LONDON, JANUARY I 94

POST-GRADUATE MEDICAL JOURNALTHE CHRONIC RHEUMATIC

DISEASESWITH SPECIAL REFERENCE TO CHRONIC

ARTHRITIS

A SURVEY BASED ON 1,000 CASES

By ERNEST FLETCHER, M.A., M.D.,M.R.C.P.

(Physician, Queen Mary's Hospital for the East End,and The British Red Cross Clinic for Rheumatism,and (with physical medicine) Royal Free Hospital.Heberden Lecturer in Rheumatism)

AND

E. LEWIS-FANING, B.SC.ECON., Ph.D.(Of the Statistical Staff of the Medical Research

Council)IN FOUR SECTIONS.

SECTION I

IntroductionThe bony changes which evolve in the course of

chronic arthritis have played an important part intracing its historical evolution. So far as ancienthistory is concerned, it therefore follows thatosteoarthritis comes into the picture more fre-quently than infective anthritis. From such datait is known that the disease antedates man.

Chamberlain and Taft (1938) describe parts of thevertebral column of a mastodon found in South Carolina.The bones showed hypertrophic changes with bonybridging, and similar changes have been noted in theskeletons of prehistoric animals in the British Museum(Fisher, I924). It is thought by geologists that themastodon existed from the mid-miocene to the end of thepliocene (from ten million to one million years ago).The earliest human case was probably that of the Nean-

derthal man of La Chapelle (40,000 B.C.). In this casethe cervical spine (5-7) and the thoracic spine (1-3) wereaffected (Pales, I930).

Glover (1928) mentions that chronic arthritis was asprevalent in the prehistoric dwellers of Nubia and Upperfgypt as amongst our Saxon forefathers of the Heptarchy.ippocrates made observations on gout and joint disease

in old age. In 1867 Charcot published his Maladies desVieillards.As Glover remarks, "the age-old history (of chronic

arthritis) is a singularly barren one."For the confusion in nomenclature, which will be

mentioned later, was at its zenith in 1763, when Sauvage'sNosologica Methodica was published. He divided gout

(= arthritis) into fourteen forms, (one of which, arthritisrheumatica, appears to be what we now call infectivearthritis), and rheumatism into ten forms. All thesematters are presented in full form by Stockman (1920).

In the nineteenth century, exact clinical and patho-logical observation led to an increase of knowledge. InI824 Benjamin Bell described eburnation of the femoralhead, and Robert Smith (1847) described what we termosteoarthritis of the hips with accuracy. Some think hedevised the term "malum coxae senilis" (I835), butGlover attributes it to Adams (I831). No reference isgiven, but presumably this is the R. Adams who wrotea section on the hip-joint in Todd's Cyclopaedia of Anatomyand Physiology. This was published by Longmansin 1839.

Probably Gruveilhier (1829) should have the credit forfirst distinguishing osteoarthritis, but the Viennesepathologist Weichselbaum (1872) played an outstandingpart in developing an accurate concept of the disease.

In later years, a great deal of hard and painstaking workhas been devoted to the chronic rheumatic diseases, andthe two Ministry of Health reports, so often mentioned inthis paper, and edited by Glover, have contributed verymaterially to a clarification of modern ideas.

This work was originally undertaken because of thedifficulty experienced in setting up a standard of diagnosisfor the treatment of the chronic rheumatic diseases.The principal study published on this subject was the

Ministry of Health report of 1924, in which a fairly largegroup of insurance practitioners undertook to record inthe form of a questionnaire their findings during a setperiod in cases of chronic rheumatic disease. Afterstudying this very useful report, it seemed likely that thefindings of so many observers would vary to a degree thatmight interfere with its homogeneity.

It appeared that to estimate its real content, the wholefield needed re-survey.Lack of reliable data particularly accounts for the pre-

vailing confusion in nomenclature and classification-andit will generally be agreed that clinical differentiation incommencement and course sometimes throw unexpectedlight.The work is based on I,ooo cases falling into the group

of the chronic rheumatic diseases. A good many, but notall, the cases were admitted to hospital for observation.

It would be of assistance if this paper could be read inconjunction with the Heberden Lecture of I939 deliveredby one of us (E.F.) as this would save a certain amount ofduplication. Suitable references to this are given inthe text.

In most branches of medicine the usual careful medicalexamination reveals all that is to be discovered by sucha method, but in that branch which deals with medicaldiseases of the locomotor system special examination andsearch must be made for abnormalities which are not atall obvious, and of which the patient has no knowledge.This special examination has to be added to the routinemedical examination, and does not at all replace it.Although it may seem elementary to add details of

examination to a paper which deals with such a specialisedsubject, yet past experience has shown that difficultieswith and even error in diagnosis is often due to incompleteor inexperienced examination, and in courses of lecturesand talks with practitioners great interest is usually shownin such details. A short r6sum6 on this subject is, there-fore, appended.

