blood vessels, pleura, serous membranes, central nervous system, heart, Lidneys, skin, lymph nodes, etc When blood vessels are affected there are usually endothelial proliferation and oc. clusion, producing the same end-result as periarteritis nodosa. The name is misleading, because the skin lesions play a very minor role and often are not present. Clinically it is characterized by fever, weight loss, fatigue, pleurisy', muscle and joint pains, gastrointestinal disturbances and, occasionally, the typical butterfly lesion across the bridge of the nose and cheek. Pleuropericardial and pericardial effursions are common. Laboratory studies usually reveal leukopenia, albuminuria and sometimes hematuria The sedimentation rate is increased The diagnosis can usually be made by muscle biopsy and by stemal marrow examination Mfultiple system disease, usually snvolving joints, serous membranes, hidneys and skin, should suggest the diagnosis 3 Dermatomyositis - This necrotizing collagen disease chiefly involves the skin, skeletal muscles and the heart There is seldom direct blood vessel necrosis, although the vessels are involved secondarily through disease of the surrounding strictures The clinical course is characterized by muscular contractions and fibrosis of the skin and fascia, ·92 RIEUMATIC DISEASES producing fixation of joints, but the most striking feature is the muscular weakness, which is progressive, usually with pronounced tenderness on pressure of the muscles. Late in the disease the muscles become firm, indurated and boardlike. Laboratory studies are seldom helpful. The diagnosis usually may be made by muscle biopsy. 4. Scleroderma involves chiefly the skin, gastrointestinal tract, heart and other viscera. Muscle and connective tissue arc replaced by an overgrowth of fibrous tissue. Induration and constriction are common. Circulation is impaired. There are muscle and joint pains and the constriction of fibrous tissue may limit joint motion. Pulmonary and myocardial fibrosis may occur The muscular layers of the gastroin. testinal tract may be replaced by fibrous tissue. The course usually is slow and may be spontaneously arrested at any time If the disease progresses, weakness and emaciation in crease and death usually is due to secondary infection. X-ray examination frequently reveals calcifications, usually situated deep in the tissue around the large joints. Gastrointestinal X-rays may show strictures or irregular dilatations, characteristic of the disease. Laboratory studies are not helpful Once the disease is established, the diagnosis is usually obvious. Rheumatoid arthritis, rheumatic fever and serum sickness are sometimes grouped pathologically with the collagen diseases, although they are not included in this discussion. DIAGNOSIS As will be readily seen, the collagen diseases, though called by diſfcrent names, often involve the same structures ·COLLAGEN DISEASES 93 and present many changes in common. Indeed, it is not always possible to give an exact name to many of the cases seen However, it should be possible to make the diagnosis of diffuse collagen disease if it is always kept in mind as a possibility in every patient seen with suspected rheumatic disease Diffuse collagen disease may imitate many other discases, but in our experience it is most frequently confused with rheumatoid arthritis and rheumatic fever, Rheumatoid arthritis is also a systemic disease but almost never presents major clinical evidence of multiple system incolvement. The differential diagnosis is therefore a quantitative one, and the more extensive the clinical and laboratory evidence of multiple system involvement, the more probable is the diagnosis of diffuse collagen disease The following case histories indicate many of the important diagnostic points and also illustrate some of the difficulties that are likely to be encountered in making an early diagnosis. REPORTS OF CASES Case 1-A woman ('K), aged 45, suffered from polyarthritis which was diagnosed as theumatoid arthritis She had been well until two years before her death when she noticed a rather insidious onset of painful swelling with some local heat in both Imees Subsequently the wrists, elbows and shoulders were painful and the proximal interphalangeal joints and terminal interphalangeal jomts of both hands were aching and stiff The patient lost about 20 lb. in two months The sedimentation rate was increased to 88 mm in one hour by the IVestergren method. The white blood cell count at the onset of the illness was 4,000, with a marked shift to the left There was moderate hypochromic, ·RHEUMATIC DISEASES microcytic anemia. The patient noticed some weather effect and she received a moderate amount of relief from aspirin The diag. nosis was rheumatoid arthritis. She was given vitamins and told to apply heat to the joints and later was advised to come to Tucson. Examination about one year before death disclosed swollen painful knees with some limitation of motion on the right. The proximal interphalangeal joints of both hands were tender and somewhat painful but there was no evidence of swelling or thichening The shoulders were moderately limited in abduction, with pain at the extremes. The patient was thin, undernourished, the blood pressure was 92/60, the pulse 110 and the rhythm regular The positive points on physical examination were essentially inanition and the polyarthritis The white blood cell count was 3,200, with a pronounced toxic blood picture, a shift to the left and toxic granules in the polymorphonuclear leukocytes. The sedimentation rate was 120 mm, in one hour by the Westergren method. There were 6-8 red blood cells per high power field in the urine and 2 plus albuminuria. The electrocardiogram revealed nonspecific changes consistent with a diffuse type of myocarditis. The chest x-ray was essentially unremarkable. A muscle bropsy revealed changes compatible with lupus erythematosus disseminatus The subsequent course was progressively severe. The temperature began to rise to as high as 103 F. in the late afternoon. The white blood cell count fell to a total of 2,000 and the hemoglobin content to 58 per cent. The urinary changes became more severe and cardiac arrhythmia developed. There was at one time a moderate pleural effusion on the right, and there were two distinct episodes of aphasia, dizziness and weakness of the right arm and leg. Careful examination of the eyegrounds at intervals revealed a few flame-shaped hemorrhages and one or two small arterioles that seemed to be obstructed. Moderate retinal eclema developed the blood urea nitrogen value slowly began to rise. Multiple areas of tenderness in various muscles and tendon sheath swelling appeared and the size of the swollen joints increased ·COLLAGEN DISEASES 95 The patient's weight continued to decline, nausea and vomiting became a feature and suddenly there developed complete obstruction of the left brachial artery This was followed by gangrene of the arm, requiring amputation. The patient died two months later, and at autopsy the diagnosis of lupus erythematosus disseminatus was proved. At no time did this patient exhibit skin lesions of the typical butterfly type over the bridge of the nose and the cheek There were no alterations in the skin other than those secondary to the nutritional disturbances and the patient's illness The suggestion that the disease was not rheumatoid arthritis buit lupus erythema. tosus disseminatus arose out of the finding of leukopema, alterations in the urine consistent with a diffuse type of vascular nephritis and the involvement of the heart muscle Subsequent involvement of the brain, of the pleura and of the gastrointestinal tract further confirmed the diagnosis. The case is a typical erample of this fatal disease, although the occlusion of such a large artery as the brachial is somewhat unusual (Fig 73) Case 2 --A young woman (ATV), aged 19, had a disease which was diagnosed as early rheumatoid arthritis for one month before the appearance of leukopenia and diffuse arteritis She died one year after the onset of her illness and at autopsy the clinical diagnosis of lupus erythematosus disseminatus was confirmed (Fig 74) Case 3 --A woman (VG), aged 57, had a disease which was diagnosed as rheumatoid arthritis for five years before the onset of multiple system incolvement The patient had profound weakness, exquisite tenderness of the muscles and diffuse systemic insolvement Biopsy revealed cutaneous ulceration and disturbances in the muscles characteristic of dermatomyositis. She died six years after the onset of the allness, and at autopsy the diagnosis of dermatomyositis was confirmed CASE 4-A Mexican man (10), aged 33, was said to have glomerulonephritis No articular disease was present Subsequently the diffuse picture became clear and, on histologic eramination, polyarteritis was evident At autopsy eight months ·Fic 73 (top) - Lupus erythematosus disseminatus; Case 1. Transverse section of a thrombosed brachial artery of the left upper arm The intima - power photomicrograph of an arteriole, showing intimal disinteg! Juur vacuolation of the muscular cells plus inflammatory changes in the adventitial coat any nuclei are undergoing haryorthesis, and the vessel shows all stages of inflammation and degeneratie attempts at replir. 06 ;

·COLLAGEN DISEASES 97 after the onset of the illness the diagnosis of polyarteritis was confirmed Case 5 --A woman (ER), aged 15, had a disease which was considered to be rheumatoid arthritis for one year before the clmical and pathologic diagnosis of lupus erythematosus disseminatus was made at this time, leukopenta developed and the histopathologic changes of lupus erythematosus disseminatus were noted She was given Benadryl in doses of 300-500 mg in 24 hours and remained on this medication She went back to work as a school teacher and at the time of writing had enjoyed an asymptomatic course for over a year (Fig. 75) CASE 6 - A man (CK), aged 45, had a disease which had been diagnosed as rheumatoid arthritis for 11 years The story of the early illness was characteristic of gouty arthritis, with sudden attacks of exquisitely painful arthritis in the peripheral joints followed by complete subsidence of pain Subsequently, however, chronic polyarthritis and tenosynovitis de eloped, and three years before his death there was evidence of multiple system intolcement A muscle biopsy revealed characteristic changes of polyarteritis. Twele years after the onset of the attacks of arthritis the patient died At autopsy, polyarteritis was found (Fig 76) CASE 7 - A man (W.H), aged 55, was told he had rheumatic fever nine months before the detection of multiple system in- Loltement Histologic examination confirmed the diagnosis of polyarteritis. lle was given Benadryl in doses of 300-500 mg in 24 hours, following wuch his course was one of progressive improvement At the time of writing, one year after the final diag. nosis was made, he was almost symptom free CASE 8-A woman (VG), aged 30, had a disease which was diagnosed as theumatic fever for one month before the detechon of lupus erythematosus disseminatus liitologic examination confirmed the diagnosis Tlus patient, although she had a stormy course, was at the time of writing consider improved She was afebrile, up and about and had no complaints She too was given Benadryl in doses of 300-500 mg per 24 hours and con.

·Fic 75 - Lupus erythematosus disseminatus, Case 5 Characteristic distribution of skin lesions on the bands and shouklers The face was not typically involved Fic 76 -Polyarteritis, Case 6. Associated changes in this patient included Dupuytren's contractures, especially in the left hand, and darkened areas of the palms and finger-ups-so-called "liver palms." 98 ·COLLACEN DISEASES 99 tinued with varying amounts of the drug during the surceeding three years without recurrence of the disease CASE 9 - A woman (F.A.), aged 30, had had asthina for eight years One year before her death the condition was diagnosed as sheumatoid arthritis and she was treated with vaccines. Finally she was referred to Tucson and six months before death there was evidence of polyarteritis Diagnosis was confirmed by histologic examination. Gradually, symptoms of multiple system disease developed and the patient died At autopsy the diagnosis of polyarteritis was confirmed (Fig 77) Case 10-A woman (ER), aged 40, had a disease which was diagnosed as sheumatoid arthritis for 13 years She had been treated with gold, transfusions, vaccines and vitamins and had had a variable course. When she was first seen by 115, three years before her death, the condition was typical of rheumatoid arthritis. Within a year, however, leukopenia developed, and on careful study multiple system involvement was evident Finally the classic lesions of lupus erythematosus appeared on the face, and at autopsy the diagnosis of disseminated lupus erythematosus was confirmed Case 11 mA man (RW.), aged 32, had a disease which was diagnosed as rheumatoid spondylitis and peripheral rheumatoid arthritis for eight years Five years after onset of hus joint complaints he came to Tucson, and roentgenographuc studies confirmed the diagnosis of theumatoid spondylitis Ilowever, withi six months of that time and two years before lus death, leukopenis gradually appeared, and subsequently lupus erythematosus and multiple system involvement became evident The clinical course was variable, and although the patient took 600 mg of Benadryl per day, he eventually died At autopsy the morphologic changes of lupus erythematosus disseminatus were observed (Fig. 78) Differentini diagnosis - Some of our patients may have had coincidental arthritis, and it is interesting to speculate that perhaps the rheumatoid arthritis gave way to ·Fic 77 --Polyarteritis, Case 9 Photomicrograph showing a collar of in Aammatory cells around an arteriole, vacuolation of the subintimal Layet, in the adventitia, a tremendous laying down of collagen matenal, and a Lberal sprinkling of acute inflammatory cells throughout FIC 78 -Lupus erythematosus disseminatus, Case 11, Section from a muscle biopsy shows a nest of inflammatory cells among the muscle fibers, which stained poorly and inconstantly The transverse striations of skrleta] muscle have disintegrated into a homogeneous mass in several muscle bundles 100 ·COLLAGEN DISEASES 101 the different clinical and morphologic picture of collagen disease in any event, it is of some interest that of our 11 consecutive patients, nine suffered for a considerable period of time from what appeared to the referring physician to be a form of rheumatic disease It would thus seem that when we are faced with an articular problem we must be exceedingly cautious in concluding that the patient suffers from either rheumatoid arthritis or rheumatic fever and that the differential diagnosis between a collagen discase and any rheumatic disease in the carly stages may be exceedingly difficult Of considerable help in the differential diagnosis is the appearance of, the total number of and the kind of white blood cells found on routine blood examinations in a considerable proportion of cases of collagen disease, leukopenia is a part of the picture and may offer a helpful guide Bone marrow studies are often characteristic More important, however, are careful history and physical examination, which may reveal appreciable changes in the hidneys, the heart and the peripheral vessels, i e, multiple system inuolcement, all of which should suggest collagen disease. It has been well demonstrated that patients with rheumatoid arthritis may have some cardiovascular changes seemingly associated with peripheral arthntis; however, in our expenence, these cardiovascular changes are never as profound as those which are seen in collagen disease Even though the patient lias in the past presented a typical prcture of rheumatoid arthritis or theumatic fever, any change suggesting multiple system involvement may mean the initiation of a new discase or an error in the previous diagnosis It appears that the diagnosis in six of ·102 RHEUMATIC DISEASES our 11 cases was erroneous, and it seems probable that four patients either liad insensible progression of the rheumatic disease into collagen disease or developed an independent new disease. In one (Case 4), glomerulonephritis was the first manifestation of the multiple system disease. It seems likely that there is a common denominator for colagen discase and rheumatic disease in the processes of intrinsic metabolism; and experience by us and others with cortisone and ACTH lends strong support to this concept. Collagen disease should be considered in any patient with an articular disturbance who shows evidence of multiple system intole. ment. It should be included in the differential diagnosis of any arthritis and especially should be thought of in patients with typical rheumatoid arthritis or rheumatic fever who subsequently have disturbances or changes in organs no ordinarily affected by a rheumatic process. In summary, think of collagen disease as a possibility when any patient with joint complaints has any one of the following symptoms: 1. Leukopenia. 2 Hematuria or albuminuria. 3 Pleural effusion or pneumonitis. 4 Myocardial changes. 5. A skin rash or skin changes of unusual character, ie, lupus (Fig. 75) or scleroderma (Fig. 79). 6 Central nervous system alterations. 7 Any unexplained systemic disorder, If diffuse collagen disease is a possibility, muscle biopsy should be done. A positive result may clinch the diagnosis ·COLLAGEN DISEASES 103 But a negative result does not rule out a diagnosis of collagen disease TREATMENT Rich was able to produce rheumatoid lesions in rabbits by the injection of horse serum Subsequent experimental work has demonstrated that the effect of horse serum noted by Rich can be blocked by antihustamine medication. We have FC 79 -Scleroderma been able to treat successfully three of four patients having collagen disease by administration of an antihistamine (Ben. adryl) in large doses (300-600 mg per 24 hours) In these three patients the condition was diagnosed in a relatively early stage. Recognizing the variable course of collagen disease, we beleve nevertheless that Benadryl may have some Tational place in the treatment of the usually hopeless con- ·101 NIJCUMATIC DISEASES dition, since the three patients are alive and apparently symptom free. Other agents--bismuth, gold, transfusions and a wide variety of other substances-have been unsuccessful in the treatment of these unfortunate patients, and thus far there is no specific cure for collagen disease.

