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^^V^ouoJ-Ousr-^ i *^(

INTRODUCTION TO THE DISCUSSION

ON THE

RELATION OF RHEUMATOID ARTHRITIS

TO DISEASES OF THE

Nervous System, Tiil)erciilosis and Rheumatism

By JAIVIES STEWART, M.D.,

Profkssou f)i- Mkuicink ami C'i.inu ai, AIkdicini;, Mcr.ii.i. I'mvursity ;

I'llYSICIAN r.) IIIK HdVAI, \ K T.)iaA HOSI'ITAI,.

1{i::munted fbo.i tiik Monimiiai. Mi.Dicai, Jdi-iiNAi,, IlEiicMnKii, 'n^.il.

HI 1 1 ■ i m um

INTRODUCTION TO

THE DISCUSSION ON THE RELATION OF RHEUMATOID

ARTHRITIS TO DISEASES OF THE NERVOUS

SYSTEM, TUBERCULOSIS, AND RHEUMATISM.

II Y

Jamks Stkwakt, M.D.,

Professor of Medicine and Clinical Medicine, McGill University; Physician to the

Royal Victoria Hospital, Montreal.

Rheumatism in its acute and sub-acute arthritic and general mani-
festations, is a very common disease in thi.s country ; while rheuma-
toid arthritis is comparatively rare. I have been unable to collect
any evidence as to its comparative frcrjuency in Canada and the
United States, and it is doubtful whethe • our inoro vigorous Canadian
climate especially predispo.ses to it or no^. It is well known that both
in the United States and Canada, gouty arthi Itis is extremely rare.
Of the few cases that I have met with, the great majority were in
people who had previously lived in England, and who had suffered
before coming to this country, or had a vciy strong gouty predisposi-
tion.

Owing to the kindness of many of my fellow practitioners in this
city and the surrounding country, I have had an opportunity of study-
ing during the past three and a half years in the wards of the Royal
Victoria Hospital upwards of 40 cases of rheumatoid arthritis. An
analysis of these cases is the chief foundation for the remarks that
follow.

The number is small as compared with the e.Kperience of many phy-
sicians in England and the continent of Europe, but as far as I know
it is the largest number that has been reported on from any one hos-
pital on this continent.

Of the 40 cases, twenty were males and twenty fi;niales. IJfiUally
the proportion between males and females is al)out five to one.

There was a family history of some foi'in of ilicimiutif affection in
eight eases, oi" tul)ereulosis in livr. and of a neurojiatliict tcndmey
in four cases. Unfortunately, little stress for useful mc(lieal work
can he laid on tlu; famil}' history olitaineil from hospitid patients.
Even well to do and educated ]ieoi)le oft<'n ,i;ivi', although uncon-
sciously, misleadin<f inforniation on such matters.

As to the exeitiny- causes of rheumatoid aithritis the followini;' were
note<.l. There was a history (jt "(jnorrha'a in more than HO pel' cent,
of all cases oeeurrin<; in miili'S, and in three of the male oiu^es there-
was a histoi'v of 2 or more attacks of ironorrho'ii. In the fennde
j)atients, howevi-r, there wiis with the exception of oiir ease an entire
ab.sei'je of .symptoms pointing' to a [last j^enito-urinaiy disturbance.
For a lon<' time it has been iau<![ht that there is an intimate connection
betwi'en uterine disease and rlieumatoi<l arthritis. In fact a veiy
ingenious theory as to the nature of the disease has been built upon
this alleged connection. But next to gonorrlxea, exposure to cold
was considered as the most likely exciting cause. It appeared to be
the sole or chief cause in five of the forty cases, which mr.y account
for the fact that in Canada the disease is rather frecpiently met with
in lumbermen. The next most frerpient cause was worr/. It was
said to have lieen present in four cases. In all four casts the worry
was of an unusually severe and prolonged character. In three caseS
alcoholism was at least a predisposing factor. Three patients had had
subcutaneous absces.ses, two had had double otitis media, two influenza
and two tonsillitis. Typhoid fever, whooping cough and diphthci'ia
were each in one case considered as beinw the chief cause.

In several cases two or more of the above mentioned causes were
present, while in about 15 per cent, no cause could be ascertained.
It will be noticed that in fully 50 per cent, of the cases the patient had
previously had some infectious trouble, the most frequent being gon"
orrh(Ea, but only in two of the gonorrhceal cases was there a history
pointing to gonorrha^al rheumatism. In both cases the gonorrh(i?al
arthritis was confined to a single joint, but there afterwards developed
a polyai'ticular rheumatoid arthritis. It appears as if the infection of
one joint predisposed to a general joint affection. It is worthy of
note that three patients had recently had subcutaneous abscesses and
two a double otitis media.