POST-GRADUATE MEDICAL JOURNALMethod of examination

The following sequence is adopted, and it ismost convenient and least tiring for the patient.On arrival at the hospital, the patient's height

and weight are taken, the temperature, pulse andrespiration are recorded and a routine examinationof the urine is made.

After the history has been taken, the patientundresses and lies supine on. a couch, and theexamination is conducted as follows:

(a) General condition.It is wise to try not only to assess the

patient's general physical condition, but alsoto obtain some insight into his generalmental make-up. In certain conditions,notably infective arthritis, there is a con-siderable psychological element, and it is aswell to be aware of this.

(b) Examination of the eye grounds, the reactionof the pupils, with a rough test of the cranialnerves.Many cases, particularly of osteoarthritis,

are associated with arteriosclerosis and withhypertension. An examination of the eye-grounds, particularly after experience hasbeen gained, will often give forewarning thatsuch a complication may be present.As pain is a prominent, if not an essential

part, of most medical disorders of the loco-motor system, the aim must always be toexclude all possible causes. The reaction ofthe pupils to light and accommodation,especially if taken in conjunction with thestate of the knee jerks, is an observationwhich should always be recorded.A rough test of the cranial nerves becomes

so necessary because cases of musculardystrophy, especially of the facio-scapulo-humeral type, may start with pain in thelimbs. This is not, of course, by anymeans the only reason, but is given as anexample of why this examination must beincluded.

(c) Examination of the tongue, teeth and faucesand temporo-mandibular joint. Transillu-mination of the antra.

It is not proposed at this point to discussthe very vexed question of focal sepsis. Itis, however, necessary to say that, althoughcases due to focal sepsis may or may not berare, it is a very poor service to a patient tomiss it if it is present. When a genuinepotent source of focal sepsis is present, itsremoval leads, as a rule, to permanent andcomplete cure. It is the greatest mistake

and very bad practice obviously to removeteeth, tonsils and other organs on the chancethat they may be an important factor. Itis, however, a greater mistake not to removethem when they are the fons et origo of thedisorder.

(d) Examination of the neck, cervical spine andthe front of the chest. Estimation of the bloodpressure. Range of movement in the shoulders.At this stage the neck is examined for

glands in the triangles, as these may oftenbe found in cases of infective arthritis, andthe localisation and character of the glandsmust be determined in all cases. It is some-times easier to palpate the paraspinalmuscles in the cervical region while thepatient is supine. Rotation of the head,which is seldom seriously interfered with,should be tested, and forward bending of thehead and neck will often give a clue to dis-order of the spine and its ligaments lowerdown, as the ligaments form a continuousband down to the sacrum. The position andsize of the thyroid may be determined now,and it is a good plan to search, especially inelderly people, for an enlarged left supra-clavicular gland, a comparatively early signin carcinoma of the stomach.

Fully circumabduct the shoulders, thearms and hands lying in a semicircle roundthe head. Palpate the brachial plexus fortenderness.The front of the chest is examined by

palpation, percussion and auscultation in theusual way, and the blood pressure is taken.

In addition to this always palpate theintercostal muscles and the costo-sternaljoints, as these are the site of the unexplainedpain in the chest in some cases.

(e) Examination of the abdomen with the super-ficial reflexes.

Especially palpate the gall-bladder andappendix regions, examining also for the sizeof the spleen.

(f) Examination of the joints of the hands, elbowsand radio-ulnar joints and their movement.Tenderness of nerves, reflexes and musclestrength.

It is as well to adopt a method of notationfor the small joints of the hands. Callingthe thumb I, the fingers are numbered onboth sides, the little finger of course being5. In addition, note the change presentand which joint is affected.

2 Janucary, I945

RHEUMATISMFor example:

R2 m.c.p. Sw. R3 m.p. D:Li c.m.c. P & T.

would mean the metacarpo-phalangeal jointof the right index finger is swollen, the midphalangeal joint of the right middle fingeris deformed, and the carpo-metacarpal jointof the left thumb is painful and tender. Tothe uninitiated this may seem slightlypedantic and unnecessary. This is notreally so, for on seeing a patient after sixmonths, say, it enables a complete check-upto be made quickly. Patrick's Goniometer(B.M.J., August 19, I944, p. 246) is invalu-able for the measurement of movement at theradio-ulnar joints, and a small protractor canbe used for the elbows and wrists.With regard to reflexes, it is usual to test

the supinator, biceps and triceps jerks andstrength is usually tested by the grip, adynamometer being used if desired, thenflexion and extension of the wrists, elbowsand shoulders.Two nerves can be palpated easily, the

musculo-spiral in its groove as it passes roundthe humerus and the ulnar nerve at theelbow.

(g) The so-called Lasegue or straight leg raisingtest is performed, and the movements of thehip and knee-joints are observed. The feetare examined and the state of their ligamentsand the mobility of the joints tested. Re-flexes are tried. Tenderness of nerve andmuscle is looked for.The straight-leg raising test is a useful one

for testing the structures at the back of theleg, thigh and low back. Care must be takenthat the back lies quite flat on the couch, andthat no tilting occurs. If a positive test isshown, its significance must not be overemphasised. It does mean that one or moreof the structures mentioned above are atfault, but it is not true that it is a test forsciatica.