·CHAPTER 8 Cortisone and Adrenocorticotrophic Hormone (ACTH) PROBABLY NEVEN the history of medicine have so much snformation and misinformation been gnen the public by magazines, newspapers and radio as has been the case since the first reports on the miraculous results" and later of the "terrible hazards” of these two substances. It was in April, 1949, that Hlench, Kendall, Slocumb and Palley, of the Jajo Clinic, made the first public announcement that these two substances would produce a dramatic remission yn rheumatoid arthritis, Cortisone is one of the many steroids said to be produced by the adrenal cortex Its structural formula is known Its chemical name is 17-hydroxy-il-dehydrocorticosterone It ss at present prepared by partial synthesis from or bile by Aferch & Co and supplied as the acetate salt in suspension (25 mg per ec ). The supply from thuis source is limited and expensive Through the recent improvement of manufacturing processes the yield las lueen increased and the cost ipduced Allocation of cortisone for research was, until January 1, 1950. controlled by a committee of the National Re- 105 ·108 RHEUMATIC DISEASES search Council. In 1950, Merck & Co., with an advisory board, are making allotments to research workers at a token price of $150 per gram and hope to increase the supply at a lower price. Many other pharmaceutical companies, as well as Merck & Co., are seeking other sources of cortisone soy beans, yams and certain African plants are being investigated. Clinical trials with other products are not sufficient to permit evaluation. The chemists are also busy attempting complete synthesis of cortisone and similar substances. The future available supply may be markedly increased by success in any of these efforts. ACTII (adrenocorticotrophic hormone) is one of the hormones produced by the anterior lobe of the pituitary. Its function is to regulate the activity of the adrenal cortex 1t is at present prepared largely from the pituitaries of hogs, The Armour Laboratories have pioneered the preparation of this substance. It is packaged in ampules of 10, 25 and 40 mg. (Armour Standard). Obviously, again, the supply from this source is extremely limited and expensive. Armour and Company and other chemists and pharmaceutical companies are seeking cheaper and better supplies from natural and synthetic sources. The allocation of ACTH for research has been carried out by Armour and Company through Dr. John Prote, Aledical Director, and an advisory research board. All statements in the following discussion on ACTII refer only to the Armour Standard; we have not had experience with ACTH from other sources, Between April, 1949, and April, 1950, we have administered cortisone to 42 patients and ACTH to 50 patients with rheumatoid arthritis. Sixty of them have been observed in the hospital on metabolic control, and numerous ·CORTISONE AND ACTH 107 laboratory and chemical estimations have been made We have been chiefly concerned with uncovering knowledge regarding the mechanism of remission and in determining, if possible, the essential chemical changes which are responsible for the remission when cortisone or ACTH is administered This experience, together with observations of other careful investigators, forms the basis for the discussion to fol. low The chemical change essential for the production of remission has not been identified with certainty, but much knowledge has been gained regarding the metabolic changes that occur during administration of these substances Nitrogen, potassium, phosphorus, uric acid and salt and water balances are affected. Globulin-albumin ratios, sedimentation rates, the number of circulating eosinophils and the blood levels and urine excretion of amino acids are altered No conclusive evidence has been offered that any of the now measurable changes are essential or specific to the remission factor. The discovery of the secret of the essential remission actor may require much additional research, but the use of these two substances as rescarch tools makes eventual success almost a certainty EFFECTS IN VARIOUS DISEASES Cortisone will (1) produce a temporary remission in the activity of rheumatoid arthritis, (2) produce a remission or markedly improve the collagen diseases, such as lupus ery. thematosus disseminatus, periarteritis nodosa and dermatomyositis, (3) dramatically suppress, if not halt, rheumatic fever, though in continuous cyclic rheumatic fever it may only produce a temporary remission ·Cortisone cannot: (1) restore destroyed joints, (2) correct deformities with joint damage of any duration; (3) be effective unless given continuously or intermittently in rheumatoid arthritis, the disease recurring sooner or later after cortisone is discontinued; (4) be given continuously over a long period without danger of toxic effects. ACTH will: (1) produce a temporary remission in the activity of rheumatoid arthritis; (2) abruptly halt the course of rheumatic fever and, unless the disease is recurrent, will terminate the attack; (3) produce dramatic response in an acute attack of gout and possibly make the patient more susceptible to the favorable effects of colchicine; (4) produce at least temporary remissions in the collagen diseases named previously. In addition to the foregoing so-called rheumatic diseases, ACTH has had wide research trial in many other disease syndromes. It will clear rather rapidly such allergic skin disturbances as hives, penicillin reactions, gold dermatitis and exfoliative dermatitis. Psoriasis is improved or cleared. Virus pneumonia, infectious hepatitis and Jobar pneumococcic pneumonia are reported to be favorably influenced Long remissions have been described following administration of ACTH in myasthenia gravis Asthma, ulcerative colitis and some eye inflammations respond well, sometimes dramatically. ACTH cannot: (1) restore destroyed joints; (2) correct deformities with joint damage of any duration, (3) be effective in rheumatoid arthritis unless given continuously or intermittently, because the disease recurs sooner or later after ACTH is discontinued; (4) be given with certainty over a prolonged continuous period without hazard of tori effects.

·CORTISONE AND ACTH 109 Research studies have indicated that ACTII is not effectrve in such diseases as poliomyelitis, tuberculosis, multiple sclerosis, Parkinson's disease and psy choses DOSAGE Cortisone - Three hundred (300) mg on the initial day of treatment in two divided doses, and 100 mg in a single dose daily thereafter has been the standard initial procedure The duration of treatment in our series has varied from eight to 14 days One patient of the 42 required 200 mg daily to produce remission Usually the period of eight to 14 days is adequate to achieve marked improvement ACTH.--This hormone is extremely active and in large doses is capable of producing profound and disturbing metabolic changes It is therefore desirable to use the minimal effective dose. Of 45 patients with active rheumatoid arthritis who have received 40 mg or less per 24 hours (10 mg every six hours), only one has required larger doses The standard routine of dosage that we have adopted is 20 mg every six hours, to 40 mg per day, for 10-20 days Thuis is sufficient usually to produce striking improvement UNDESIRABLE PHYSIOLOGIC EFFECTS Toxic Reactions! Following the aforementioned dosage schedules, three patients on cortisone des eloped very slight rounding of the face which disappeared within two weeks after the medication was discontinued One patient, who had previously had a coronary occlusion, had mild pulmonary edema on the seventh day of cortisone administration Of hre patients recen - ing 80-160 mg of ACTH daily, one had transient hyper- ·110 RIEUMATIC DISEASES of tension and one, etlema. Of the 45 patients given 40 mg. ACTII or less daily, three had transient rounding of the face, which disappeared within a few days. On the 40 mg. daily schedule, there were no other measurable disturbances such as hypertension, glycosuria, hyperglycemia, sodium and water retention, hirsutism, mania or voice changes. Exhilaration and mild cuphoria with some insomnia were occasionally encountered both with cortisone and with ACTH. CLINICAL RESPONSE The clinical response in patients with active rheumatoid arthritis to the administration of cortisone and ACTH is, so far as we can tell, identical Within 48 hours the patients described a feeling of well-being and a decrease in joint stiffness, rest pain, motion pain and joint tendemess. There was sapid recovery of strength Nearly all patients show a pronounced increase in appetite and energy. There was marked improvement in strength as measured by the grip. Foint swelling began to diminish by the third day. Patients in the early stages of the disease, with little or no joint destruction, usually underwent complete clinical remissions. Figures 80 and 81 illustrate the clinical course. All 92 patients exhibited measurable remission Eighteen (with minimal joint destruction) experienced a complete clinical remission; 70 had striking improvement. Four evi denced measurable remission of some degree but were unsatisfactory for further studies. Duration of improvement.-The period of improvement has varied in this group of patients from one day to more than cight months. The average patient begins to relapse the ·SA (Wintergrun? housands 100 2007 HILS no/e mm 100 HIRT NIT* PAIN 1 STUFFNESS tm Hols SHENNESS # weltable depressed stimuleled dearly hungry malond Cool I WO 116 WEICHT 1> CORTISOME (Morek) 400l soc 2001 JOOL COH45104 DAYS 1 THEATMENT DAYS FC 80-Typical response of rheumatoid arthnuts to cortisone ·00 ESK nh: Wolergren) 20 12 WBC puping wwmo B 6 EOSINO PHILS ww as you 300 2001 100 PAIN With H # WER stimulated Insomnia hungry swap hoppy th MLDOD TENDERNESS STIFFNESS PRESSURE mm Hg 140H 120 100 60 swoim WEIGHT ITB 116 114 N2 BOH ACER Bu Armour Stondo) OM 23.4 5 CONTROL DATS 2 3 4 5 6 7 8 9 10 12 B 14 TREATMENT DAYS FIC 81 - Typical response of rheumatoid arthritis to ACTII 112 ·CONTISONE AND ACTJI 113 second week and gradually within a month returns to his previous state. Three patients have maintained 75 per cent of improvement for more than sıx months Fifteen patients maintained definite Improvement for more than three months Three relapsed sathin 48 hours The duration of remission is unpredictable The rest of our group are being studied on maintenance routines so are not available for a report on duration of rcmission. Attempts to maintain rcmission -When a patient has achieved a marked improvement with cortisone or ACTII, on the dosage schedule described, the physician is faced with the problem of attempting to maintain this remission Two general methods are open to him lle may discontinue the medication and depend on repeat courses in the hope that the remission will be maintained longer after the addtronal courses, or he may elect to try the smallest effective maintenance dose given continuously 1. ACTH Remission can, in some instances, be maintained by continuous small doses One patient has been maintained in complete remission for more than six months on 5–10 mg daily. Ten patients have retained maximal improvement on 10 mg daily, in divided doses, for three to sur months in two of thesc, transient edema developed interrupted courses of treatment have been tried on seven patients who have experienced a maximal remission on four occasions during the past year on 20 mg or less daily (divided doses), for a treatment period varying from 10 to 14 days It is our impression that divided doses-a minimum of twice daily and preferably four times daily are superior to the single dose 2. Cortisone Remissions in some instances have heen ·114 RILEUMATIC DISEASES maintained by others with doses of 50–75 mg. daily. One hundred (100) mg. three times weekly has been tried. We have limited our studies to the interrupted course method, using the dosage schedule already described and allowing a three week rest after completion of the course before repeating the course of cortisone It is not known whether improvement will be prolonged after discontinuance of the medication We have observed no serious toxic effects so far in the 30 patients on this routine. 3. The basic treatment program, consisting of corrective and postural exercises, correction of anemia, blood transfusion, etc., has been helpful in naintaining muscle tone and joint motion gained during the ACTH or cortisone remission 4. Miscellaneous Gold therapy in conjunction with ACTH or cortisone is being tried, but insufficient time has passed to allow judgment of its advantages Many medications, including some of the other steroids, have been used in an attempt to maintain the remissions, but so far without uniform benefit PRECAUTIONS IN USE OF ACTH AND CORTISONE Although it is true that patients receiving low doses of ACTH and cortisone (in the dosage described for a limited period) seldom have undesirable physiologic effects, the most careful observations may be required to avoid these complications Rounding of the face, sudden weight gain, edema, severe fatigue, elevation of blood pressure, glycosuri or hyperglycemia and disturbing mental changes may occur Sodium and sodium chloride intake should be reduced to a minimum if it is necessary to give larger doses or to continue ·CORTISONE AND ACTH 115 treatment for longer periods This should be done also whenever there is evidence of water or salt retention Fluid limitation may also be helpful Potassium excretion in the urine is increased with the administration of ACTH, the symptoms of potassium deficiency, such as weakness and characteristic electrocardiographic changes, can be eliminated by regular administration of one of the potassium salts in doses of 3-5 Gm daily ACTH and cortisone have a profound effect on carbohydrate metabolism It is probable that in the dosages discussed neither hyperglycemia nor glycosuria will occur in the nondiabetic individual These substances also increase the insulin requirement in the diabetic, and patients known to have diabetes should not be given ACTH or cortisone unless the most rigid conditions of study are carried out The evidence points to the probability that glycosuria and hyperglycemia that have developed during a study period have disappeared after a week or two Patients with chronic nephritis should in general be excluded from ACTH and cortisone therapy Patients with psychopathic personalities, known psychotics or patients with a known history of psychosis should not recen e ACTH or cortisone owing to the known effects of these substances on cerebral function ACTH EFFECTS ON COMPLICATING DISEASES In addition to rheumatoid arthritis, one of the following conditions in one or more patients were dramatically relieved by ACTII asthma, Sjogren's syndrome (keratoconjunctivitis sicca, with dry mucous membranes), psoriasis, severe peni. millin sensitivity reaction, atopic eczema, virus hepatitis with ·116 RIIEUMATIC DISEASES jaundice, hyperthyroidism, gold dermatitis and various inflammations of the eye, including severe iritis. COMMENT It is obvious from the foregoing data and information that much more research work must be done before these substances are suitable or available for routine treatment of rheumatoid arthritis. More information must be gained regardıng long-term administration, ways must be found to prolong remissions once they are achieved, new substances must be sought that are cheaper and more easily available and, above all, the remission factor X should be sought It it quite conceivable that when the specific mechanism of remission is known, it may be produced and maintained at the cost of a few cents instead of many hundreds or thousands of dollars.