I will now take up the consideration of the more immediate object
of this paper viz., a discus.sion of the relations existing between
nervous disease, tuberculosis, rheumatism and r}iPumatoid arthritis.

I. The relation Itotweon rhojimatolil 'irtlirltis Hn<I ncrvims iliseoM.

Tliti peculiar joint artoctioii met with in cases of talx's dorsalis
first fully descrihed l»y Charcot, presents many features hoth clinical
and anatomical similar to those of rheumatoid arthritis. It was, I
believe Remak who first, in l.S(i:i, drew attention to this striking,' re-
semblance, and who sufj^jnreftt'.'d the possible spinal ori;^nn of rheumatoid
arthritis. Much has been written lately on the similarity. Tn the
<,'reat majority of stanihird medical works of the present day, the
favourite theory for the explanation of the disease is that it is bioufjlit
aliout by chanifes in the spinal cord. IJut \ -hen tlie whole subjt^ct is
carefully considered it is dilUcult to understuiid why such a view has
becfjine so popular. It certainly has no sullicient ground work to
entitle it to l)e generally accepted as a full and true explanation of
the nature of rheumatoid arthritis. The reasons usually advanced for
adopting the nervous origin of rheumatoid arthritis, are these :

1. The fact, that in certain diseases of the spinal cord, as tabes,
syringomyelia, progressive nuiscular atro|jhy, joint changes of a
somewhat similar character are met with.

2. The very frequent early and pronounced mu.scular atroi)hy oV»-
served in cases of rheinnatoid arthritis.

3. The history fre(|uently obtained of eau.sos, having a markerl
effect in lowering the resisting power of the central nervous system to
disease.

4. The frequent onset of rheumatoid arthi-itis with symptoms of a
nervous character, .symptoms pointing to a central or peripheral nerve
disturliance, and there can be no (juestion that in a certain proportion
of cases about the first symptoms complained of are tingling and numb-
ness in the extremitie.s. In 10 of my 40 cases such an onset was
described, and simultaneously with this perverted sensory disturbance
or soon subsequent to it, stiffness of the joints supervened.

The neihropathic arthropatlik's. In a number of well recognised
lesions of the central nervous system marked joint changes are
occasionally met with. They are probably more frequently seen in
syringomyelia than in tabes dorsalis. They are rare in progressive
muscular atrophy, hemiplegia anil ataxic paraplegia.

The joint changes in tabes may take the form of atrophy or hyper-
trophy of the structures entering into its formation, or there may be
atrophy of some parts and hypertrophy of others. Usually the onset
is very sudden and painless, and a characteristic feature is sudden
distension of one of the larger joints, the knee generally, from fluia
effused in the synovial sac. This effusion may disappear after a
time without permanently damaging the functions of the joint.

Mori! frofniciitly .sij^ns of ilisorf^ani/ation In-eoinr' iip|>arfnt. The car-
tilai^t! is (Icstioycfl. Tin: licads of the Itoiics waste mid soinctiuH's
bony ovi'r^rro\vtl)SH])i'infj; from tin- eritls aiul tlu-y aiv also i.iot with in
the iK'ri-articuhir .structures.

Occa.sionally the liuih hecunies cnoriuously cnlarijed from the
exce.ssiv(( jirowth of lioiic, ami as sodn as the chaii'it's in the honts set in
there is no tendency to repair. Clinically tliere is little or no dif-
ference bt'tween the joint att'ections of tabes and syrini^om^clia.
Anatomically they also correspond. In a few ea.ses of tabes the Joints-
have lieen openeil early in the di.sease, and in se\eral ea.ses of
.syrine;()myelia. where s\ir;;ieal intctrferenoe was consideied necessary
I'arly in the disease, j^ood opportunities were pre.sentitl of a.seertain-
in|f the exact changes present in tlu; joint liefore the destructive pro-
cess b.ad made much nroeress. The cartilage is found to lie more or
less destroyeil and covered here and there with polypoid ^^nnvtlis.
In .several cases the ends of the bones weii; <lisea.sed, there being
usually a considerable increase in the cortical substance and a wast-
ing of the spongy .structure. The caps-ule is found gieatly expanded
from'tlie accumulation of the polypoid growths which vaiy much in
S' :e, the smaller ones being soft and vascular and the larger ones hard
in consistence and containing but little V)!ood. Bony plates are also
to be met with on the internal surface of th(; capsule. Tht; above
intracapsular changes are precisely like those met with in cases of
rheumatoid arthritis that have been operated on earl}' in this
disca.se. There hiis been for .some time a difference of opinion as
to th(! .structures lirst involved in rheumatoid arthritis, .some con-
tending that it first shows itself in the cartilage, while others
think that it ari.ses primarily in the .synovial membrane. Early
changes, however, are met with in both structures, which are inrlis-
tinguishable from those seen in syringomyelia and in tabes. In
nervous arthropathies effusion into the Joints is more common and
reaches a greater degree than it does in rheumatoid arthi'itis. The
destructive process reaches a greater degree and runs a much more
rapid course in the former than it does in the latter. The clinical
difference between the two is much greater than the anatomical.
Rheumatoid arthritis is attended by great pain, while the nervous
arthropathies usually run a painless course. The Vuuhs in the latter
can be bent in all directio • without causing any pain, the extreme
flexibility of the joints bein^, lUe to the .stretching of the ligaments and
other structures l)y the copious effusion into the joint.