If, however, it is positive, it is wise tomeasure both thighs six inches above theupper border of the patella and the legsfive inches below the lower border, as wast-ing of muscles is a common finding in somenerve lesions.Any swelling of a joint must be measured

and compared with the other side if it issound.Examination of the feet will, of course,

note the presence of pes cavus or flat foot.Tenderness of the metatarso-phalangeal andmid-phalangeal joints should be recorded.

Tenderness of nerves, especially the pos-terior tibial, should be looked for, and theusual reflexes, including the plantar reflex,tested. The usual way to test strength ofmuscles is to try flexion and extension ateach joint, but the important movement inearly lesions of the hip joint is abductionand adduction.

(h) With the thighs held down the patient isasked to lean forward and touch his toes.This is rather a complicated test to evaluateaccurately. In its simplest form it is anindication of the mobility of the lumbarspine, but before this can be accepted severalother conditions must be fulfilled. In thefirst place, it must be ascertained by palpa-tion that the hamstring muscles are notunduly short, and it must also be clear (seeunder g) that the hip joints have a full rangeof movement. A tender and inflamedsciatic nerve will interfere with the test, andso will myalgic conditions situated either inthe back of the thigh or in the low back.In making the examination, therefore, it is aswell simply to note that in trying to touchhis toes lying the patient fell short by somany inches. At other stages any extra-neous cause will be found.

(j) Whilst leaning forward the back of the chestis percussed and auscultated, and thepatient is then asked to reach up to theceiling with his fingers.A number of cases will be found complain-

ing of pain in the arms or back who aresuffering from pulmonary or pleural lesions.Bronchiectases, for instance, may give riseto pains anywhere in the body, and it is,therefore important to exclude such acomplication. On more than one occasion apatient referred for osteoarthritis has beenfound tobe sufferingfromcarcinomaofthelung.

Failure to reach the fully vertical whenreaching up to the ceiling with the fingershas two main and several subsidiary causes.The two main ones are periarthritis of the

shoulders (Dupley's Syndrome) and a fixeddorsal kyphosis. These two can be separ-ated by putting the shoulders through a fullrange of movement and asking the patientto put his arms round his back. If the rangeof movement in the shoulders is full, thenthe dorsal spine should be carefully examined.

If neither of these tests reveal any abnorm-ality a variety of lesions must be looked for,and it should be remembered that weaknessmay (occasionally) be the cause, and that a

really stiff neck may be a factor.

January, r94.5 3

POST-GRADUATE MEDICAL JOURNAL(k) With the hands down again the cervical and

dorsal spines are tested for movement bylateral bending and torsion of the trunk.The back of the neck and its muscles areexamined. The chest expansion is measured.

Testing the cervical spine for movement isa special manceuvre. Standing on the rightof the patient the left hand is placed roundthe neck at the back so that the cervicalspine (so to speak) lies between the palm andthe fingers. Holding the top of the headwith the right hand, it is gently movedsideways in both directions. As the headmoves the flexibility of the spine can benoted with the left hand. The importantpoint is not to let the hand rotate; lateralbending is the essential movement. Rota-tion of the head is seldom interfered with,but should be tested next.

Chest expansion is naturally conditionedby many considerations, and it may bedifficult to evaluate them all, but the point'we are looking for is interference with therange of movement in the costo-vertebraljoints. In certain conditions, such as anky-losing spondylitis, this is seriously inter-fered with.

(1) The patient is then asked to turn on to hisface: the way he does so is noted, hyper-extension of the hips is tried, and tender spotsin any of the spinal and para-spinal musclesare looked for. The posterior sacral liga-ments are palpated, as are also the posteriormuscles of the buttock, thigh and calf.Tenderness is sought for in the more super-ficial nerves.

This is the stage at which extraneouscauses for a positive straight leg raising testare usually found. Myalgic spots in thehamstrings and gastrocnemii are easilymissed.

(m) In certain case of unexplained pain in thearms and legs additional blood pressurereadings are taken in the arms and legs andoscillometric readings taken.

(n) The patient is asked to stand up and touchhis toes.The general posture is noted, deviations

of the spine in any direction are observed,and the degree of lumbar lordosis.

The principal advantage of this sequence ofexamination seems to be that nothing is forgotten;also it involves the least amount of inconvenienceto the patient and can be easily recorded.

In making a report to the Joint TuberculosisCouncil on the method of recording tuberculosis

in the United States and Canada (Tubercle I93I),I gave it as my opinion that a printed form wasnot so good or so useful as a blank sheet on whichthe physician could enter what he thought ofvalue. I had to reconsider this view when tryingto decide on the best way of recording chronicrheumatism, and I think the reasons were that thephysical signs of rheumatism are so diverse and sofar-flung, even in a single case, that the wholebody must be examined in order to arrive at areasonable conclusion, whereas pulmonary tuber-culosis seems to behave in a more sequential andorderly manner and to have better understoodcomplications.The patient is then sent for X-ray examination

of the appropriate parts. If the sinuses trans-illuminate well, X-rays are comparatively seldomrequired, but it is sound policy to ask for X-raysof the teeth in most cases where many teeth aredoubtful, and especially when dead teeth arepresent.