·CHAPTER 9 Prevention and Correction of Deformities PREVENTION OF DEFORMITY RHEUMATOID ARTHRITIS DRUGS AND COMPOUNDS, including cortisone and ACTH, will not mobilize a frozen joint vor make the deformed cripple jump from his wheel chair and dance The new compounds hold great promise as guides to discovery of a way to stop the innammation and progress of active arthritis, but they will not restore damaged joints nor release tight adhesions With the expectation of a new method to stop the progres. sive destruetive activity of arthritis, it becomes more than eler before the duty of every physician treating arthritis to teach every patient methods of preventing deformity and maintaining tunction Not only can many of the deformities be prevented, but joint function can be maintained by simple measures that every patient can follow By following a good program, the patient has a chance to salvage a useful body when the disease process either burns out or is arrested medically, be it after six months, six years or longer.

·118 RHEUMATIC DISEASES Prevention of deformity must start at the onset of the disease with a careful explanation to the patient of the nature of the disease and its serious consequences. If the onset is acute and sufficiently severe, the patient is usually quite willing to accept a full routine of treatment to get relief. With the more common slower, insidious onset that charac terizes so many cases, it is more difficult to convince the patient that he must follow a program that will often seem drastic or out of proportion to the amount of discomfort he is suffering The significance of the early swollen finger joint or wrist is often minimized and the patient goes on straining the joint in his daily occupation. The first signs of rheumatoid arthritis which appear in the feet are frequently mistaken for fallen arches and the patient may walk on them unadvisedly for months. It is during the early months of this disease, before too much damage has been done, that the patient should have the benefit of a careful explanation of the problem At this point, if the physician will take the time for a careful evaluation and explanation, much crippling damage can be prevented. Not only will he help his patient but he will avoid the need for many hours of explanation later when the patient is dissatisfied and is still looking for an easy cure The first thing the patient must understand is that rheumatoid arthritis is a progressive crippling disease and that if it goes on unchecked for many years, as it does it can leave him a helpless cripple or, at least, seriously handscapped. The patient who understands the insidious nature of the disease will much more readily accept a broad program that is going to protect him for years to come Until we have found a short cut, a way to stop the activity and the most cases, ·PREVENTION OF DEFORMITY 119 progress of the disease, the patient must learn and follow a başıc program to protect his joints and maintain motion, re. gardless of how long the disease may last. He should also understand that the disease involves all parts of the skeletal system-demineralization of bones, erosion of cartilage, atrophy of muscles, inflammation of joint capsules, weakening of ligaments and tendons around joints, all of which cause progressive stiffening, loss of motion and ultimate ankylosis unless active preventive steps are taken. After showing the worst of the picture to the patient, one can encourage him by explaining that there are ways of mnimızıng defornity and maintaining a large mcasure of joint function. To accomplish this objective, the patient must fully understand and be carefully directed in the execution of the three fundamental parts of his program (1) avoidance of strain to joints and muscles, (2) proper rest, and (3) proper exercises 1. AVOIDANCE OF STRAIN TO JOINTS AND MUSCLES Many cripples have been made by the very bad advice that they must "keep going" because if they ever quut they will not be able to walk again Consequently, the patient often struggles along on sore feet, ankles, knees and hips, increasing the joint damage and deformity with every step until he can go no longer This bad practice has been generally followed simply because no one has told the patient that he could better preserve motion and strength by evercising in bed without strain on his jounts. Some types of occupation are often helpful in maintaining strength and motion, but too often we find the occupation harmful, for example, ·120 RILEUNSATIC DISEASES duties of the housewife may cause daily trauma or strain to the affected joints. The individual may be able to continue work for an indefinite period, but lic runs the risk of progressive and total destruction which may completely disable him ultimately. If the patient is lucky, the disease will bum out before he becomes too badly crippled; unfortunate}y, these cases are in the minority. It is here that it becomes important for the doctor ta evaluate the extent and progress of the disease. The problem is to make the joint function last as long as the patient needs it for economic reasons and for his happiness. The patient should be encouraged to work as long as his occupation is not damaging. Son patients with minimal involvement may be allowed or encouraged to do full-time work, others part-time work, and some may have to change the type of occupation The patient with a severe form of arthritis ultimately may be much better off economically to take six months of from work at the onset rather than to go on until he becomes crippled for the rest of his life. To the young patient, wage carner or housewife, the doctor has an exceedingly serious problem in the advice he is going to give. In outlining a program of treatment, many factors have to be consideredthe extent and severity of the disease, rapidity of its proches ress, estimation as to prognosis and the individual's temperament, economic status, etc. When there is active inflammation in the weight-bearing joints, the patient should stay off fuis feet as much as possible If the inflammation is minimal and his posture not too bad, he may be allowed to walk short distances to the bathroom, table or automobile, provided this does not aggravate the joint disturbance or the deformity. Pain during use or exer- ·PREVENTION OF DEFORVITY 121 cise usually has no significance so long as it does not persist alter exercise and is not any worse when the same amount is done the next day. This "rule of tolerance” is an important gude and more is said about it later (p 141), When there is a deformity in the foot or ankle or a flexion contraction of the knee or lup, there is naturally a strain on M. T BAR NOS 4. FIC 83-Size, shape and location of the fourt supprit are important in rheumatosd arthnts the joint on weight-bearing Thus strain, through poor posture and mechanics, Decurs often enough to maintain signs of activity in the joint, such as heat, redness, ssvelling and sore ness This fact can be denionstrated by disappearance of signs of active arthritis when a clclornity is corrected and proper weight-bearing posture established. Feet -Feet are conimonly molved at the onset of rhen- ·122 RIDEUMATIC DISEASES matoid arthritis. In the carly stages, beforc x-ray changes develop, it is sometimes difficult to differentiate between the pain of arthritis and the pain of a fallen arch. If there is actite arthritis in the feet that cannot be relieved by the wearing of proper shoes and supports, the patient should not be al- FC 83 (top) -A good sturdy shoe with metatarsal bar is essential to prevention of arthrite deformity. Fic 81 (bottom).-The arthriuc patient is not permitted to wear slippers lowed to walk or at least shondd walk only minimal distances. When the pain and symptoms can be relieved by proper shoes, supports, metatarsal pads, bars, etc , the patient may walk to tolerance. Proper support for the foot is indicated to give correct ·Fics 85 AND 88 (top) -- Tension in the arthritic font is satisfactoril regulated by use of elastic bandages Elasticity is restored to the bandage by washing every few days FC 87 (bottom) --Example of a footboard that can be des used to pre- Sent footdrop 123 ·124 RHEUMATIC DISEASES balance and posture to relieve strain to the joints. It is usually sufficient to prescribe a low-heeled, straight-last, strong shoe, of adequate size, to which can be added sponge-rubber longitudinal arch supports and metatarsal pads as required (Figs 82 and 83). Soft slippers aggravate sore feet and increase deformity (Fig. 84). High narrow heels may produce strain on all weight-bearing joints as well as throw too much weight on sore metatarsal joints. The longitudinal and metatarsal pads must be of the correct size, large enough and placed properly in the shoe Adjustment of position and change to new ones is often necessary. Metatarsal bars placed on the outside of the shoe are often an additional advantage and remove pressure from sore metatarsal heads Wedging of the shoe may be necessary to give proper alinement (see p. 169). For further relief of strain on the longitudinal arch and ankle, a small 2 in. elastic bandage is helpful (Figs. 85 and 86). Dependent edema is very common when circulation is poor and the patient sits too long. Edema is increased by garters, so their use is forbidden. The patient should never allow the ederna to persist and, when possible, the legs are elevated long enough each day to eliminate swelling If the patient must be on his feet it may be necessary to use elastic bandages or stockings Relief of strain on the foot and ankle at rest is also important. For the patient in bed, a footboard (Fig 87) is suggested to prevent footdrop Medium-sized sandbags can be placed on the outside of the foot and leg on the bed to prevent external rotation and eversion (Fig 87). Knees – If treated adequately and early, 100 per cent of the flexion contraction of knces can be prevented with knee involvement the patient seeks relief in flexion Pillows under ·deformity F 88 (top) --A means of relief commonly assumed by patients with arthritis in the knees This contributes greatly to flexion contraction and Fac 69 (bottom) ---For the patient with arthritis of the knees, ordmary boards should be placed full length under the mattress Blacks elevate tie bed to lessen strain on the joints when getting in and out of bed 125 ·126 HEUMATIC DISEASES the knees, which give relief, simply add to the flexion costraction and have been the greatest curse in producing de formity (Fig 88) With any more than the very minimal activity of arthritis in the knees, the patient should not be allowed to bcar weight. Walking with inflamed knees, even though they are still straight, may increase the inflammation and the active arthritic process with a hent l.nan oh... vation is fore wain prann.. ot -Uulu alu sandbags hold the knees in the correct position for maximal rest and relaxation. With out the sandbags the feet tend to evert, causing torsion and chronic strain at the knees even at bed rest (Figs 90 and 91). If there is enough "give" to the bed so that the knec cannot be rested in maximal extension, a small towel is folded and placed under the ankle to insure full extension (Fig 92). PLASTER SHIELLS (CASTS).-}f inflammation and pain in the knee are not relieved by rest on a flat bed, a plaster shell is recommended When the knee is acutely inflamed it necessary to give a narcotic or even a light anesthetic to apply the first cast to make a rest cast for the knee, the leg is wrapped in sheet wadding from the hip down over the foot and well above the toes, using two or three layers. After this, 6 in rolls of plaster of paris bandage are used to make a solid leg cast extending from the hip down over the foot and up 2 or 3 in above the toes (Figs. 93 and 94). While the cast is bemg put on, it is important to keep the leg in may be ·ty FIC 90 (top) - Torsion and lack of support increase strain on the arthritic knee FC 91 (bottom left) --Correct support and alnement oblamed by sandbags and footboard provide maximal relaxation FC 92 bottom right) -Early minimal contraction is presented by proper placement of a folded towel 197 ·128 RHEUMATIC DISEASES maximal extension, holding the foot in correct alinement and at right angles to the leg. A quick-setting plaster is used, and as soon as the plaster is set a top strip is cut from the cast with a sharp knife. The cast is then spread, making a FIC 93 (top) -Rest cast for the arthritic knee. Sheet wadding adds to comfort The leg is held in maximal comfortable correction while the cast is applied Foc. 94 (bottom; –Plaster is rolled on to the desired thickness, sık roll of 6 in plaster bandage being the average requirenent (Posterwr plaster strips help strengthen the cast) shell with high side walls (Figs. 95 and 96). (The high side walls are important to keep the leg from rolling out when the patient uses the cast for resting. The high foot constric tion is helpful in keeping the weight of the bed clothes off ·Fic 93 (top) - The cast is easily cut and spread open after the plaster Sets and before it hardens or is entirely dry FiG 96 (bottom) --When the cast has dried it is lined with stockinet, sheet wadding as lield in place by short strips of adhesive tape ·130 RIIEURIATIC DISEASES the feet.) The cast is then removed, allowed to dry and later is lined with stockinet (Fig. 96). The cast is then ready for the patient to use as a rest cast in bed for as many hours a day as he can tolerate it comfortably. By complete support of the leg in such a cast, the patient gets maximal relaxation of the flexor muscles, and inflammation of the knee will subside most readily with this type of support. Periodically the patient is taken out of the shells to sit up on the side of the bed or in a chair for relaxation and for the exercises de scribed later (pp. 145 ff.). With an acutely inflamed joint one may choose to leave the leg in the solid cast (the strip is cut, but tied in, Fig. 97) for five or six days. This gives complete immobilization and will often help quiet an acutely inflamed or hot joint. On occasion the joint may be kept immobilized longer-tip to one or two weeks, but not longer because ankylosis sets in rapidly. Although ankylosis will stop pain and is recommended by some, we do not advise it as long as the patient has a chance of maintaining a functioning useful joint. When the patient has limited knee involvement but his knees are straight he is allowed to walk. If he cannot walk without limping, use of crutches is advised to relieve strain to the knee joints. A cane is never used (Figs 98 and 99). Crutches should have rubber pads and tips and must fit. To fit them, with the patient in good posture and shoulders relaxed, measure from the axilla to the poor at a point 8 of 10 an out from the foot. When using crutches, the patient does not lean on them but simply uses them for balance, apply. ing the alternate crutch-to-leg method to keep a normal gait without limp (Figs. 100 and 101). Even though the knees are strong enough for the patient ·PREVENTION OF DECORVITY 131 to walk, there may be enough active arthntis to be aggrarated by climbing steps or sitting down on and rising from chairs; consequently steps and low chans are to be as orded In such a case it is very helpful to elevate the toilet seat, (Figs 102 and 103) and put blocks under the bed and chairs (Figs. 104 and 105). With elevated seats and bed the pa- FIC 97.When complete immobilization is required for a short pxxxx) the cost may be ent are the strp tied back in place, permitting easy conserslun to a rest cast later tient can get up and down readily with a minimum of strain and damage to the knees. Low seats not only cause more stram when the patient gets up Init promote bad posture and dcformity (Fig. 105). If the knee is swollen or somewhat unstable but it is decided that weight-bcaring is not harmful, the use of a 3 in elastic bandage to give some pressure and additional sup port (Fig. 106) is often helpful This bandage must be ·132 11 ' Fic 99 (left) -A cane gnes no support to the knee and does not present limping FiG 99 (center left) - Crutches belp maintain good pristure and normal gait by balancing. Fics. 100 AND 101 (centes stght and right) Per correct use, swing the crutches as one does the arms in normal walking The right crutch balances for the left leg, the left crutch, for the right leg The crutch parallels the fut. Avand reaching out too far an oling to long stess ·PREVENTION OF DEFORIT 133 applied with care so as not to place it too tightly above or below the knee hut yet give good firma pressure as it is drawn over the condyles laterally and medially llips -Involvement of the hups in rheumatoid arthritis presents one of the most difficult of problems Here again weight-bearing must be limited or at times forbidden Weight- Pc 103 (left) -Commocle built on casters to bed height. The hack is en to permit to hng over the talet Fu 103 (right)-Wanden frame, cohered myide and out with time of alumum, elevates the toilet seat to cow enlent beight Bearing on inflamed hips adds strain to the points which in turn increases muscle spasm and produces limitation of mo. tion and progressive and increased loss of cartilage With hip invok cment it is essential to use a flat bed with hoards under the mattress to keep maximal extension of the hips Periodically the hips are rested in different posi-

·x
FG 104 (top) -Left, boy frame built to the desired height to fit a well
selected chair The patient hicks the footrest aside when ready to stind
Right, specially built chair designed to provide suitable height, frin seat arre
straight back and arms
Frc 105 (bottom) --Low chair means bad posture and joint strain whe
the patient gets up
184

·PREVENTION OF DEFORJITTY 17 trons-fesed, abdacted, extended and rotated. The ines sits up periodically for maintenance of Betion on the intentar and relaxation from rest in the extended position infinuation has subsided sn Sciently and the aloved to walk, he must tise catches of being Thost. torom ved at 2. cf should be I tvennt S Caracter de esta w Eated. - Oructens + జటe is les x that prassifiem her pic - Errand fr. 1.- gmcriv anclued ef barn! rantain correct postire nad Critches are used for Con the hics. Us Cppor cremities - daarna batut is usually es murrant to teach that is 6.