Two different views are at present held as to the nature of the
nervous arthropathies, one being that they are brought or by inter-

fereuce witli tlio function of the so-culled troiihie centnss for the Joints
in the spinal conl. Ft is ciiiiniud that tin; ili';^onorativo process in tahes
and syrinirouiyelia involves such parts in the spinal cord. The other
view, and one that is steadily i^aining Lfi'ound, is that owitis;' to the
lessened or disturhed si'iisation so fnMU'.eiitly met with in both tal)es
and syringomyelia, traumatic inthn'iices have much to do with setting
up the inHammatory action, and according to this view it is not neces-
sary to assume the presence in the cord of centres having a trophic
iuHu. nee (jver the joints, the <lestruetion of which Wrings al)out the
changes. In the great majority of eases of both tabetic and syringo-
myelic arthritis, a iiistory of a fall or injury is obtainable Tin re is
nothing special in the joint changes that could not Ite explained by
an inHanuuatory action excited l>y an injury. The clinical difference
is accounted for by the sensory disturlmnce in the joints, anil all
things considered, it appears mori consistent with ol)served fact to
explain the arthi'itis on the assumption of an injury than that it is
brought about i>y the involvement of certain deiinite parts of the
spinal cord.

The (jUestion of tlie cause and nature of the joint changes m tabes,
syringomyelia, etc, is still a mattei- of doubt. It is u)iwise to speak
too positively on this matter. There is, liowt'Ver, very strong ground
for taking the view that the joint changes in rheumatcnd arthritis are
not due to disease of the spinal cord. .ShouKl such changes be brought
about in that way, it is hardly conceivable that they should not
present evidence of not only microscopic, Init mucroscopic changes in
the spinal cord. In several cases the spinal cord has been c.vamiucd in
rheumatoid arthritis after dt;ath, and no abnormal appearances have
been discovered Folli in two cases saw some wasting of the cells of
the anterior coriiua, but elsewhere nothing. Changes in the peri-
pheral nerves have also been met with in a few cases, but neither the
slight changes descriljcd by Folli or the nerve changes are constant,
and, therefore, cannot be considered as .sufficient cai ''the joint

changes in rlu^umatoid arthriti.s.

It is difficult to explain the marked and comparatively early atrophy
of the muscles that occurs in rheumatoid arthritis. It does not
correspond clinically to that met with in anterior polio-myelitis_
for we do not meet with any marked reaction of degeneration. The
electric reaction is often normal, and is rarely more than slightly
lowered. The view commonly held at present is that the wasting is
brought about in a reflex manner. This theory receives support from
the experiment of Raymond that division of the posterior spinal
roots prevents wasting from taking place in joint disease. It must

ixi rt'iiuMiilM'n'il that ntropliy of tlic muscles takes place in all t'uniis
'>r chronic arthritis, ami even in snliacute cases ; syphilitic and
tuherculous and ha-Mitiphilic arthritis are ire(|Uently attended l)y
atrophy. No matter what the canst! is then, it must he due in the first
place to some chani^e in the joint, and not to any supposed chaiif^es
in the spinal cord. It is in the first ])!ace an arthritic aU'ectioJi.

The fact that causes that are well known to i)rin^ ahout a lowered
resistin<^ ptnver of the nervous system are often prominent in rheuma-
toid arthi'itis does not directly prove the involvement of the nervous
sy.stem. .Such causes act as well on the jufeneral nutrition as on the
joints.

The not infre(|uent ))erverte<l sensory disturliance preceilinj^ the
<aiset of rlu'umatoid arthritis has lieeii advanced as tending to prov«!
the nervous orij.'-in of the rlisease. I have never heen able to ascer-
tain that there was an ohjt-ctive ilisturhance of sensation in rheuma-
toid arthritis. No matter how extreme the muscular atrophy, it is
not attended with any lo.ss of sen.sation. Sulijective disturhanct; of
sejisation is a fretpient symptom of many jfeneral conditions, due
{generally to auto-intoxication from the intestinal canal, and its fre-
(|uent presence in rheumatoid arthritis does not, as far as I can judge,
lend n)U(;h support to the neuropathic origin of this disea.se.