In addition, examinations and tests are done asthe case demands, and the special department'sco-operation is asked where needed.

The problem of classificationThis section deals principally with the recording

and classification of cases of chronic arthritis.The Nomenclature Committee of the Inter-

national League against Rheumatism are said tohave gone through sixty different methods ofnomenclature from different countries (Fox andvan Breeman, I934). Every conceivable basis isused: clinical, anatomical, pathological, radio-logical, and so on. There would be little to begained by enumerating or quoting these classifi-cations of rheumatism, but they were carefullystudied when the present work was embarkedupon. On the whole, it was thought that three ofthese systems should be more carefully considered.The Ministry of Health classification (Glover,

I924) obviously needed study, for it representedthe most careful work extant at that time.

Dr. Glover's Classification.A. The acute rheumatic group

(i) Acute rheumatism(ii) Sub-acute rheumatism

B. The fibrositic group(i) Muscular rheumatism

(ii) Lumbago(iii) Sciatica and brachial neuritis

C. The arthritic group(i) Rheumatoid arthritis

(ii) Osteoarthritis(iii) Gout(iv) Unclassified arthritis

Januzary, 194.5

RHEUMATISMAt this stage it became necessary to decide what

qualities a classification should possess to be ofthe greatest use.

First, it must be complete and embrace every-thing which could be met with in the course of thework, and nothing which was outside the field.Secondly, it must be helpful, that is to say, somedefinite advantage must accrue from its use.Lastly, it-must not group together things which didnot possess similar qualities. That was as far asI could go at that time, but subsequently otherauthors have defined what they need from aclassification more completely and more clearly.From the point of view of completeness, Glover's

classification seemed to fall short. The skinlesions and the nerve lesions which could properlybe called rheumatic were not included as therewas no mention of erythema nodosum, panni-culitis, or other forms of painful fat, or of inter-stitial neuritis except so far as sciatica and brachialneuritis secondary to fibrositis were concerned.Ankylosing spondylitis was considered so rare asto need special notification. On the other hand itwas helpful, in that similar things were groupedtogether, but on the whole it did not suit my pur-pose for the reason mentioned.

I then turned to the classification first issued bythe Nomenclature Sub-committee of the BritishCommittee on Rheumatic Diseases, appointed bythe Royal College of Physicians.

The Royal College of Physicians Classification.Group I. Rheumatic fever, acute or sub-acute

(synonym: Acute rheumatism)Group II. Acute goutGroup III. Chronic arthritis

(A) Rheumatoid type (atrophic, proliferative)(a) Known aetiology(b) Unknown aetiology

(B) Osteoarthritic type (hypertrophic, degener-ative)

(a) Known aetiology(b) Unknown aetiology

Group IV. Non-articular rheumatic affection.

TABLE II.(amplifying Table I)

Group I. Rheumatic fever, acute or sub-acute(synonym: Acute rheumatism)

Group II. Acute goutGroup III. Chronic arthritis

(A) Rheumatoid type (atrophic, proliferative)(a) Specific causation, known aetiology

(i) Gonococcal arthritis

(ii) Tuberculous arthritis(iii) Syphilitic arthritis(iv) Arthritis following other specific

infections, such as dysentery,scarlet fever, rheumatic fever.

(b) Non-specific causation in known aetiology(i) With known associated factors(A) Metastatic or focal arthritis,

including the so-called mul-tiple infective arthritis

(B) Associated with disorderedmetabolism (e.g. Gout)

(C) Climacteric arthritis (villoustype)

(ii) With no known associated factors(A) Classical type of rheumatoid

arthritis of women usuallyof child-bearing age

(B) Rheumatoid arthritis in chil-dren, including Still's dis-ease

(The term "rheumatoid arthritis"when used should be confined tothe above two conditions, all otherforms being designated "rheuma-toid type").

There was no doubt that so far as chronicarthritis was concerned, this was complete, but thegreat group of non-articular affections was left asa whole and not sub-divided. Seeing how large apart of the subject fell into this group, I thoughtthis detracted from its value. When I came toconsider whether it was helpful, I was struck byone or two outstanding disadvantages. I thoughtit unbalanced, as acute gout could hardly compareon an equal footing as a main group with chronicarthritis. The division of non-specific rheumatoidtype arthritis into those "with known associatedfactors" and those without such factors did notseem to me particularly helpful, for it leads to onegroup which includes focal arthritis, gout, andclimacteric arthritis, which really have compara-tively few similarities.