·138 RIIEUMATIC DISEASES his body from the chair or the bed, as so many do when they have knce and hip involvement. When getting up from a low chair the patient is likely to raise himself by pushing up with his arms (Fig. 107). The fingers are ſexed underneath FiG 107 (left) -When rising from a low chair, pushing up with the - wbvarity IW Y, to a standing position the hand and are strained. The wrist and elbow also suffer a considerable strain in this maneuver. High chairs, high toilet seats and high beds help avoid this strain on the upper extremity Whenever it is practical the patient should ask for help in getting up from low places in order to reduce the strain A safe and easy method for the attendant and the ·helpful to make a plaster shell for the patient to rest in PREVENTION OF DEFORMITY 137 patient is shown in Figure 108. Note that the patient comes up with stuff legs to avoid strain on knees The attendant lifts by using his legs, knees bent, back stiff and pulling backward, letting his own weight do a good part of the work. Many occupations that require lifting and heavy twisting of the arm or wrist (and many of these are found in household work) frequently add strain to the involved joints with inevitable damage. Occupations that require strain of the joints of the upper extremities obviously should be avoided The greatest harm that comes to the upper extremiti is usually from improper rest positions (Fig 109) Characteristically, patients are found with the arms at the side, elbons flexed, hands over the chest or abdomen and wrists flered This is the most comfortable position and the one most patrents seck, but it inevitably increases flexion contractions When the shoulder is involved encourage the patient to rest periodically and as often as is convenient with the arms abducted For sitting, arrange a chair with high arms so that he may rest with the shoulders in abduction The elbows too should be rested as often as possible in maximal extension On the bed this is accomplished by placing a small pillow or a folded towel under the forearm and extending the arm as far as it can be done comfortablu The palm is turned up so that the wrist may rest in an extended position over the edge of the towel (Fig 110) A small pad or toxel is placed under the upper arm to take pressure off the elbow In very acute stages of inflammation it may be En maximal extension. Care should be taken to prevent loss of

·Fic. 109 (top).-Flexion contractions of the upper extremity are waits
ened by this position
FIG 10 (bottom).--Folded towels are used, with thickness adjusted to
give maximal comfortable ertension
138

·PREVENTION OF DEFORMITY 139 Benon of the elbow, for a fixed straight elbow is obviously worthless Wrists notoriously develop wristdrop with fleuon contraction A wrist that is in flexion definitely limits the patient's ability to make a good grip, whereas with a wrist that becomes ankylosed in extension the grip need not be lunited (Fig 111). For this reason, with wrist involvement and a tendency to flexion contrachon it is important to supply protection by means of a splint when the patient is up and about or for resting in bed when he is unable to rest in er: tension as already described The best splint for the wrist is a light weight cock-up made of a few layers of plaster The plaster can be molded well to the patient's arm, wrist and hand and can be extended up over the ulnar side to prevent the common ulnar deviation (Fig 112) The splint is best carned down to include support of the proximal phulanx By doing this we prevent excessive abnormal contraction at the metacarpophalangeal and proximal interphalangeal joints. The proximal interphalangeal joints that tend to hyperextend can be flexed over the end of the cast If the cast is made light weight and small enough, the patient can still use his fingers This is a great advantage, allowing the patient to wear the cast and continue many of his daily activities as well as pull the bedclothes over him at night Spine -Although the spine rarely offers much of a problem in peripheral rheumatoid arthritis, attention should be ghen to good posture Standing too long, working in bad positions and sitting on low chairs with cun ature of the spine increase strain and deformity To maintain correct posture and obtain the proper kind of rest, a flat bed is preescribed If the bed is not firm, boards should be placed full

·-
Fic 111 (top) -Wristdrop Grip is always puor.
FIC 112 (bottom).--Plaster cock-up provides extension with comfort
High side wall presents ulnar deviation
140

·time erercising. Regularity and balance of the daily schedule PREVENTION OF DEFORMITY length under the mattress. When the patient is allowed to sit up, a good straight-backed chair should be furnished that gives proper support to the spine Sitting for long hours at a time should be discouraged. Occupations that require the patient to bend over a table or a desk and such activities as making beds, ironing and leaning over a sink may increase fatigue and strain to the back 2. PROPER REST Before prescribing the proper rest for a patient with rheumatoid arthritis, it is important to take sufficient time to review with him the different causes of strain and to outline a specific program and methods of avoiding them The amount and kind of rest, including splinting, will of course depend on the activity of the disease and the judg. ment of the physician Excessive or prolonged rest should be avoided because this leads to more stiffening and loss of motion Frequent turning in bed or change of position helps rest different muscle groups Sound sleep under sedatives aggravates the morning stiffness Aspirin, to promote relaxation and rest, is usually beneficial and sufficient However, aspirin should not be used to cover pain and thereby allow the patient to sit up longer or go beyond his physical capacity. Patients must be warned not to sit in one position an hour usually being the limit At certain times a patient may need five or six short rest penods during the day. As he improves, he spends less time resting and more for rest and exercise must be followed oo long, ·142 REUMATIC DISEASES 3. EXERCISES Exercise is essential to the maintenance of function. In the presence of atrophy and the tendency to contraction that characterize rheumatoid arthritis, the prescription of the kind of exercise and the amount is of paramount importance. Unfortunately, too many patients are simply told to exercise as much as they can to maintain motion and strength with out being given specific directions. It is a mistake to hard the patient a list of exercises and expect him to follow them properly without some instruction and follow-up supervi. sion. The time taken at the beginning not only in teaching patients a good system of exercise but in explaining to them the reasons for csercise is well spent. Reasons for exerrisc -With careful explanation, any pa. tient can be made to understand why the assigned exercises are important to his future well-being. 1. To maintain and increase motion Marimal Tange of motion will be maintained in joints only by putting every joint through its maximal range daily and up to tolerance. This helps prevent deformity. 2 To strengthen muscles that support joints. Exercises will build muscle strength Without muscle support, joints bang on their ligaments, causing chronic irritation, subluxation and deformity. Muscle support prevents deformity. 3. To increase circulation. Circulation in theumatoid arthritis is notoriously bad, and regular exercises will do more to improve blood flow than any other treatment. A patient with much involvement of the weight-bearing joints cannot walk far enough to preserve his muscle tone and strength In addition, the walking does not require full ·PREVENTION OF DEFORMITY 12 range of motion of the legs. In bed, however, with daily use of a good set of corrective exercises without the imtation of weight-bearing, muscular development is unlimited Bu using corrective exercises of all muscle groups he has a better chance of maintaining a full range of motion Many patients say they get all the exercise they need through their housework or other occupations Here it should be explained that most housework and many occupations produce strain on joints and may do more harm than good, and certainly do not provide for the full range of motion of each joint daily If the patient is able and required to work he is much better equipped for work if he has developed good musculature through regular daily exercises Tolerance for crercise --The amount of exercise prescribed is very important. Too often the patient says "Yes, I was given a set of exercises, but when they hurt my joints I quit." Ilere one must immediately explain to him that there is a definite amount of exercise every patient can tolerate without aggravating his joints Because of atrophy and weakened muscles, the tolerance for exercise in a patient with rheumatoid arthritis may be exceedingly limited It therefore is important that he follow a definite schedule of so many exercises per day on a definite training program process is very acute or active the tolerance may he only two or three contractions of the muscle fatigue sets in Practically every patient can start with two or three contractions of each muscle group without having trouble. This series is repeated tuo or three or four times alaily, and after two or three days, if the patient is tolerating This amount, the number is increased by one when this is Olerated, after three or four days, the number of exercises When the group before ·144 RHEUMATIC DISEASES is increased again. A 10 per cent increase at a time is safe. Exercising only once a day with three or four contractions is not going to build muscle or be sufficient to do any good, so the patient must be impressed by the fact that he must have at least two or more exercise periods per day to make any substantial gain. RULES OF TOLERANCE -1. Some muscle pain and soreness may be expected when the exercises are first started, but this will usually subside within a few days to a week 2 Pain during exercise is not significant. 3. Pain that persists for hours after the exercise period or increased pain with the same exercises the next day means that the exercises should be decreased until the added pain is gone The exercises are decreased, not stopped As soon as the increased pain has subsided the exercise again may gradually be increased as scheduled. Tolerance for exercise varies, of course, according to the weakness and length of non-use of the muscles and the amount of inflammation of different joints Certain exercises can be pushed along much faster and in greater numbers than others, for example, exercises 1, 2, 8, 11, 12, 14 and 16 in the following list. The patient learns this as he As the patient gains strength, he is constantly encouragec do more things for himself as long as the extra activities not produce joint strain or unusual fatigue. The prescription of exercise. --This must, of course, ! individualized in each case, depending arthritis, the degree of activity, the general state of nutrition, strength, etc. A physical therapist trained in muscle re-education work will be able to carry on with the patient after simple directions from the doctor. Without the help progresses. on the extent of the