On the whole it must \n> considered that the evidence pointing to a
nervous origin of rheumatoid arthritis is very meagre.

II. T/ui Reldtion of Ji/i<niinat(ml Arthritis to Tuberculosis. — Pul-
monary and other forms of tuberculosis appear to be more frequent in
the families of sufferers from rheumatoid arthritis than they are in
other non-tuberculosis diseases. In the series of 40 reported cases such
a history was only obtained in three cases, a pi'oportion not greater, if
as great a.s, in people in good health. J^uller, in a report on 119 cases
of rheumatoid arthiitis, found a history of phthi.sis in 23 cases.
Charcot and sevei-al other observers have found tuberculosis of the
lungs and lymphatic glands not infrequent antecedents in their ex-
perience. \ few cases have been published where both disea.ses were
apparently present at the same time, one joint l)eing tuberculous,
while others resembled the joint lesions of rheumatoid arthritis.
There i.s, however, nothing in common l)etween the two diseases,
although in some respects there is a similarity between them. Tuber-
culosis is an infectious disease, prone to attack those who have an
inherited predisposition to it. There is every reason to Vtelieve that
rheumatoid arthritis is also of an infectious nature, nor is there any
doubt that there is an inheritance of what we call an arthritic
diathesis ; that is an inheritance which involves a tendency to intlam-

Illation of iuiiits iitnl Hl.n)n.s stnictun's. Indiivctly, a tultL'ivuloiis tcii-
fleiicy may, l»y lowcriiij; tliu rt'sistaiicc, tcml to Itriiij,' alioiit a rluMiiiui-
toid artliritiH, and it is only in this si'iist-, as I understand it, that
thoi'«! is a coinu'ction Ix'twccn tlic two diseases.

III. The, RcldJioii af lihi'miinlit'id Arlhrilis to Aciiir, Siihiiridi' <ni(l
(!hn>n'ic liht'ii iniitiniii. — Is rheunmtoid arthritis a Fro(|n»!nt or an occa-
sional continuation or result ot" an attack of acute, sultacute or chronic
rheumatism ? This rjuestion is constantly heiuL; forced on ev(;ry
physician who sees much of this dist^ase. In a very considerahle
pro)K)rti(ai of ail cases a history of acute or suKaciite rheiimutism is
fortlu'omine', hut the vaj,fueness with which the word rheumatism is
,t;'enerally emplo^'ed, renders the clinical hi.storyof such fuses far from
exact. Makin<ij a certain allowance for this, there can l)e no (|uestion
that a certain, even a very considerahle numlu'r of cases that are imlis-
tinnuishahh^ in the lieninninn' from acute rheumatism develop after-
wards, it may lie gradually or more or less suddenly, into rheumatoid
arthiitis. In four of my 40 cases of rheumatoid arthritis there was
a very clear history of acute rheumatism. In tun of the foui' cases,
there were found the physical siyns of ortranie disease of the heart. In
one, a female, aged 85, there was both mitral and aortic disease. She
was said to have had rln-umatic fevei' at 10 and sevei-al suhacute
rheumatic attacks subsequently. Whe.i under tib.servation in 1<S94,
she presented all the marked symptoms of a poly-articular rheunuitoid
arthritis. In a second, a female, age<l 70, was under observation dur-
ing the early stage of her illness, which clinically was not to be
distinguished fi-oin an ordinary attack of acute rheumntism. Early
the physical signs of mitral disease were discovered, and after several
I'elap.ses of the arthritis, the signs and symptoms of rheumatoid
arthritis gradually developed. There can, I think, be no (piestion
that in both of these cases we have a rheumatoid arthritis gradually-
developing as the result of I'cpeated acute rheumatic attacks. In
neither case was there a history pointing to an hereditary tendency
to rheumatism.

In thirteen cases, the onset resembled that of an ordinary subacute
rheumatism, pain and swelling of the joints being the first and only
prominent features of the early stage. The rule in such cases being
that after lasting a few days the intensity of the symptoms subside,
but only for a short time. Repeated attacks occur, till finally we have
a fully established case of rheumatoid arthritis. In twelve cases the
onset was very slow, with stiffness and swelling of one or more joints,
coming and going till finally the condition was one of undoubted
rheumatoid arthritis. In the great majority of the cases of chronic

onset some time passed before the characteristic changes of rheuma-
toid arthritis were developed.