Lastly, I turned to the classification of theInternational League, and here I was met with adifferent difficulty, for the first group was sub-chronic arthritis, an arthritis, apparently, whichfollowed rheumatic fever.

International Classification.A. Articular

(i) Sub-chronic rheumatic arthritis (follow-ing on rheumatic fever)

(ii) Rheumatoid arthritis (arthritis variouslydescribed as focal, chronic infective,

Janucary,. i945 5

POST-GRADUATE MEDICAL JOURNALnon-specific or multiple infective, ofunknown origin atrophic, U.S.A.)

(iii) Climacteric arthritis (endocrine, meta-bolic, hypo-glandular rheumatism,villous arthritis, cf. rheumatic gout,gout in women)

(iv) Osteoarthritis (hypertrophic arthritis,arthritis senile, monarthritis)

(v) Spondylitis (spondylosis rhizomelica,ankylosing spondylitis).

B. Non-articularFibrositis, myositis, cellulitis, panniculitis

(lumbago, sciatica, perineuritis, adipo-salgia, etc.).

The remainder of the classification appearedfairly straightforward, the only real attempt toclassify being to divide the subject into two groups,articular and non-articular. From this point ofview there seemed little positive advantage to begained from its use.On considering the title "sub-chronic arthritis"

I tried to visualise cases of arthritis followingrheumatic fever, and it became clear to me thatwhen "such cases ran a protracted course, theyalways fell into the group of rheumatoid, or infec-tive, arthritis, that as far as I was concerned thatwas what I called them, and that if a specialgroup was made for them, the classification wouldbe unbalanced, for there would only be a few casesin any one man's experience.As the subject is a very difficult one, it is helpful

to quote Stone (I942), as his views coincide withmine and have been published. He says that anartificial classification is useful only for indexingand reference, but that a natural classificationshould so group things that they share a largenumber of common properties. To attain thisend, a sound natural classification should conformto several rules. It should be exhaustive, and eachclass in the division should be defined, each divisionbeing grounded on one principle or basis. Forexample, in classifying doctors, they can bedivided by the work they do-physicians, surgeons,obstetricians, etc.-or by nationality, personality,or success. But if these principles are mixed inthe same division, we might find-physicians,surgeons, Welshmen, critics, rogues, and theEditor of the Lancet-which makes no sense. Inthe same way, as each sub-group is dealt with,only one principle should be used.

Further, one should not proceed from a wide toa narrow basis: for example, I cannot dividedoctors into the Editor of the Lancet and thosewho are not the Editor of the Lancet, and thisillustrates the general rule that the principle ofdivision must be appropriate, that is to say, it

must be something from which as many things aspossible can be inferred.On these principles Stone tried to make a natural

classification, using as his definition of rheumatism"painful disorders of the locomotor system whoseaetiology is obscure."He found he had to use as his first main divisions

"diseases" of the locomotor system, and as hissecond "component syndromes," meaning by this,part of a concurrence of symptoms, so that myalgia,for instance, may be a bit of the pattern of a

general toxic state, or a symptom of peripheralvascular disease. Very naturally these componentsyndromes were only subject to artificial classifi-cation.At the outset I was not able to envisage the

problem as clearly as this, but proceeding by trialand error and by a study of the existing classifi-cations, I came to the conclusion that any realand useful classification of the chronic rheumaticdiseases would be very complex, so that I gave upthe idea of classification and simply recorded thecases as they appeared by the name of the syn-drome to which they belonged. This is a well-tried, time-honoured method in clinical medicine.The disease index in its final form appeared asfollows. (Abbreviations are also shown.)

Disease. AbbreviationI .Infective arthritis I.A.

Spondylitis ankylopoietica S.A.Osteoarthritis OA.

Sub-group (A)-with normal weight andnormal blood pressure OA.A.

Sub-group (B)-with obesity and nor-mal blood pressure OA.B.

Sub-group (D)-with obesity and highblood pressure OA.D.

Sub-group (N)-with normal weight andhigh blood pressure OA.N.

Sub-group (H)-traumatic type and V OA.HSub-group (O)-occupational arthritis ASub-group (Spine)-osteoarthritis of the

spine OA. Spine(includes hypertrophic spondylarthri-tis and hypertrophic spondylitis)

Sub-group (Hips)-osteoarthritis of thehips OA. Hips(It is unfortunate that the letters ofthe sub-groups of osteoarthritis do notfollow alphabetically: this is due tothe fact that certain groups dealingwith other variations were eventuallycut out as having no significance.)

GoutUnclassified (set out in detail later)Interstitial neuritis (including intercostal

neuralgia, brachial neuralgia, sciaticneuralgia and "others")

MyalgiaMalposition of the spineOsteochondritisRheumatic feverSub-acute rheumatism

G. I.G. II.

Int. neur.

Malposn.Ost. cho.Rh. F.S.A. Rh.

Januzary, i945

January, 1945SynovitisLesions of the shoulder-girdleNon-rheumatic conditions

RHEUMATISMSyn.