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·144 REUNISTIC DISEASES is increased again. A 10 per cent increase at a time is safe. Exercising only once a day with three or four contractions is not going to build muscle or be sufficient to do any good, so the patient must be impressed by the fact that he must have at least two or more exercise periods per day to make any substantial gain. RULES OF TOLERANCE“). Some muscle pain and sore. ness may be expected when the exercises are first started, but this will usually subside within a few days to a week. 2. Pain during exercise is not significant. 3. Pain that persists for hours after the exercise period or increased pain with the same exercises the next day means that the exercises should be decreased until the added pain as gone The exercises are decreased, not stopped As soon as the increased pain has subsided the exercise again may gradually be incrcased as scheduled. Tolerance for exercise varies, of course, according to the weakness and length of non-use of the muscles and the amount of inflammation of different joints. Certain exercises can be pushed along much faster and in greater numbers than others, for example, exercises 1.2, 8, 11, 12, 14 and 16 in the following list. The patient learns this as he progresses. As the patient gains strength, he is constantly encouraged to do more things for himself as long as the extra activities do not produce joint strain or unusual fatigue. The prescription of esercise. This must, of course, be individualized in each case, depending on the extent of the arthritis, the degree of activity, the general state of nutrition, strength, etc. A physical therapist trained in muscle re-education work will be able to carry on with the patient after simple directions from the doctor. Without the help ·PREVENTION OF DEFORVITY 145 of a physical therapist the doctor will be obliged to take more time to explain the list of exercises to his patient and to teach him at the start It is well to remember that deformity comes mostly in flexion, therefore extension exercises are stressed For simplification, active exercises that would be suitable for a patient with rheumatoid arthritis and multiple joint involvement are outlined as follows Achee Exercises for Rheumatoid Arthritis 1 Lying on back, legs straight Take a deep breath, expanding the chest. Hold the chest expanded until the count of 5, then relax. 2. Lying on back, legs straight. Contract the abdominal muscles, flattening the abdomen Hold the abdomen fat while breathing naturally. 3 Hands a) Male a fist b) Stretch the fingers straight c) Spread the fingers apart d) Pull the thumb over to the tip of each finger, making as round a circle as possible 4 land resting on the bed, palm down, or on body if elbow will not straighten Raise the hand for wrist motion 5 Elbow bent at a night angle, upper arm resting on the bed a) Bring the fingers to the top of the shoulder. b) Keeping the palm turned up, push the hand doxını vard the bed, straightening the elbow 6 Arms resting at sides, palms toward body a) Raise the arm sideways away from the body, then back b) Raise the arm, thumb leading, forvard, upward and as pack as it will go, then down to the side in res erse order c) Lying on back, legs straight, arms at side Raise the arm ard, upuard and as far back as it will go Then swing the out to the side and around back to the side Lying on back, legs straight Curl the toes down, keep the ·146 RHEUMATIC DISEASES toes curled and turn the foot in and pull the foot up, stretching the heel cord, hold the three motions until the count of 5. Then relax the whole foot. 8. Lying on back, legs straight: Contract the muscles on top of the thigh, pulling on the patella (kneecap) and flattening the knce. This exercise is increased up to 10 times a day, 10 times each, if knees are particularly involved. 9. Lying on back, legs straight: Holding the leg straight, take the leg 15 in. to the side and back. Do not go far enough to tilt the pelvis. 10 Lying on back, knees bent, feet on the bed: Raise the knee toward the chest, straighten the knee by lifting the foot in the air, stretching up with the heel; let the knee bend and the foot return to the starting position. Alternate knees 11 Lying on back, knees bent, feet on the bed: Pull in the abdomen, then squeeze the buttocks muscles as if to roll the seat up off the bed, tilting the pelvis and flattening the lower back hard on the bed. 12. Lying on back, legs straight. Flatten the neck by making a double chun, and at the same time stretch up through the top of the head as if to pull the ears away from the shoulders. 13 Lying on back, legs straight: Turn the cheek as far as possible toward the bed, stretch, keeping shoulders flat on the bed, come back to straight position and rest, 14 Lying on back, legs straight: Pinch the shoulder blades together. 15. Lying on back, legs straight, arms at sides with elbows and backs of hands on the bed. Keeping the hands and elbows as near the bed as possible, push the arms up until the upper arms are beside the ears, stretch; pull down to the sides in the same manner. 16. Lying on back, knees bent, feet on the bed. Take a deep breath, cypanding the chest, hold the chest expanded and push the diaphragm up and down fise times (panting). 17. IVhen the knee has a severe ferion deformity, add knee ·PREVENTION OF DEFORMITI extension in the sitting position on the side of the bed (contracting muscles on top of the thigh and pulling the patella) Again it should be noted that these exercises can be vanied according to the degree and extent of the involvement in each patient. Some patients will not need or be required to do all of these exercises, others may be given additional crercises to suit their particular needs. In any event the patient should be furnished with a typewritten list of the exercises he is to do, with specific instructions how to do them and how many to do daily He should be given specific instructions about reactions and rules of tolerance so that he does not stop because the joints begin to hurt After the patient is given the first course of instruction and a list of the exercises, he practices the exercises for a weck and then is observed to make sure he is doing them correctly. It may be necessary to continue checking some patients weekly or perhaps only monthly to make certain that they are doing their exercises up to their tolerance It is well also to inquire into the amount of time spent at erercises -ccause many patients tend to hurry through them The crage patient builds up to two or three hours or more of ercise daily The patient, of course, should be instructed to establish egular schedule for his exercises, doing them at regular rs each day All exercises are done slowly, with complete xation between each crercise As the patient improses, tance can be added he patient who has not had regular erercises and who ad the disease for any length of time will usually be sed and much pleased to note how much he has ac- -shed in the first month or two on a regular exercise ·150 RIIEUMATIC DISEASES tient is encouraged to use more of his own muscles, making a combined active-passive exercise. With the development of still more tolerance the therapist can give extra push traction to gain maximal motion up to normal range. or ANKYLOSED JOINTS When there is no joint motion, exercise is necessary to maintain the best state of nutrition and prevent the trophic disturbances and dependent edema that come with inactivity. This type of exercise is called muscle tensing and is accomplished by the patient's learning to contract or set his flexors against his extensors By the tension muscle exercises the patient not only maintains a much better state of nutrition than he otherwise would have but is usually much more comfortable, with less soreness and aching of muscles Exercises 1, 2, 8, 11, 12, 14 and 16 (pp. 145 f.) are important for all patients with rheumatic disease but are specially tioned here because they can be done in spite of joint ankylosis. Pool exercises.-Exercises under water are, as a rule, highly beneficial and their practice is encouraged whenever possible. In patients with subacute arthritis and in the presence of much muscle tension and spasm, water promotes relaxation Exercise under water is especially good when the weight-bearing joints are involved The patient gets much better knee and hip motion than he could in bed or from valking and has no strain of weight-bearing. The Hubbard ink is useful, but a pool shoulder-deep affords better chance er walking and maximal extension. The patient should be men- ·PRET ENTION OF DEFORMITY 151 cautioned firmly agamst (1) overdoing, and (2) chulling. Rclaration exercises 1. Tale a deep breath, fully expanding the chest, hold the chest erpanded until the count of 5, then let the breath out and relar completely, breathing naturally 2. Stretch the right arm down, stretching, stretching to the count of 1-2-3, then relax the arm completely and make the entire body become relaxed and limp 3. Repeat with the left arm 4 Stretch the right leg down, stretching, stretching, then relax the leg and whole body 5 Repeat with the left leg 6 Stretch the neck, fattening and stretching right up through the top of the head, then relar the neck and whole body 7 Rest 20-30 seconds after each stretching exercise, and repeat the list two or three times Occupational therapy, aside from its diversional and possible economic rehabilitation aspects, can be a lughly useful adjunct in the preventise and corrective exercise program General physical activities and working should be encouraged but guded in the kind and amount by the rules of tolerance. Work or outside activities should be undertaken at regular hours, with a gradual increase to as much as the patient can do without undue fatigue and strain of joints Durmg a flare-up, patients tend to do nothing for weeks or months, then, when feeling better, suddenly do much more than they are conditioned for and consequently strain their joints and induce another relapse A safe rule for increasmg physical actnuty is In add 10 or 15 per cent to the total for the day, and be sure of tolerating this for several days before adding another 10 per cent ·152 RHEUMATIC DISEASES SPONDYLITIS The deformity in spondylitis is nearly always characterized by a flexion of the spine, rib cage contraction and loss of normal posture with rigidity. The spine in spondylitis will I ultimately ankylose in varying degrees, the extent depending on the stage at which the disease is arrested. Ankylosis usually starts in the lumbar segment and spreads upward, with early involvement of the dorsal spine and loss of chest motion Frequently it affects the entire spine, including the neck The serious crippling comes from a frozen flexed spine, the patient drawn over with face to the ground, unable to sit or stand erect. A straight, stiff "poker" spinc is not a serious deformity. After the active discase has subsided the stiff straight back does not interfere with the execution of most jobs and normal Jiving The acute form may develop rapidly with so much muscle pain that immobilization in bed or application of a cast or both is necessary, along with other appropriate measures (p. 56). Rest should, of course, be on a flat bed to maintain maximal extension (Fig. 89, p. 125). A posterior rest shell (body cast), carefully made with the back as straight as possible, is highly satisfactory for resting and relaxing the spastic erector spinae muscles. Hip and shoulder involvement, followed by severe limitation of motion, is frequently seen in the more severe types. In a few instances the process finally invades peripheral joints, causing the typical changes of rheumatoid arthritis. The chronic form, with insidious onset and progress, is much more common. This type, not too disabling at the spasm and ·PREVENTION OF DEFORMIT 153 onset and much slower to cause deformity over a period of years, requires much more understanding and co-operation of the patient. The first step in prevention of deformity is a thorough explanation of the disease, so that the patient years hence does not discover too late that he has a deformity that cannot be corrected By farthful adherence to the correct preventive program, the back can be kept straight Rest to heep nomal posture is prescribed to fit the stage of the diseasc. A fat, nonsag bed, with boards under the mattress, is essential for all The amount of rest depends on how fast the patient loses normal posture and develops fatigue In the more or less acute or subacute stages the patient may not be up more than an hour before he begins to "droop" lle is advised then to rest flat on his back for 10-15 minutes, or as long as necessary to regain normal posture, before getting up again During the time he is up, the patient should use straightbacked chairs, and occupations that require poor posture, as leaning over a desk, bench or the like, are to be as orded Patients who work away from home can often arrange to have a cot available for short posture rests during the day, and are thus able to stay on the job When this is not practical and the patient must work beyond his tolerance, a Taylor brace or body cast is prescribed However, when possible, the rest program is better In ambulatory patients, a good method for watching posture is to have the patient stand back to the wall, heels and buttocks touching, and then measure the distance between head and wall Chesterpansion, measured with a tape, can also be quickly recorded Ilip and shoulder in ok cment may come on insidiously nd cause rather severe limitations When these joints are ·152 RHEUMATIC DISEASES SPONDYLITIS The deformity in spondylitis is nearly always characterized by a flexion of the spine, rib cage contraction and loss of normal posture with rigidity. The spine in spondylitis will ultimately ankylose in varying degrees, the extent depend. ing on the stage at which the disease is arrested. Ankylosis usually starts in the lumbar segment and spreads upward, with early involvement of the dorsal spine and loss of chest motion Frequently it affects the entire spine, including the neck The serious crippling comes from a frozen flexed spine, the patient drawn over with face to the ground, unable to sit or stand erect A straight, stiff “poker” spine is not a serious deformity. After the active disease has subsided the stiff straight back does not interfere with the execution of most jobs and normal living The acute form may develop rapidly with so much muscle spasm and pain that immobilization in bed or application of a cast or both is necessary, along with other appropriate measures (p. 56). Rest should, of course, be on a flat bed to maintain maximal extension (Fig 89, p. 125). A posterior rest shell (body cast), carefully made with the back as straight as possible, is highly satisfactory for resting and relaxing the spastic erector spinae muscles. Hip and shoulder involvement, followed by severe limitation of motion, is frequently seen in the more severe types In a few instances the process finally invades peripheral joints, causing the typical changes of rheumatoid arthritis. The chronic form, with insidious onset and progress, much more common. This type, not too disabling at the is ·153 PREVENTION OF DEFORMITY onset and much slower to cause deformity over a period of years, requires much more understanding and co-operation of the patient. The first step in prevention of deformity is a thorough explanation of the disease, so that the patient years hence does not discover too late that he has a deformity that cannot be corrected By faithful adherence to the correct preventive program, the back can be kept straight. Rest to keep normal posture is prescribed to fit the stage of the discase A flat, nonsag bed, with boards under the mattress, is essential for all. The amount of rest depends on how fast the patient loses normal posture and develops fatigue In the more or less acute or subacute stages the patient may not be up more than an hour before he begins to "droop" He is advised then to rest flat on his back for 10-15 minutes, or as long as nec. essary to regain normal posture, before getting up again During the time he is up, the patient should use straightbacked chairs, and occupations that require poor posture, as leaning over a desk, bench or the like, are to be avoided Patients who work away from home can often arrange to have a cot available for short posture rests during the day, and are thus able to stay on the job When this is not practical and the patient must work beyond his tolerance, a Taylor brace or body cast is prescribed Monever, when possible, the rest program is better in ambulatory patients, good method for watching posture is to have the patient Etand back to the wall, heels and buttocks touching, and en measure the distance between head and wall Chest er. ansion, measured with a tape, can also be quickly recorded Ilip and shoulder in ohement may come on insidiously El canse rather severe limitations When these joints are ·154 RISEUMATIC DISEASES affected, preventive measures should be started at once, as outlined for theumatoid arthritis. Exercises.-In spondylitis, corrective exercise is not as offective in maintaming motion of the spine as is exercise in the peripheral joints Every patient, however, should take corrective exercises daily to preserve normal posturc, chest expansion and hip and shoulder motion (see the list of active exercises on pp. 145 f.). Special emphasis is given to exercises 1 and 2 and 7-16. One of the most important is chest expan. sion. The same rules of tolerance apply for spondylitis as for theumatoid arthritis, DEGENERATIVE JOINT DISEASE (OSTEOANTHNITIS) Prevention of deformity in this type of arthritis is important, but not nearly as much of a problem as in rheumatoid arthritis Osteoarthritic deformities are most likely to appear in the hips, back, hands and sometimes the knees Ilip involvement, malum coxae senilis, is the most common and at times the most serious problem in the acute or subacute form with much pain and limitation of motion, weightbearing and walking must be limited or even forbidden for a while The use of crutches is nearly always prescribed to relieve weight-bearing in the affected joints. With crutches the patient can learn to put the leg through a walking range to preserve motion and strength without joint irritation. Canes are not satisfactory. The principles and advantages of protecting the joint, saving what cartilage is present and maintaining motion for the rest of the patient's life, must carefully be explained. Many are grateful for the knowledge that they can do much more with crutches and with less discomfort than without them.