It will be observed that in a very large proportion of the cases the
beginnings of the disease were the same as in ordinary rheumatism.
In at least .30 per cent, the onset was either that of acute or sub-
acute rheumatism — the unavoidable inference being that a very
intimate connection exists between rheuniatoid arthritis and acute and
subacute rheumatism. How is it that the great majority of cases
of both acute and subacute rheumatism recover perfectly and that a
few cases do not, but eventually go on to destructive changes in
the joints. It is a well recognized fact that irrespective of the cardiac
changes neither acute nor subacute rheumatism are followed by any
permanent damage of the structures involved.

There is no recognised well marked dividing line between clu'onic
rheumatism and rheumatoid arthritis.

We meet with all jxjssible grades of ditierence from paroxysmal,
slight pain anil stiti'ness of one or more joints, up to cases in which
nearly all the joints of the body tirv practically useless from destruc-
tion of theii' tissues and the formation of new bony tissue. We
characterize the cases at one end of this scale as chronic rheumatism,
and at the othei- end as rheumatoid arthi'itis. But the naming of the
cases that we meet in the borderland between these two extremes is
a difficult matter. One and the same case may be called by com-
petent observers, chronic rheumatism or rheumatoid arthritis. This
goes to show that there is nothing distinctive about the clinical fea-
tures of these cases. It is only in marked types of rheumatoid
arthritis that a diagnosis is easily made, and one that would be
accepted universally.

In Germany and France it is the custom to call cases chronic
rheumatism which in England would be called rheumatoid arthritis.
There are no anatomical differences between boi'derland cases of
chronic rheumatism and rheumatoid arthritis. In both we find dis-
tension of till capsnlo from pcjlj'poid growths and the accumulation of
serum.

There are grounds f(jr hoping that the bacteriological examination
of the joints may help to clear up the difficulties suri'ounding the
nature of chronic rheumatism and rheumatoid arthi'itis.

As 3'et we have no absolute proof uf acute rheumatism being due
to a micro-organism ; there are strong reasons, however, for believing
that such is the ease. Riva, of Parma, in a recent paper has made
a very important contribution tending to prove the infectious nature
of this disease. Until comparatively recently thei'e was no evi-

dence pointing to the microbic origin of rheumatoid arthritis, but
from the bacteriological researches of Schiiller of Berlin, Bannatyne
and Blaxall, and of Chaufford and Ramond, it is highly probable that
we have here to do with an infectious disease. The acute and subacute
poly-articular forms of rheumatoid arthritis have all the clinical
characters of an infection. Schiiller, who has practised arthrectomy in
many cases of rheumatoid arthritis,^has examined the tissues for jnicro-
organisms and has constantly ftiunda small bacillus present and occa-
sionally an agglomeration of micrococci. He has also made cultures
from the fluid in the joints removed by tapping. Ho found bacilli
develop on various media. The best stain is carbolised fuchsin. In-
noculation into the knee of a rabbit produced an arthritis resembling
that of chronic rheumatism, but withe at any changes in the carti-
lages or bones.

Drs. Bannatyne and VVohlmann, of Bath, working with Dr. Blaxall,
of London, have demonstrated the presence of an organism which is
said to be constant in its characteristics. It is a very small bacillus,
presenting marked polar .staining. It was found pre.seut in the
.synovial fluid in 24 out of 25 ca.ses examined. It was al.so found
in the blood in three out of Ave cases. A bacteriological examina-
tion was made of the synovial fluid from joints diseased from other
causes with a negative result as far as the special bacillus is con-
cerned. The observers have not succeeded by re-inoculation as yet
in producing the original disease in animals.

Ciiauftbrd and Ramond have still more recently found in the
synovial fluid in cases of rheumatoiil arthritis a diplo-bacillus. They
also found the same organism in the swollen lymphatic glands in the
neighbourhood of the <li.seased joints, Imt did not succeed in culti-
vating the bacillus.

Much work yet requires to be done in the bacteriology of this
disease before a true estimate can l)e made of the value of tlio
researches referred to. In some points they all lack in the extreme
care that such work demands, and before they can be accepted the
work must be i-epeated by diti'erent observei's.

Prof. Baumler, of Freiburg, the most recent writer on this subject,
considers that it is highly probable that the disease is of an infectious
nature. At the recent meeting in Berlin of the Congress for Internal
Medicine, he read a very able paper on the subject.

I will conclude with the following sunnnary of the chief points in
this discussion.

1. Rheumatoid arthritis is a disease prone to occur in people of a
rheumatic tendency, and who have suflered from sub-acute rheumatic

attacks. The presence; of infectious disease of any kind tends to in-
crease this tendency, as does also the operation of all causes havinj^ a
depressing influenet! on the resisting power of the nervoxis system
(won-y, exposure to cold, and triiumatism.)