Comment on the disease indexAn explanation is necessary as to how the index

appeared in this form.As the matter was to be considered purely from

the point of view of chronic rheumatism, it seemedright to exclude from the list associated, and even,possibly, aetiological factors, and simply, todescribe the pattern of the reaction which theycaused. For example, if we take five cases ofPaget's disease, we see they were entered asfollows :

(I)(2)(3)(4)(5)

Osteoarthritis (Group N)Osteoarthritis (Group A)Osteoarthritis (Group A)Osteoarthritis of the hipsSciatic neuralgia

So that on analysing, say, sciatic neuralgia, we findone case due to Paget's disease, and the next maybe due to a prolapsed nucleus pulposus.

This method of recording was not used at thebeginning, and a good deal of thought was givento the matter before it was finally adopted.

It seemed to me that in a piece of work devotedto chronic rheumatism, I should keep to thebetter-known rheumatic patterns. Patients werereferred to the hospitals because they sufferedfrom a syndrome which the doctor diagnosed asrheumatism, and indeed in many cases it wasdifficult to make a diagnosis with any certaintywithout an X-ray, so that I thought it right tokeep the diagnosis to the pattern caused and thento enter the important and possibly aetiologicalfactor after it. I have given the reverse angle ofthe same facts under the patterns caused-in thecase of Paget's disease, psoriasis and diabetes.This will be discussed later.

I hope it will not be thought that I have undulyraised the importance of the rheumatic side, orfailed to realise the significance of such conditionsas I have mentioned.

Table I is a statement of the material on whichthis paper is based. Sex and age differences forthe various types of rheumatism are fully dealtwith in Part II.Having taken the rather bold decision to keep a

simple disease index, it remained to justify theassertion that all the cases of chronic non-specificarthritis could be given a name. In the opinion ofa great many people the group of chronic non-specific arthritis is so complex and confusing, andthe boundaries of diagnosis between the groupsso blurred, that it is not possible to separate thegroups clearly.,

7

In view of the confused nomenclature in rheu-matism already mentioned, a preliminary surveywas made to estimate the possibilities, and itseemed likely that there were only in fact twotypes of bone and joint response to the greatmajority of insults and traumata. It seemed tomatter little what they were called so long as theycould be clearly defined, but the first appeared tobe of an infective character, and so was calledinfective arthritis. The second was called osteo-arthritis, and this term has the sanction of commonusage.

It seemed probable that infective arthritis hadmany differences in individual cases in incidence,course and prognosis. It was tempting to make.sub-divisions, or even main groups of these differ-ences, but it was felt that a substantial proportionof the difficulties in nomenclature had been broughtabout in this way.

In case other groups should be found in thecourse of the work, an unclassified group was madeso that this could be enlarged into a main groupif it became necessary. This group must not becompared with Glover's (I924) group, which wasunclassifiable. The unclassified group in this seriescontained cases which were insufficient in numberto make groups of their own, and would havecontained "unclassifiable" cases if they had beenfound in large numbers.The sections which follow deal with the stand-

ards of diagnosis which were used for arriving atthe different classes of chronic non-specific arthritismentioned in the disease index and in Dr. Lewis-Faning's paper. It may be as well, however, firstto consider the relationship of rheumatic fever(or acute rheumatism) and infective arthritis, sothat, by deduction, we may be left with a stableresidue of cases.

The relationship between rheumatic fever andinfective arthritis

There can be no question that at first sight thereseems to be little in common between a typicalcase of rheumatic fever in a child with its slowlydeveloping carditis, and the classical picture ofinfective arthritis in an adult with its maximumincidence in joints, and so it would seem almostunreasonable to put forward the thesis that thedifference is more apparent than real. Never-theless there is some evidence of a link between thetwo conditions.A diagnosis of rheumatic fever would be generally

agreed in any patient who fell ill with pyrexia, anarthritis of'the bigger joints and some evidence ofcardiac involvement. And more particularly ifsweating' was a marked feature. In the acutestage, clinical evidence of carditis is generallyrestricted to a mitral systolic or diastolic murmur,

8 POST-GRADUATE MEDICAL JOURNAL January, 1945

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RHEUMATISM

and, as is well known, this comes and goes, andmay disappear altogether only to return manyyears later as fully fledged valvular disease. It issaid' by many authorities that the electrocardio-gram at this stage shows alterations in the Twave in lead iv. Master and Jaffe (I933) foundelectrocardiographic changes indicative of myo-cardial damage in 63 consecutive cases of rheumaticfever, but not in one case of 46 cases of infectivearthritis. This is an extreme finding, but is ahelpful point in diagnostic difficulty.

This murmur on which the diagnosis may besaid to depend only occurs in about half the casesof rheumatic fever, and, as stated already, is notcontinuously present. In the remainder of thecases the yardstick of clinical cardiac involvementcannot be applied for lack of evidence. Theelectrocardiographic evidence is unreliable, andalthough electrocardiographic tracings should betaken in every doubtful case, most cases of rheu-matic fever will be found to show normal curves.Tachycardia and a systolic bruit may be presentin any infectious disease.