·155 PREI ENTION OF DEFORMITY Frequent periodic rest on a flat bed is prescribed to main. tain extension, the amount of rest varying with the stage of the disease and age, strength, etc, of the patient Corrective exercises are just as important as in rheumatoid arthritis and the same rules apply (pp 145 f.) Assistive stretching to heep extremes of range of motion is sometimes helpful Surgery is rarely, if ever, indicated Spinal involvement is extremely common, but disability is minimal Patients should be warned about the dangers of trauma, hard labor and lifting, especially lifting with rotatron Patients are taught to set their backs rigid and lft obccts by bracing their backs (bending hips and knees). Gardening, hoeing, weeding, etc, often cause trouble Firm beds and boards under the mattress, if necessary, are prescribed Straight-backed chairs are best, and patients are advised not to sit too long in one position (automobile riding included). Corrective exercises to keep the back strong is good surance against strain or trauma of ordinary activities The joints of the fingers and hands are often involved but seldom become seriously crippled, although at times motion is quite limited. Ilere the usual rules apply regarding avoidance of chilling, strain in occupation, etc Keeping warm, Mearing gloves, using correctnc exercises are some of the measures always prescribed In- BURSITIS Bursitis is common in many locations, but only in the shoulders is it very disabling Bursitis is often mistaken for arthritis because in the shoulders, like arthritis, it can be cute, with pain and pronounced limitation of motion, or ·156 RHEUMATIC DISEASES develop gradually with a slow progressive loss of function Unchecked, it can go on to ankylosis of the joint and severe atrophy. Early diagnosis of bursitis is important to prevent loss of motion, Start rest periods in abduction and external rotation. Add corrective exercises and include "wall-creeping“ daily to maintain motion Wall-creeping is best carried out by standing facing a wall with the toes about 12 in out from the wall. The hands are placed on the wall as high as possible and alternately, using the fingers, creep up the wall as far as the patient can reach. The crercise may be done with one hand at a time, but simultancous use of the two hands is preferable because it achieves better balance. By carly establishment of the routine, nearly all disability can be prevented Shoulder motion that is already limited usually can be worked out by assistive, corrective exercises and stretching carried out by the physical therapist. The application of heat to the shoulder-hot compresses, heat lamp, electric pad or diathermy-for a half hour before the darly stretching will often prove helpful. Shoulders in which motion has been limited for a long time are more resistant to daily physical therapy, and manipulation under anesthesia may be necessary to break the adhesions. It must be remembered that daily passive and assistive exercise must follow manipulation in order to main. tain motion. CORRECTION OF DEFORMITY Unfortunately, patients in a search for relief from pain rest in flexion and develop contractions before they or the doctor realizes what is happening in the beginning, the ·CORRECTION OF DEFORMITY 157 slight contraction may go unnoticed, and further contraction is so insidious that it may be missed until it becomes pronounced. Frequent checking by the physician, with the patient stripped so that his range of motion is clearly observable will help detect early limitations At this time, corrective measures are relatively simple, re, proper rest, extension and erercises to gain motion. For early contractions of only a few weeks' or months' duration, the simple measures may be all that is necessary Do not wait until active arthritis or inflammation subsides to start corrective procedures If the joint is acutel inflamed it may be necessary to wait a few days or more, but with delay until all signs of activity and sedimentation rate have subsided, it will probably be too late Some activity may persist in joints for years More selere contractions and those of longer duration require more strict attention The basic principles of rest and relaxation are followed Gentle, firm, daily assistive exercises and stretching are helpful, but care must be taken not to irritate the joint by use of too much force, secondarv irritatron and pain will cause more contraction and "splinting" of the joint For this reason, we object to the use of traction or wedge casts To obtain lengthening of the flexors, the flerors must be comfortable They must relax to gain maximal ertension SHOULDERS The shoulders are rested in abduction and extension as frequently as indicated and tolerated Assistne erercises and stretching are practiced daily, use of a heat lamp, heat pad or hot packs on the joints before extension and stretching ·158 NHIEUMATIC DISEASES may help. The degrees of range of motion are measured every two to four weeks. As long as improvement in range is noted on routine check-up, the procedure is continued. When and if no further progress can be made and it is still necessary to gain more motion, manipulation under anesthesia should be considered. This procedure, however, requires training and experience on the part of the operator and skilled physical therapy help afterward. Shoulders are usually very painful after manipulation, and even a well trained physical therapist is not always able to maintain increased range of motion in this joint. Success also depends on choice of the optimal time for manipulation and the stamina of the patient to go through with it ELBOWS Elbows present a real problem. They are especially difficult to keep mobilized after manipulation. If there is ankyfosis or serious limitation, surgical resection by an experienced orthopedist may be considered. WRISTS Deformed wrists are nearly always in flexion, wristdrop, and sometimes in ulnar deviation. Nothing need be done about an ankylosed wrist that is straight or in extension, as these positions are optimal for the use of hands and fingers, making a grip, etc When a wrist is fexed sufficiently to im. pair the use of the fingers in grasping objects and in other necessary activities, but is not too firmly ankylosed, it can be reset in a more useful extended position under anesthesia.

·CORRECTION OF DEHORNITIES 159 IIIPS Ilips that are contracted or have serious limitation of motion are also difficult to manage. They respond poorly to force, especially if there is joint irritation because of weightbearing or active arthritis Fortunately, hip involvement is not as common as deformities and limitation in other joints To gain hip motion, weight-bearing must be curtailed or forbidden altogether until signs of joint irritation, muscle spasm and pain subside. With a minimum of joint irritation, more force can be used in assistive stretching along with bed exercises Exercise and stretching under water are especially beneficial. If after the signs of acute activity of the arthritis have subsided, assistive stretching and bed exercises have not given enough motion to permut walking or sitting, or both, manipulation under anesthesia should be considered. This procedure has definite limitations in that it should be donc only by an experienced physician and when the requisite physical therapy facilities are available for proper follow-up. To mobılıze the hip joint, arthroplasty may be indicated in a limited number of patients in whom the foregoing procedures have failed This operation has not proved too successful, giving only a limited range of motion in approximately 50 per cent of cases KNEES Knee contractions cause more serious disabiliti in more people than any other deformity attributable to arthritis With methods now developed this situation should in the ·160 RHEUMATIC DISEASES future be reversed. First, all knee contractions could be prevented if they were treated early by the methods outlined carher in this chapter, under prevention. Second, a method for correction of knee contractions has been devised that gives good results. Routine for contracted knee.-1. Stop weight-bearing, Every step on a bent knee aggravates the condition and leads the patient that much faster to bed or wheelchair. Therefore, as long as there is a chance of correcting the con. traction and restoring function, the patient should not be allowed to walk. Every contracted knee should have the benefit of an attempt at early correction unless there is on vious bony ankylosis. 2 Make a rest cast to hold the leg in maximal extension (Figs. 93-97), using the technic outlined on page 126 llave the patient rest in the cast as many hours in every as possible Casts must be comfortable to give maximal relaxation of the flexor muscles 3 Start corrective exercises at once and insist on their being pushed to tolerance. Emphasize the quadriceps set, or "patella pull” (exercise 8, p. 146), having the patient do this exercise up to several hundred times daily. 4. As the flexors relax and the leg straightens, add pads under the ankle inside the cast to take up the slack and gain more extension, 5. If contraction at the start has been severe, a second third cast may be necessary to fit the leg as it extends. 6. Measure the knee contraction every two to four weeks with an anglometer or simply the distance from the top of the patella to a hard table, to keep a record of progress (Figs 113 and 114).

·Pics 115 AND 116 -Six years after manipulatwn, both knees straighten 1 180 degrees and flex past 90 degrees in free motion without pain Despite inspicuous subluxation, cartilage loss and porosis, this youth, aged 21, alks satisfactorily 103 ·162 NIILUMATIC DISEASES 7. Continue the foregoing routine until the leg straightcns to 180 degrees or has reached maximal extension. If on the monthly check-up, measurement slows no further improvement and the knee is not straighıt, manipulation is indicated. 8. Manipulation is performed under anesthesia, only after the foregoing routinc has been followed and then only by one trained and cxperienced in the technic, Proper physical therapy facilities for follow-up care are cssential. Manipulation.--The degree of damage of the knee visualized on x-ray examination is not a reliable guide in choosing cases for manipulation. Some of the worst cases, by x-ray criteria, have resulted in well functioning knecs; others that did not look too bad have been the most difficult. From X-ray and other examinations it is impossible to predict the results that will be attained (Figs. 115 and 116). It can be cmphasized, however, that the longer the duration of the contraction, the less chance there is of good results because of tighter muscles, adhesions and increased joint damage. Although we cannot pretend here to teach the details of the procedure, a brief outline of our method is presented We insist first on carrying out steps 1-7, outlined above. After this preparation, which means two to threc months at a minimum, the patient is hospitalized. Under general anesthesia the bent knees are manipulated to the best correction possible, usually they can be straightened to full 180 degrees Solid leg casts are applied, cut and tied (Figs. 93-97). After 24-48 hours, acute pain is gone and warcotics are no longer reqmred Muscle tensing exercise is started at once (in the cast). After five or six days the leg fcels loose in the cast. The cast is then opened, the leg removed for a few minutes, and ·A B . Fic 117-A, woman, agrd 31, with anthints for seven scars, has had free contraction of 55 degrees for is mythe B, three years after mampulsfon, she walls with normal notion and guit 165 ·161 REUMATIC DISEASES the physical therapist starts passive exercise through the greatest range of painless motion The leg is returned to the cast until the next day Each day the motion is increased to tolerance and active-assistive exercises are added Usually in four to cight weeks the patient is strong enough through graduated active exercises to hold his legs straight and fler the knees When sufficiently strong, he begins to stand without braces, but using crutches for balance. Careful daily supervision is necessary to teach proper posture, then joint motion, standing in place and finally the normal guit. With this program and follow-up, we have patients who are walking as long as 14 years after manipulation By maintaining good posture and following the rules of rest, exercise and avoidance of strain, there is no excuse for a recurrence of flexion contracture (Figs 117-119). In 65 consecutive cases of manipulation on knees, reported previously, there were severe contractions and attempts at straightening by simple measures had failed. Some patients had undergone attempts by other methods elsewhere, without success. Age range of the group was 17-68 years Average duration of arthritis was 7.2 years and average duration of contraction 3.2 years. These patients were doomed to a wheelchair or bed. After manipulation, 40 walked normally, 12 walked with crutches unaided, 11 walked with crutches but required some help and 2 had ankylosed joints. Sixty-three of these patients were walking an average of eight years after manipulation. Many of these patients had active arthritis in the knees at the time of manipulation, but we have never seen a fareup or exacerbation produced by manipulation of the knees Frequently, it is noted that active arthritis in the joint sub- ·B For 119 - , man, aged 38, with arthnas for 23 scars, has had 55 degree het contraction for flere years the left hop is atracted, with 75 ur nitkoss of cartilage > B, same patient as preceding walong with somma! lion of the Inces 12 years after manipulation He irses crutches to protect bad luft hip and maintain motum in it wonen aged 53, with thritis hinn cars and 60 degree kniee contractiun fost test walls with nal range of mon sen years after manipulatum 167

·A
B
Fc 118-A, woman, aged 32, with arthritis for eight years, for four
years has had knee contraction of 50 degrees, with prominced loss of car.
tılage and secondary hypertroplac changes B, two years after manipulation
she walls with normal motion and gut
166

·CORRECTION OF DEFORMITIES 169 foot with relared arches that are sore and tender (especially metatarsals), so common in rheumatoid arthritis, needs correction when weight-bearing is permitted Often the large sponge rubber metatarsal pad, properly fitted and located in the shoc, will be sufficient When not, the metatarsal bar is prescribed (p 124). A proper-sized shoe, strong and large enough, and with a straight last to prevent crowding of the toes, can usually be found in various makes. The heel should he low or not more than medium height The longitudinal arch support, also made of sponge rubber, must be of the proper size and located in the shoe with care When the deformity is more severe, with eversion of the foot, wedging may be necessary. This is usually started with a ' in leather wedge inserted into the heel and sole by the shoemaker If in wedging is tolerated, but not sufficient to gre correct alnement, another " in. wedge is added The stiff or rigid foot, cold, and often very painful, can be helped dramatically at times by manipulation, in addition to the cvercises Two or three times a week the therapist or physician firmly grasps the tarsal bones (long arch with one hand and gives one firm rotary twist of the inetatarsals in each direction with the other hand With this maneter one may hear the popping of many adhesions The patient should be warned that the first few times the mancun er mas be quite painful momentarily, and he must relax the foot as much as possible for best results In a short time with thuis procedure the foot is often noticeably warmer and less painful When joints are acutely inflamed, manipulation is deferred. Ilammer tocs, also extremely common, can often be cor.

·168 RHEUMATIC DISEASES sides after manipulation. This is probably due to removal of joint strain by placing the joints in a more normal anatomicophysiologic position and complete support for several days to a week in a cast. Surgery.-Posterior capsulotomy may be resorted to in the badly damaged and subluxated knee. We have used surgery less and less as we have gained more experience with manipulation. ANKLES Ankle deformity is usually in the form of footdrop. Again, in the early cases much can be done by daily stretching of the Achilles tendon by the physical therapist. In long-standing cases with severe contractions, manipulation under anesthesia will often be sufficient to correct the shortening When this fails, a tenotomy by the orthopedic surgcon may be indicated FEET Deformity in feet is not only one of the most common developments but one of the most neglected. The wearing of poor shoes without support, or bedroom slippers, may lead to flattening of the arches and eversion of the foot. With tight shoes and no exercise, the rigid or boardlıke foot develops, often with hammer toes, bunions and related deformities. A foot that is only fat, but still strong, and has motion and good alinement for weight-bearing is usually of no great concern. If it is asymptomatic and function is good, correction should not be attempted with arch supports. The flat ·AIDS TO THE CRIPPLE 171 Aids to the Cripple Crutches --Ilandles on crutches can be angled, moi ed up or down or placed on the outside to facilitate easier grip by the deformed hand The lower the handle, the better for extending the flered elbow. Rubber tips present slipping and rubber shoulder pads decrease shoulder soreness (See also the note on fit of crutches, p 130) Wheelchairs -The type of wheelchair selected should fit the patient, to assure proper posture They are for moving the patient and are not good for long hours of sitting A sturdy kitchen chair with large casters is often useful about the house The quadriceps develop as the patient propels himself backward Commodes on casters built to bed height and with open back are often helpful in moving the patient to the toilet or for use beside the bed (Fig. 102, p 133). Ramps - The difficulty of negotiating a few steps can often lie overcome by placing a simple wooden ramp Ingh chairs.-These help avoid much strain in getting up and derwn. Chairs with straight backs and arms are best and can casily be elevated to proper height by 6 X 6 m wood blocks Extrafirm cushions may be used to raise the seat small bor or footstool is then necessary to support the feet (Figs 104 and 105, p 131) Iligh toilet seats --Proper height is easily obtained by remos. ing the seat, building a simple woud frame on top of the bou! and placing the seat on top (Fig 103, p 133) Automobile riding -To get into an automobile, back up to the front seat, sst down and pull the legs in afterward Bedstde tables - Many types are available One with adasstable height and tilt top and book rest is an advantage un oping good posture during reading or writmy Some are made tum upside down and have clamps to hold readmg material patients who must be on their backs I'rise coch-up-d simple splint can be made with 3 10 mm ca board pridded with bandage 13 m roller bandage is ·170 RHEUMATIC DISEASES rected by early stretching of the extensors by the technician. The technic is simple. Grasp the left longitudinal arch with the left hand, placing the thumb under the distal head of the metatarsal, then take a firm grip on the corresponding distal phalanx, apply traction to separate the joint and pull downward to stretch the extensor tendon. One good firm pull is painful for a second but becomes less so on subsequent maneuvers if done two or threc times wechly. The same procedure is applied to cach toe requiring it, remembering to give adequate support and traction before flexing The hands are reversed for the opposite foot. Increased or persisting pain and soreness indicate either that too much force has been used or that the arthritis is still too active to justify the maneuver. In long-standing contractions that cannot be relieved by the foregoing methods, surgery with resection of the distal metatarsal heads may be indicated. In selected cases, propcrly done, the resultant rehabilitation is quite gratıfying While we search for a cause and cure, prevent deformity.