2. There is no shai-p dividing line between certain cases of chronic
rheuniatisni and the earlier stages of I'heuniatoid arthritis.

3. There is not sufficient evidence to support the views commonly
held, as to the nervous origin of rheumatoid arthritis.

'. There is no direct relationship between tuberculosis and rheu-
matoid arthritis.

5. The polyarticular forms of rheumatoid arthritis have clinically
the features of an infectious di.sease.

6. The result of recent investigations points ver^' strongly to its
infectious nature.

I have only a few words to say on the ti'eatment of the disease,
especially on the ti'eatment by super-heated air baths.

It is universally recognized that the medicinal treatm.'ut is very
unsatisfactory. Whethei- surgical interference will ever become
practically applicable is difficult to say. Tiiere appears to be a field
for surgery in these cases. .Schuller, of Bt'rlin, and other Gei'man
surgeons have published results which certainly tend to make one
think that much may be accomplished in this way. Something also
may be accomplished by the injection into the diseased joints of
various antiseptic agents. Reports hy Schuller and others on this
way of dealing with the disease are more or less .satisfactory.

At the present time the most universally applicable and successful
method of dealing with early rheumatoid arthritis is by means of
baths of various kinds.

The Scotch douche is in certain cases a veiy valuaVjle means. It
consists in the direct application of an alternating stream of hot and
cold water. It promotes the absorption of the exudations into the
joint, and it also relieves pain.

Dry baths are, however, generally more effective than moist ones
The dry sand bath has for a long time been used with more or less
success. But in my opinion the most valuable of all methods of
treatment is the use of baths of super-heated diy air, after the Taller-
man method. It has Vteen used in 20 cases of rheumatoid arthi-itis
in the Royal Victoria Hospital during the past nine months with
gratifying results.

The apparatus consists of a copper cylinder, of various shapes and
sizes. The usually employed model is sufficieutl}' long to admit a lower
limb to some inches above the knee. By means of valve taps the

moisture from the limb is expelled, so tlmt the nir in the chamber is
kept dry. The temperature in the chambei- is kepo usually from 240°
to 300°. The first marked effect is copious per«piration all over the
body. The puLse is increased froui 1.5 to 30 Itcats, and th(! tempera-
ture is usually elevated from 1° to 2°.

In all we have treated twi'nty cases with the hot iiir bath. In
fourteen of the twenty cases pain in the affected joints was present
and of a severe character. In the great majority of the cases the
relief was marked even after the first bath, and after several baths
the patient, except on movement, was practically free from pain. As
a result of this relief, sleep, which usually befoi-o was greatly dis-
turbed, becomes possible. In addition there was .some apparent change
foi* the better in nutrition. In spite of losing daily mon? than a
pound in weight from the loss of fluid by perspiration, the patient
u.sually steadily gains in weight. Gains of from three to four pounds
weekly have been (juite common. As regards the effect on the
affected joint it is various, depending on the amount of effusion and
the degree of (i.vclii/losis.

Generally a considerable increase i" the molality follows after the
use of a few baths.

It cannot be expected that restitution can take place in advanced
cases, but befon; nmch actual destruction takes place, there is eveiy
reason to look for a decided check to the progressive character of the
disease.

Dr. Shingleton Smith (Bristol) (juestioned whether the term
rheumatism should ever be used in connection with the disease, and
he preferred the term rheumatoid arthritis to that now advocated in
Germany by Dr. B umler, chronic pol^'^articular i-heumatism. He
believed that the ordinary theories of the di.sease failed to give a satis-
factory explanation of its phenomena, that it had no connection
with tubercle, syphilis or nerve disease, and that probably it had little
connection with ordinary acute and chronic rheumatism. One fact
mentioned by Dr. Stewart, that 30 per cent, of the male cases had a
history of gonorrlxea, gives us a clue to a more satisfactory view of
the nature of the malady ; it has been abundantly shown that
gonorrhoeal rheumatism is due to infection from the urethra, and is a
form of pyiemic infection due to the gonococcus. Is it not probable
that rheumatoid ai'thritis is also due to some microbic infection, and
that the coccus described by Drs. Bannantyne and Wohlnian, of Bath
and cultivated bj' Dr. Blaxall, may be the real cause of the polyarthritis
in its early stages, whereas the subsequent phenomeua are only the
sequelae of the arthritis itself ? This theory gives us a more hopeful

view of the possibility of a more successful treatment before the
incurable deformities and other s(U|Uol8e have occurred.