It is always said that the bigger joints are in-volved in rheumatic fever, yet cases with involve-ment of the small finger-joints are seen occasionallyand infective arthritis may often start in the knee-joint, or even in the hip-joint. (For analysis ofjoints involved, see later.)

Sweating occurs about equally in both conditions,and the pungent odour attached to it is a commonfeature. A curious point is that the odour maycontinue in infective arthritis long after the condi-tion has become clinically quiescent.

Pericarditis is undoubtedly far more common inrheumatic fever, but it occurs occasionally inconnection with infective arthritis. In the illus-trative case-notes which follow, a case is includedwhich demonstrates this (case 2).

It is generally said that the arthritis of rheumaticfever is of a fleeting nature, "flitting from joint tojoint," each joint resolving as the process passeson, and it is really astonishing how quickly a red,swollen, exquisitely painful joint may clear up.The argument is that a case is not one of rheumaticfever if the joints fail to clear up, yet it is not anuncommon experience to find that the first hintthat the case is one of infective arthritis is thefailure of the joints to resolve, and they may evenrelapse after having apparently cleared up (seenote on diagnosis under Classification).

Subcutaneous nodules are well known to occurin both conditions. In America, where the his-tology of these nodules has been extensivelystudied, opinion is divided: some think the nodulesin the two conditions are identical, while othersthink not. McEwen (I933) says that rheumaticgranulomata, as exemplified by subcutaneous

nodules, show large cells which stain character-istically with supravital stains, such as neutral redand Janus green, and differ from the cells oftuberculous and syphilitic lesions. Similar cellshave been found by McEwen in nodules from 7cases of rheumatoid arthritis. They were notfound in 63 joint exudates, 8 pleural effusions, or4 pericardial effusions, from 33 cases of rheumaticfever and 27 of other diseases. In rheumaticfever, polymorphonuclear cells were increased, butdecreased in proportion to the clasmatocytes asthe joints recovered.So far as a small personal experience goes,

these nodules appear to be identical. Certainlytheir appearance is not the prerogative of rheu-matic fever.

Prodromal symptoms, such as sore throat, areperhaps more common in rheumatic fever, butsome of the worst cases of infective arthritis startwith a streptococcal throat infection. Response tosalicylates has always been looked upon as acharacteristic of rheumatic fever, yet not all casesrespond, and some cases of infective arthritis aremarkedly influenced by this method of treatment.Pleurisy is said to have a high incidence in rheu-matic fever, and some authors say it occurs in44 per cent of rheumatic children, but McEwen(v.s.) was not able to find the typical cells of therheumatic granulomata in pleura, pericardium, orsynovia.

Case 2 again illustrates that pleurisy may super-vene in infective arthritis, and this is a less un-common accompaniment than pericarditis. Ery-thema nodosum is little help in diagnosis. Thereseem now to be so many cases of unknown aetiology:formerly the cases were thought to be eitherrheumatic or tuberculous, with a greater numberoccurring in tuberculosis-it certainly occurs inrheumatic fever, but quite a number occur in casesof infective arthritis.

Finally, the incidence of the two conditions isremarkably alike. They are both diseases ofhumid, temperate climates, and uncommon intropical and sub-tropical zones; both apparentlyshow their maximum incidence in Great Britain.A good deal of the work on rheumatic fever has

naturally been carried out in children, and it isgenerally agreed that the carditis is maximal atthat time of life, and the arthritis maximal inadults. Salicylate therapy also shows its bestresults in children. Infective arhtritis in childrenmay take the form known as Still's disease, withenlargement of the spleen and lymphadenopathy,and rheumatic fever at that time of life tends to anacute form. In adults, however, both rheumaticfever and infective arthritis, with certain excep-tions, tend to be less acute, and it seems possiblethat age itself may be a very important factor, a

januatay, x945 9

POST-GRADUATE MEDICAL JOURNALvariation of the thought lying behind the "soil andthe seed." Schlesinger's (I935) view is thatrheumatic fever is becoming more common inadults, and less so in children.The foregoing represents the chief clinical

arguments in favour of common factors, and possi-bly a common aetiology in rheumatic fever andinfective arthritis. From the laboratory angle evenless difference may be found. In both conditionsthe erythrocyte sedimentation rate is usually andsignificantly raised, and a leucocytosis of a moderatecharacter, with a shift to the left in the Arnethcount, is noted. Apart from these two findings,laboratory data are meagre. At the same time itwill be better for the present to regard them asseparate syndromes, for it is only the border-linecases which point the similarity, and the greatmajority are unlike, as indicated in the firstparagraph. Researches in aetiology are indecisive,but whether a haemolytic streptococcus or a virusis to be incriminated, the manifestations must bevery protean if they are to include both conditions.It will, nevertheless, be as well not to divorce thementirely in one's thoughts.

In this series there were IO cases of rheumaticfever and 254 of infective arthritis.