·rek Index NOTE -An asterisk (*) following a page number mdicates reference to an illustration Abdominal exercise for arthrities, 115 ACS for theumatord arthritis, 41 ACTII, 41, 105 FE clinical experence with, 106 ff clinical response to, 110 F, 112 comtraindications, 115 dosage, 103 to maintain remissum, 113 effects on various diseases, 108 negatre, 109 positive, 109 fur gold tonicity, 49 nature and sources, 100 precautions in use, 114 I missun in arthnks from muntenance, 113 Search for factor, 107 srdle-elects, 109, 114 toxic reactions, 109, 114 Adrenocorticotrophuc hormone, sce ACTII Anemia, m rheumatoid arthritis, 21 Cyrrection, 40 Ankles deformities-- (Tercctron, 165 in rheumatoid arthritis, 19' Ank, linis fmm delty m exercising is acule arthritis, 149 erercises for, 150 F relaxation, 151 under waler, 150 of knees-evaluation, 130 Antihistamines for collagen deseuse 103 Antity and generalized fibroitus, 77 ff Arms, in rheumatoxł arthritis prevention of deformity, 135 rest position for, 137 138 Arthritis, see olso Runtato ar thritis classification, 131 gender diagnosts 35 Infectious differential dugu, 33 'mured, 33 old folks, '59 pucumomcic - differents ROSIS, 35 rheumatord, rc Rheumat thritis Arthritis and Rlicumatism F tson, 12 Arthroplasty fes lup de futini Aspinn fror arthritis, 40 misuse, 141 for degenerative wat disease in gout therapy, 89 173

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·Index Sort.-An asterisk (*) following a page number indicates reference to an illustration A exercises for, 150 F Abdominal erererse for arthntics, relatation, 151 115 under water, 150 ACS for theumatoid arthritis, 41 of knees-- aluatson, 130 ACTH, H, 105 ff. Antihistamines for collagen disease clinical erpencace with, 106 # 103 curucal response to, 110 ff, 112. Anucty and generalized fibrosis, contraindications, 115 77 dosage, 109 Arms, in rheumatoid arthritis to maintain remission, 113 presention of deformit 135 effects on vanous diseases, 108 rest position for 137, 139 negatzse, 108 Arthnlis, sce also Rheumatend arpositive, 10s thatus for gold toxicity, 49 classification, 131 nature and sources, 106 gonococci--diagnosis 35 precautions in use, 114 infectous -- differential diagnosis, remission in arthritis from 35 maintenance, 113 mited, " 33 search for factor, 10 "old folks," 59 side effects, 109, 114 pneumococcic - differential dinge tonc reactions, 109 €, 114 nosis, 35 Adrenocorticotrophic hormone, sec rheumatoid, see Rheumatoid ar- ACTH thritis Anemia, m thetumatoid arthritis, 22 Arthnts and Rheumatism Founda- Correction, 40 tion, I2 Arthroplasty for lup de formaits 159 deformites--correction, 168 Aspirin m theumatoid arthritis, 19* Ash loss for arthritis, 10 misuse, 141 from delay in erercising is acute for degenerative mint disease 72 arthritis, 149 un gout therapy, 89 173 ·172 RAIEURIATIC DISEASES strapped on top of one end for cock-up and hand rest. It is applied with a short 2 in. elastic bandage. Rubber shoelaces --These are helpful, used in Oxfords, for patients with hip or knee involvement that prevents them from reaching their feet. Handy stich.-ſany variations are easily made. One on the market has a look and ring on one end for picking up articles, pulling on socks and trousers; in the other end is a magnet which proves very useful. Telephone - Bedridden, ankylosed patients can have a hanri. piece mounted next to the head of the bed and a button switch placed at the finger-tip for control Electric blankets.-These are light weight and very helpful in keeping even temperature. Crodle „A large paper carton or wire frame takes the wesght of bed clothes off sore joints Pillow splint.-A very hot or acutely inflamed joint can be temporarily splinted by folding a large pillow around the exa tremity and bandaging it in place. Cellucotton This comes in sheets about 2 in thick and can be cut to desired size and shape for relieving pressure soses it is cheap and disposable. Sponge rubber, foam rubber.--These are good for seat pads and are also available in various thicknesses and sizes for mattress pads With a little effort and ingenuity the home mechanic can make other aids and accessories to facilitate rehabilitation and relieve strain on the joints.