Dr. LiND.SAY (Belfast) would base his remarks on twelve; or thirteen
years of liospital practice in Belfast, where the disease was frequent-
He had seen nothing to justify the theory (jf any special connection
between rheumatoid arthritis and tuberculosis. He had been much
struck with the nervous symptoms present in rheumatoid arthritis,
especiall}' the atrophy of musch's. He was ii.<clined to suspect that
these .sj'mptoms were due to chanj^es in tht- peripheral nerves, po.ssibly
due to some toxic influence. He thought, there was a real and fre-
(|uent connection between rheumatoid arthritis and chronic articular
rheumatism. He had seen many cases where the former had super-
vened upon the latter, and had seen other cases in which he found it
quitv-^ impossible to draw^ the line between the two diseases. He
thought the two conditions presented considerable analogy as regards
their etiology. As regards treatment, he had not found much advan-
tage from the ordinary anti-rheumatic remedies. He thouglit cod-liver
C'il and a general tonic line of treatment offered the greatest prospect
of benefit.

Dr. A. Jacobi (New York), .said : In his very concise and compre-
hensive paper Dr. Htewart had omitted om.^ thing — namely, to tell us
what he meant or we are to mean by arthritis deformans or rheuma-
toid arthritis. We have been told about lioundai-y lines and gradual
transitions, but I have been unal)le to learn his opinion of thy patho-
logical anatomy. One thing is certain : it is not acute articular
rheumatism and not a sequela of it. The latter is an affection
(anatomically speaking) of the .synovial membranes, never of the
cartilage. Arthritis deformans is an affection (again anatomically
speaking) of the cartilage, which, w'hile fii'st e.xhibiting prolifei-ation,
terminates in atrophy and absolute lo.ss, and finally in circular hyper-
trophy and eburnation round the atrophic cartilage. From gout it
differs liy the absence of uratic deposits. I cannot tell what arthritis
deformans is : the pixvsence of cocci in a few cases does not prove the
latter to be the cause. It may be that in the future it will be best to
study the cases of arthritis deformans in childhood, where it may be
expected to be primary an<l uncomplicated. Two such cases in girls
of 10 and of 6 years were published here in Montreal by Dr. Nicholls ;
one was published by Dr. Koplik (girl of 7). In none was there acute
rheumatism or any rheumatism previously. As far as the latter is
concerned, we should :.'ot use the term except in acute rheumatism .
The best treatment had been in his hands arsenic in increasing doses,
continued months and m .nths with occasional interruptions, and the
iralvanic current.

Dr. J. C. Wilson said : The use of tlie term rheumatism is a stumb-
ling block in the way o*^' our knowledge of diseases of the joints. It
.should be restricted to the disease known as acute rheumatism, or
better, as rheumatic fe\er. Such a restriction would clear the way
for a bcttel^abderstunding of the medical arthropathies There are
various foi-ms of joint di.seases, very different in tlieir clinical mani-
festation. s, which must be legarded as arthritis deformans. Many
cases in their early course progress by attacks ?resend)ling those of
subacute rheumatic fever. Tliese cases suggest a reseml)lance to that
disea.se which is only superlicial, bnt lend support to the view that
the di.sea.se may be of inicrobic origin.

Dr. FuKDiCHKJlv C. Slf.VTTiX'K (Boston ) .said : I risi; with some diffi-
dence, having unfortunately been prevented from hearing Dr.
Stewart, lait venture to touch briciti}' on .sevtM'al points. In the first
place, I cordially concui' in the opinion which .seems to be generally
held that our ignorance with reefard to this di.sease is lamentable
Pathologically- and therapeutically alike it is one of the opprobria of
medicine. Since the appearance of the observations of Smith and
Lindsay, Dr. J. E. Goldthwaite, of Boston, has been carefully studying
the fluid obtained from joints affected with arthritic deformans where
such could be had. Thus far he has not confirmed Smith and Lindsay s
observations, having found no organisms of any knid. Some eight
years ago my attention was forcibly arrested by an article in the
American Joitrrtal of Medical Sciences by Blake. He relates several
cases which seem to conclusi\ely show that stippuration, especially' if
concealed, may have the most intimate relation with arthritic disease,
non-rheumatic, .similar to arthritis deformans in .some I'espects. One
of these cases was that of a clergyman of middle age who became the
subject of severe, intractable, advancing arthritic disea.se. Blake found
a nasty condition of things beneath a toot'i plate, careful attention to
which was followed by complete recovery. Since then I have care-
fully sought for concealed suppuration in all cases of chronic and
obstinate arthritis which have come under my observation. I have
failed to find such save in one case — one of advanced and severe
arthritis deformans anfl psoriasi.s. In this patient I found a neglected
Riggs's disease. The teeth were thoroughly treated by a competent
dentist, and a very sharp acute exaet'rbation of the arthritis pi-omptiy
followed. There would .seem to be an analogy between Blake's cases
and those of gonorrhoeal synovitis. I trust that any gentleman whose
attention may have been called to this point will speak of it.