·INDEX for spondylitis--use, 154 Curare for degeneratae point dis- Cysts, subcortical. in arthritis, 22, 29* esse, 72 175 D Deformities comechon in ankles, 163 in elbows, 158 un feet, 168f in hirs, 159 in knees, 159 ff in shoulders, 157 in wrists, 158 prevention, 117 # in bursitis, 155 in degenerative joint disease, 151 in theumatoid arthritis, 117 ft In theumatord spondylitis, 152 ff Degenerate joint disease, 59 ft causes, 59 cervical spine in, 639 differentiation from fihrositis of neck, 77, 789 head traction for, 72 classification, 14 deformstes--presention, 151 € exercises, 155 Test, 153 diagnosis, 60 € differenbal diagnosis, 67 from rheumatoid arthritis, 33 erythrocyte sedimentation rate, 60 generabzed, 59 of lup, 65, 66° punts invoked by, 60, 61 61 localized, 59 of spine, 60, 63, 65 ff Orvical portion, 69, 77, 78° suelung in, 60 treatment, 71 Permatitis in yold toxicity, 47 ermatomyositis, 91 blood vessels in, 91 ase, 95 ortisone effects, 107 differentiation from arthritis, 31 Diabetes ACTII and cortisone contraindicated with, 115 Durtherms, short wave for bursitis (subdleltoid), 76 Diet for gout, 87, 58 for rheumatoid arthritis, 39 Diethylstilbestrol for senile osteoporosis, 69 Dupuytren's contractures with polyarteritis, 99* with rheumatoid arthrtis, 34 C Clbows deformutes-Correcto 158 in theumatoid arthritis exercises for 145 rest positions for 137, 139° Endocrine systems in arthritis etology 37 Erythrocyte sedimentation rate in degeneratie joint disease, 60 an lupus erythematosus, 93 in periarteritis nodosa, 91 in Theumatoid arthritis, 23 in shoulder-hand svudrome, 31 in spond, btes, 56 Exercises for abdominal muscles, 145 for ankylosed joints, 150 € for bursitis, 76, 156 for chest, 145, 116 for degenerative funt disease 155 for elbows, 115 for fect, 145 for hands, 115 for hips (assistisei 143 for knees, 146 pain during--significance, 120 passive (for acute arthritis), 143 Taratron, 151 for rheumatoid arthritis, 142 ff active (int) 145 € assistile, 148, 150 for kups, 148, 150 passise, for acute stage, 149 ·174 INDEX pain low in 102 Asthma ACTH effects on, 108, 115 Chest exercise, for arthritis, 145, 146 B in spondylitis Back compression sign, 55, 56 herniated fatnad in. 76 expansion muted, 53, 55° flattened, 53 causes, 67 Cinchophen for gout, 89 dugnosis, 65 Climatotherapy. For arthritis, 46 straight, in spondylitis, 53, 5.1° Cock-up, wrist, 139, 140, 172 BAL for gold toxicity, 48 Colclucine for gout, 87, 89 Bandaging ACTH effects on, 108 of foot, 123, 124 Coltis, ulcerative. ACTII effects, 108 of knees for support, 72, 131, 135º Collagen diseases, 90 ft Bed ACTII effects, 102, 108 for arthritic spine, 139 classification, 90 ff. for spondylitis, 153 cortisone effects, 102, 107 Benadryl for lupus erythematosus diagnosis, 92 ff disseminatus from muscle boopsy, 91, 92, 94, cases, 97, 99 95, 100°, 102 dosage, 103 white blood cells an, 101 Blood vessels differential diagnosis, 99 ff in dermatomyositis, 91 from theumatic fever, 93, 101, in lupus erythematosus, 91, 96° brachial artery occlusion, 95, from rheumatoid arthritis, 31, 96° 93, 99, 101, 102 in periarteritis nodosa, 90, 100° symptoms, 102 Brace Taylor, for spondylitis, 153 treatment, 103 f Brucellosis diagnosis, 35 Commode: for arthritic, 1330 Bursitis, subdeltoid, 74 ff Cortisone, 44, 105 ff deformity-prevention, 155 f. clinical experience with, 108 ff wall-creeping technic, 156 clinical response, 110, 111° frozen shoulder with, 74, 75° contraindications, 115 treatment, 76 dosage, 109 to maintain remission, 113 C effects on various diseases, 107 Cane for arthritic, 130, 132 negative, 107 Cartilage carpal, in rheumatoid arpositive, 107 nature and sources, 105 thritis, 25 Casts precautions in use, 114 Temission in arthritis from rest, fo arthritic knee-technic, maintenance, 113 129 ff Search for factor, 107 for spondylitis, 153 side-effects, 109, 114 for wrist, in arthritis, 139, 140* totic effects, 109 f, 114 Cellucotton for cripples, 172 Crutches, 171 Chairs for arthritic, 131, 134° for arthritis elevated, 171 hips-use, 135 low, method of arising, 136, 137 knees--technic of use, 130, 132* ·INDEX 177 J cinchophen, 89 colchicine, 87, 89 in inter als between attacks, 87 f. low purine duet, 87, 88 ur!c acid and, 81, 83, 84° x-tay picture - punched-out areas of arthritis confused with, 29° Grp, in Theumatoid arthntis response to ACTII, 110 test, 16, 22 ands 11 exercises--for arthritas, 145 normal (x-ray), 24° % polyartentis, 98 in rheumatoid arthritis, 24 1° in scleroderma, 103 with sul deltoid Lursitis, 75 swelling, in shoulder-band syn. drome, 31 Heberden's nodes, 61 incidence, 59 Heratitis, virus ACTH effects, 103, 115 Ilips deformities--correction, 159 an degeneratie jomt disease, 65, Juundice and arthritis, 44 Joints ankylosed etercises for, 150 f occupational therapy, 151 in dermatomyositis, 92 diseases of classification, 13 f in lupus erythematosus, 91 metacarpophalangeal, an arthntis, 17, 21°, 250 in periarteritis nodosa 91 protimal interphalangeal. in arthritis, 17 in rheumatoid arthritis, 17-21 avoidance of strain, 119 ff single and multiple in ohement, 16 sacroilac, in spondylitis, 56, 57* x knees bindaging for support, 72 contraction manipulatron, 162 measurement, 160, 161 routine for, 160 deformity --correction 159 f manipulation-technic, 162 ff routine for contraction, 160 in degenerative joint disease, 64* exercises for arthrtes, 146 in gout, 85 in hy drarthrosis (intermttent), 30 normal (x-ray) 26, 27, 61° in Theumatoid arthritis, 18, 19, 26, 27, 28° ankylosis-evaluation, 130 bandaging for support, 72, 131, 135 casts (test) for, 129 ff plaster shells--technic, 129 ff position in bed, 124, 125, 126, prevention of deformity, 121 ! 66° in rheumatoid arthritis bed for, 133 exercises (assistive), 149 prevention of deformity, 133 £ in spondylıtıs, 53, 152, 153 prevention of deformity, 154 llormone therapy for degenerative mint discase, 72 for sende osteoporosis, 69 Hidrarthrosis classification, 14 Intermittent --clmical picture, 30 I Infection un arthritis etroligy, 37 with fibrositis of nech, 77 127 ·176 INDEX Erercises, hips (cont ) prescription of, 144 rules of tolerance, 144 tolerance for, 143 for theumatoid spondylitis, 154 for shoulders, 146, 149 under water, for ankylosed points, 150 for hips, 148, 150 for wrists, 145 Extremities, see also Arms, Legs, etc. upper, in arthritis prevention of deformities, 135 1. rest position for, 137, 138 Eye inflammations, ACTH effects, 108, 115 F Fatpad, herniated, 76 Feet, sce also individual components deformities--correction, 168 ff evercises, for arthritis, 145 manipulation-procedure, 169 in rheumatoid arthritis handaging, 123, 124 first signs, 118 prevention of deformity, 121 supports for, 121, 122, 124 Fever therapy for arthritis, 41 Fibrinold degeneration, 90 Fibrositas classification, 14 generalized, 77 ff differentration from arthritis, 33 treatment, 79 € localized, 74 ff of neck, 76f differentiation from osteoarthritis of cervical spine, 77, 78 infection and, 77 Fingers, see also Joints in degenerative joint disease, 60, 61° in theumatoid arthritis, 17", 20°, 21°, 2 fº punched-out areas, 22, 29* sul cortical cysts, 22, 29* ulnar finger deviation, 18* in shoulder-land syndrome, 31 Footboard for arthritic, 123, 121 Footdrop prevention, 123, 121 с Gait with crutches--method, 130, 132 with spondylitis, 51 Gold sodium succinumde, 46 Gold sodium thiomalate, 46 Gold sodium thiosulfate, 46 Gold therapy for theumatoid arthritis, 45 € contraindications, 48 dosage, 48 f. indications, 45 precautions in use, 49 preparations, 46 response, 42, 46 toric reactions, 47 treatment of torcity, 48 for rheumatoid spondylates, 50 toric reactions, 47 ACTII for, 108, 116 BAL for, 48 treatment, 48 Gold thoglucose, 46 Gold thioglycoanılıd, 46 Couty arthritis, 81 ff ACTH effects, 108 des elopment and life history, 81, 820 diagnosis, 82 ff. differential diagnosis, 83 from palindromic rheumatism, 33, 86 from polyarteritis (case), 97 from theumatic fever, 83 joints insolved by, 83, 84, 850 renal disturbances un, 83 and rheumatoid arthritis, 33 shin changes over joint in, 83, 86 Surgery with-preparation, 87 tophaceous, 84, 85 treatment ACTH, 87 acute attach, 86 aspuin, 89 ·INDEX cinchophen, 89 colchicine, 87, 89 in mter als between attacks, 87 177 luw purine diet, 87, 88 unc acid and, 81, 83, 81 -ray picture - punched-out areas of arthritis confused with, 29* Cnp, in theumatoid arthritis response to ACTII, 110 test, 18, 22 H Blands exercises--for arthritis, 145 normal (r-ray), 21 in polyartentis, 98° an rheumatoid arthritis, 24 f. in sclerodermia, 103 with subdeltoid bursitis, 75 swelling, in shoulder-hand syn. drome, 34 Heberden's nodes, 61° incidence, 59 Hepatitis, virus ACTH effects, 103, 115 Hips deformities--correction, 159 in degeneratre joint disease, 65, 66 in theumatoid arthritis bed for, 133 exercises (assistive), 148 prevention of deformity, 133 ff in spondylitis, 53, 152, 153 prevention of deformity, 154 Hordone therapy for degenerative point descase, 72 for senile osteoporosis, 69 Ivdrarthrosis classification, 14 intermittent-chnical picture, 30 J Jrundice and arthntis, 41 Joints ankylosed exercises for, 150 F occupational therapy, 151 in dermatomyositis, 92 diseases of-classification, 13 f in lupus erythematosus, 91 metacarpophalangeal, in arthritis, 17, 21, 25° in periarteritis nodosa, 91 proximal interphalangeal, in arthritis, 17 in theumatoid arthritis, 17-21 avoidance of strain, 119 ff single and multiple insohement, 18 sacroiliac, in spondylitis, 56, 57 K Knces bandaging for support, 72 contraction manipulation, 162 # measurement, 160, 161 routine for, 160 deformity --correction, 159 ff manipulation-technic, 1628 routine for contraction, 160 in degeneratre joint disease, 6+ exercises for arthritis, 146 in gout, 850 in hy drarthrosis (intermittent), 30 nonnal (x-ray), 26", 27°, 61' in theumatoid arthnts, 18, 19, 26, 27, 28° ankylosis--evaluation, 130 bandaging for support, 72, 131, 135 casts (rest) for, 129 ff plaster shells-technic, 129 position in bed, 124, 125, 126, prevention of deformity, 124 # faction en arthritis etiology, 37 with brositis of nech, 77 1270 ·176 INDEX Exercises, hips (cont) prescription of, 144 rules of tolerance, 144 tolerance for, 143 for theumatoid spondylitis, 151 for shoulders, 146, 149 under water, for ankylosed joints, 150 for hips, 148, 150 for wrists, 145 Extremities, sce also Arms, Legs, etc. upper, in arthritis prevention of deformities, 135 ff rest position for, 137, 138 Eye inflammations, ACTH effects, 108, 115 F Fatpad, herniated, 76 Feet, sec also individual components deformities-correction, 168 ff exercises, for arthritis, 145 manipulation--procedure, 169 in theumatoid arthritis bandaging, 123, 124 first signs, 118 prevention of deformity, 121 ff supports for, 121, 122, 124 Fever therapy for arthritis, 41 Fibrinoid degeneration, 90 Fibrositus classification, 14 generalized, 77 & differentiation from arthritis, 35 treatment, 79 f. localized, 74 € of neck, 781 differentiation from osteoartirtis of cervical spine, 77, 78* infection and, 77 Fingers, sce also Joints in degenerative joint disease, 60, 61 in theumatoid arthritis, 17", 20", 21°, 24 F punched out areas, 22, 29° subcortxal cysts, 22, 29' ulnar finger deviation, 18° in shoulder-hand syndrome, 3-4 Footboard, for arthritic, 123, 124 Footdrop. prevention, 123, 124 G Gait with crutches-mcthou, 130, 132 wath spondyktis, 51 Gold sodium succinimide, 46 Gold sodium thiomalate. 46 Cold sodium thosulfate, 46 Gold therapy for rheumatoid arthritis, 45f contraindications, 48 dosage, 46 f. indications, 45 precautions in use, 49 preparations, 46 response, 42, 46 toric reactions, 47 treatment of toxicity, 49 for rheumatoid spondy hus, 50 toric reactions, 47 ACTII for, 108, 116 BAL for, 48 treatment, 48 Gold throglucose, 16 Gold thioglycoanıld, 46 Gouty arthritis, 81 ff. ACTH effects, 108 development and Itſe history, 81, 820 diagnosis, 82 ff. differential diagnosis, 83 from palindromuc rheumatism, 33, 86 from polyarteritis (case), 97 from rheumatic feser, 83 joints involved by, 83, 81', 85 renal disturbances in, 83 and rheumatoid arthritis, 33 skin changes over joint in, 83, 86 Surgery with-preparation, 87 tophaceous, 81, 858 treatment ACTIT, 87 acute attack, 88 aspirin, 89 ·IYDEX 179 Procaine for degenerative joint disease, 72 intravenously, for theumatord arthrts, 41 Psoriasis ACTII effects, 108 with rheumatoid arthritis, 31, 33* Psychoneurosis with skeletal symp tams, 77 Psychosis ACTH and cortisone contraindicate with, 113 R Ramps, 172 Rester's syndrome, 36 Rest for arthritis, 39, 141 for degenerative punt disease, 155 fur spondylitrs, 153 Rheumatic disease classification, 131 incidence, 11 Rheumatic fever ACTII effects, 108 cortisone effects, 107 differential diagnosis from collagen diseases, 93, 101, 102 from gout, 83 from theumatoid arthntis, 23 Rheumatism muscular," sce Fibrositis palindromic chnical picture, 30 differentiation from gout, 86 psychogenic, 78 terminology, 11 Rheumatoid arthntis, 15 f ACTIt for clical response, 110 ff dosage, 109 Temission-factor, 107 remisstou--Maintenance, 1 13 activity, increase of-rule, 151 anemia of, 29 correction, 40 atypical clinical picture, 30 basic routine for, 39 f' classification, 13 chmate and, 46 cortisone for Clinical response, 110 FF dosage, 109 remission-factor, 107 Temision-maintenance, 113 deformitics-correction, 150 A in ankles, 169 in elbows, 158 in feet, 168 € in hips, 159 In knces, 159 FF in shoulders, 157 in wrists, 158 deformities--presenton, 117 F in arms, 135 an elbows, 137, 138° in feet, 121ff an hips, 1.33 FE joint and muscle stran-avondance, 119 € in knees, 124 ff in shoulders, 137 in spine, 139 in upper extremities, 135 F In wrists, 139, 140* demumeralization with, 24, 20 diagnosis, 15 ff diferental diagnoses, 23 ! from atypical forn, 30 from collagen disease, 31, 93, 99, 101, 102 from degeneratne pomat disease, 32 from fibrosztus (generalized), 35 from gout, 33 fmm hydrarthrosis (internnttent), 30 from infectious arthritis, 35 from palindromiç sleutism, 30 from Reiter's disease, 36 from theumatic fever, 23 from shoulder-hand syndrome, stiffness as clue, 16 erythrocute sedimentation rate, 23 ·178 INDEX N Nails, in psoriatic arthritis, 31, 32* Neostigmine: for rheumatoid arthri. Nerve block. for shoulder-hand syndrome, 34 trs, 41 L Lauron, 46 Leukopenia with collagen disease, 101 Liver palms in polyarteritis, 980 Lupus erythematosus disseminatus, 91, 980 Benadryl for cases, 97, 99 dosage, 103 blood vessel changes, 91, 96 brachial artery occlusion, 95, 90° cases, 93, 95, 97, 99 cortisone effects, 102, 107 differential diagnosis, 31, 99 ff muscle bwpsy m diagnosis, 91, 1000 Occupation of rheumatoid arthritis continuance in, 119 f. detrimental, 137, 143 with spinal involvement, 141 Occupational therapy: for arthrities, 151 Osteoarthritis, sce Degeneratae point disease Osteoporosis, senile, 69, 70 testosterone-diethylstilbestrol for, 69 19 ME Malum coxae, 65, 66° Manipulation for bursitis, 76, 156 of foot--procedure, 169 of knecs-technic, 162 Marie-Stnimpell disease, 50 Metabolism 20 arthritis etiology, 37 intrinsic, in collagen diseases, 102 Metatarsal bars for arthritic, 121°, 124 Metatarsal pads for arthritic, 121, 134 fuscle biopsy in lupus erythe.. tosus, 91, 100 Fuscles atrophy, in spondylitis, 52 lumbar spasm and tenderness in spondylitis, 53 In rheumatoid arthritis, 22 avoidance of strain, 119 iterusses atrophy, 21, 22 quadriceps atrophy, 18, 19, 22 Myasthenia gravis ACTII effects, 108 • Myochrysine, 46 Pairt low back causes, 67 diagnosis, 65 in theumatoid arthritis during exercises - Signabcance, 120 relief, 40 "tensson," of generalized fibrositis, 78 Penicillin reactions to, ACTII ef. fects, 108, 115 Periarteritis nodosa, 90 blood vessels in, 90, 100' cases, 95, 97, 98, 99, 100 cortisone effects, 107 differentration from arthritis, 31 Physical therapy. for theumatoid arthritis, et aluation, 41 Pneumonia ACTII effects on, 109 Polyarterites, 90 cases, 95, 97, 99, 99, 100* and gouty arthritis (case), 97 Polyarthritis un rheumatoid arthritis, 15 Pregnancy and rheumatord arthntis, ·INDEX weight loss with, 51, 53 X-ray picture, 51 ff 10 young men, 51, 53, 58 Rib cage fixed, m spondylitis, 52', 53 Rubber sponge and foam, 172 181 S Sandbags for arthritic foot in bed, 123, 124 for arthritic knee in bed, 126, 127 Sanocrysin, 46 Scleroderma, 92, 103 differentiation from arthritis, 31 hands un, 103° Shoes, for arthritic, 121, 122, 124 rubber laces, 172 wedging, for eversion, 169 Shnulder-hand syndrome, 33 ff management, 31 Shoulders in bursitis "frozen," 74, 75 prevention of deformity, 155 deformities-correction, 157 exercises, for arthnus, 146, 149 In theumatoid arthritis rest positions for, 137 m spondy lates, 51, 52, 53, 152, 153 Skin allergic diseases-ACTH effects, 108,115 of er joint, in gout, 83, 86 in lupus erythematosus disseminatus. 91 in scleroderma, 92 Salganol-B oleosum, 46 Spine cervical, in degenerative point disease, 69 differentiation from fibrositis of neck, 77, 78° head traction for, 72 Eith degeneratave jomt disease, 60, 63*,65 ff. xun deformity with spondylitis, 51, 52, 519 Humbar in degenerative jomt disease, 63 fattening of cune, 52, 53, 54 Dorinal (x-ray), 62, 70° in rheumatoid spondylitis, 51 Hizmbosacral joint-normal (x-ray), 62 in theumatoid arthritis prevention of deformity, 139 in spondylitis, 51, 52, 54, 152 flexed frozen, 152 "poker," effects, 152 prevention of deformity, 152 155 Splints pillow, 172 for wrist in arthritis, 139, 140° for wristdrop, 272 Spondyltıs, see Rheumatord spondy- Iztus Still's disease, 36 Sulfur for theumatoid arthritis, 38 T Tarsus in rheumatoid arthritis, 19° Telephone for cripple, 172 Test grip for arthritis, 16, 22 Testosterone for senule osteoporosis, 69 Tibia sharpening of spipes in de generatne joint disease, 64" Toes big, in gout, 83, 81 hammer-correction technic, 169 f Toilet scat for arthritics, 131, 133, 171 Transfusions for rheumatord arthritis, 42 of pregnant blond, 42 U Uric acid and gout, 81, 83, 84* V Vaccine therapy for theumatoid arthritis, 41 Vascultis, necrotizing, 90 ·180 INDEX Rheumatoid arthritis (cont.} etiology-theories, 38 fi exercises for, 149 ff actise (list), 145 R In acute stage (passe), 149 assistise, 149, 150 for hips, 148, 150 passe, 149 Prescription of, 144 rule of talerance, 144 tolerance for, 143 under water, 148, 150 in feet, first signs, 118 and gout, 33 hand in, 24 f immobilization early, 119 1 incidence, 16 infection As cause, 37 removal of, 40 and jaundice, 41 joints insolved by, 16, 17-21, 24-29 Juvenilc, 30 Inees in, 18, 19, 20, 279, 28* correction of deformity, 159 Measurement of contraction, 160, 161" muscle atrophy in, 18, 19, 21, 22 occupations continuance, 119 E. detrimental, 137, 143 onset, 15, 18 pregnancy effects on, 44 prevention of deformities, 117 With porsasis, 31, 32 Temission mechanism with cortisone and ACTH, 107 spontaneous, 23 rest u, 141 and rheumatoid spondylstrs, 50 sites, 16, 17-21 stiftness in, 16 aggravation by sedated sleer, 141 straight back in, 53, 51° swelling in, 18, 60 symptoms constitutronal and c3f- Culatory, 16 test grip for, 16, 22* treatment, 38 #. basic routine, 39 st. correction af deformities, 150 ff diet, 39 elective procedures, 41 fever therapy, 41 gold therapy, 42, 45 ff reostigmune, 41 of pain, 40 prevention of determitas, 117 procaine intravenously, 41 rest, 39, 141 transfusions, 42 vaccines, 41 X-ray, 44 roray changes, 22, 24-29 Rheumatoid spondylstys, 50 T. acute development, 152 chest changes in, 52, 53 compression sign, 55, 50 fattening, 53 chronic-development, 152 deformities-prevention, 152 ff. erercises, 15-4 Test, 153 diagnosis, 53 ff. early, 51 erythrocyte sedimentation rate, 58 gait with, 51 lumbar curve Rattened in, 52, 53, and lupus erythematosus (critse), 99 onset, 51 peripheral joints with, 52, 153 posture with, 51, 52, 549 rest schedule fos, 153 and rheumatoid arthritis, 50 nb cage fixation with, 52, 53 sacrorlac joints in, 56, 57* symptoms, 51 treatment, 581 constrtutional, 56 x-tay therapy-technic, 59 51

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·182
INDEX
Vertebrae, in degenerative point dis in theumatoid arthritis, 17", 20",
ease, 60, 63°
25°
cervical, 68
fletion, 18*
W
splint for, 139, 140, 179
Wall-creeping method, 156
X
Wheelchair, 171
X-ray therapy
Wristdrop with arthritis, 139, 140° for bursitis, 76
Wrists
for degeneratave joint disease, 72
deformities--correction, 158
for theumatoid arthritis, 41
exercises, for arthritics, 145
for spondylitis-technic, 58

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