Dr. MooiiHOUSE said : I believe that there is an intimate relation-
ship between arthritis deformans and ordinary rheumatism, l)ut that

the disease has advanced a stop farther in attacking the substance of
the synovial membranes and cartilages. I am (juite in accord with
])r. Lindsay (Belfast) both as to cause and treatment, believing that
tonic treatment is the better plan, never having seen any benefit from
the ordinary antirheumatic treatment, tonics such aw^on, piinine,
arsenic, cod liver oil, etc. I do not think that any microscopical germ
has yet been di.scovered.

])r. J. E. (iUAHA.M (Toronto) said: 'i'he <liagnosis lietween gout
and clu'onic rher.niatic arthritis has given me the greatest difficulty-
This, I suppo.--.', was not referred to by J)r. St(!wart, because the
differentiation between chronic rheumatism and arthritis deformans
is (|iiite sufficiently extensive for one discussion. 1 agree with I)r
Jacobi that we should have a clear idea of thc«pathology of the dis-
ease ; the hyperplasia and destruction of cartilage, and the eburnation
of the ends of bones are marked characteristics which differentiate
this disease from those affections of joints which are usually placed
under the head of chronic rheumatism. It is unfortunate that the
term "rheumatism" should be given to a number of joint affections
arising from causes altogeth(;r distinct from those of acute and .sub-
acute rheumatism. 1 have found arsenic one (;f the most valuable
remedies in the treatment of this very obstinate disease

Dr. G[HNKV (New York) expressed his inability to contribute to the
differential diagnosis between arthi-itis defoi'mans and I'heutnatism, or
even to the etiology and pathology. He failed to hear Dr. Stewart's
paper, but learning that this paper included a discussion of the treat-
ment by superheated dry air, believed that he ;night contribute his
experience which was in general t'.rms satisfactory. He had found
the hot-air treatment specially valuable immediately after surgical
means, such as breaking up adhesions or improving the position of
the limb. He called attention to the importance of protecting the
joint in examination by absolute immobilization, and of affording a
limited amount of protection on the subsidence of the exacerbation>
especially in the management of the knee, the ankle, and the elbow-
This he does by an appliance limiting the range of motion to that
allowed by Nature herself. He found valuable assistance in arsenic
and cod-liver oil.

Dr. Tyson (Philadelphia) thought the .subject thoroughly covered
by what had been said. Personally he inclined to the view that in a
certain number of cases the true rheumatic condition, or that gener-
ally conceded to be it, had at least a predisposing, and possibly through
its specific cause a direct causal relation to rheumatoid arthritis
However this may be, he considered that an infectious nature must

be concorlod in other cases, as attested by the large proportion (HO per
cent; in which there was previous presence of an infectious disease
reported liy Dr. Stewart. As to treatment, his e.xperience, like that
of others, luul liecii most uiisntisfiictory ; no cnics, hut simply pallia-
tion, followed in most cases hy relapsi'. His method of treatment has
invariably been by general rcstojative measures, amonif which he
included especially coddiver oil, arsenic, the bcht of food, and hyffiene.
Nbissage, too, he thouijjht was sometimes au ertieient palliative.

The Pkksidknt (Dr. Steplii'ii Maeken/ic) commenced by paying .1
tributes of res])ect to Dr. Stewart for his very alile handling of such a
ditticult subject as arthritis dei'ormaus. lie indieated that in his
(;xperience arthritis tlefoniians was a disciise distinct from rheumatism,
acute and chronic, and had nothing whatever to do with gout. Me
especially ilii'W attention to the class in which the |)iimary artlnitic
attack could not be <listinguislied from rheumntie fevei-, and recovery
took [ilace without any appreciable deformity of the joints, but which
subse(|Uently came under ob.sei'vation in an attack of ordinary and
undoubted subacute or chronic arthritis deformans. The late J )i-. H.
G. Sutton drew attenticm to the association of osti.'o-ai'thritis, rheu-
matism, and insanity in families. He also pointed out that though in
a considerable proportion of cases of arthritis deformans there was a
history of rheumatic fever, yet in not 1 per cent, of cases of arthritis
was heart di.scase found on post-mortem, examination. He (juit(!
agreed with .some previous speakers, especially Dr. J. C. Wilson, that
under the term arthritis di.'formans there was pi'ol)alily a number of
groups of cases which would ultimately be separated as clinical
entities.