Three Cases of Infective Arthritis(To illustrate the point made in the text that it

may very closely resemble rheumatic fever insome cases, and have no resemblance at all inothers.)Case I.

S.H. Male. Age 20. Soldier.This man was passed fit into the Army in January,

i940, but gave a history of an attack of rheumaticfever in April I940, when he was in hospital for sixmonths, but passed out fit. Except for this, he hadalways been well, but his father had suffered fromvalvular disease of the heart.On 11.2.41 he was admitted to hospital again, and

said that six days previously he had quite suddenlynoticed dyspnoea on exertion and pain and swellingin the ankles and left knee.On examination, the temperature was IoI 4° F.,

pulse rate' 96, and respirations 20. The heart wasenlarged and showed pulsus bigeminus, due to extra-systoles. Blood pressure was 104/68. The electro-cardiogram showed left ventricular preponderance andventricular extra-systoles.Two weeks later he developed swelling in the wrists.At this time the W.B.C. count was 8,400, with 54

per cent lymphocytes.In a month's time the heart was apparently normal

again, except for a systolic murmur. The knees andankles were normal, but the wrists were still swollenand painful. The blood sedimentation rate, originally98 mm.s at the hour, fell to 48 mm.s at this stage.The man stayed in hospital for six months. At

the end of that time the sedimentation rate, whichhad fallen to 9 mm.s, rose to I6 mm.s. The wristsand hands were deformed, swollen and painful, and

he thought the pain was coming in the feet. He waslost sight of on discharge.

This case illustrates how very alike rheumaticfever and infective arthritis may be.

Case II.F.C. Female. Age 27. Shorthand-typist.Came to hospital in October 1940, complaining of

pain and swelling of the small joints of both hands.The wrists and elbows were also affected. She saidshe had always been well, but her brother had sufferedfrom rheumatic fever.On examination, there was swelling of the wrists

as well as of the hands. She was pale and inclinedto sweat easily. There was a systolic murmur at theapex, but no enlargement of the heart. Blood pres-sure was II8/76. There was no enlargement of theliver or spleen.The sedimentation rate was 48 mm.s at the hour,

and the white cell count was 8,900 with a relativelymphocytosis. X-rays showed early change of aninfective type in the wrists and hands.

She was admitted to hospital for treatment, but atthe end of the first week she developed a right-sidedpleural effusion which, on aspiration, showed a smallnumber of polymorphonuclear cells, but was sterileon culture. At this time the temperature began toswing between 10 * 2 and 99° F.A few days later she developed a pericardial rub

and became seriously ill. The W.B.C. count rose to14,000, and the sedimentation was 60 mm.s.With small fluctuations she remained in this con-

dition for a month, when the heart began to settledown. The X-ray had previously shown greatenlargement, which was confirmed clinically, but nowthe apex beat began to come in. The lung base alsobegan to resolve, and at the end of September I941(ten months after admission) she left hospital. TheW.B.C. count was 8,ooo and the sedimentation22 mm.s The systolic murmur was still present,and she still looked pale and ill, with a haemoglobinof 80

I saw her twice more, but she never recoveredcompletely, and the hands and wrists became moreand more deformed. Eventually she died of con-gestive heart failure in December I941.No post-mortem was obtained.

This case is quoted because it illustrates the factthat cases which can reasonably be regarded asinfective arthritis, may develop complicationsusually regarded as those of rheumatic fever.

Case III.F.W. Female. Age 48. Housewife.Came to London in January, I942, complaining of

pain and swelling in the hands and knees. Has hadpains in various parts of the body, but no swelling ofjoints till two months previously. Her father hadgout, but she had aways been well except for recur-rent dislocations of the right shoulder.On examination she looked well, but the metacarpo-

phalangeal and mid-phalangeal joints of both handswere swollen, as also were the wrist-joints. There wasmarked muscle wasting. The right shoulder wasankylosed. The knee-joints showed a bilateraleffusion.The sedimentation rate was 55 mm.s at one hour,

10 ~Janu~ary, i945

RHEUMATISMand the blood uric acid was 2 8 m.grms. per o00 c.c.s.The W.B.C. count was 12,400, with 65 per cent ofpolymorphs.

She was treated with glucose and insulin, and herweight rose from 7 st. 8 lb. to 8 st. 6 lb., when thetreatment was discontinued. After this, gold treat-ment was instituted, and the condition graduallybecame quiescent.

She is still under treatment and at no time has thetemperature or pulse rate been raised. The jointsare resuming their normal functions, but musclewasting and deformity remain.

This case illustrates how unlike rheumatic feverinfective arthritis may be, and how difficult itbecomes, on occasion, to think they have a commonaetiology.The Two Groups of Chronic Non-specific

ArthritisAs mentioned already, the significance of the

facts elicited in the course of the paper--as far asnon-specific arthritis is concerned-will depend onthe truth of the statement that only two groupsof cases are found in practice.

It will be right, therefore, to state in detail themethods that were used in their separation andthen to describe the results obtained. This matterhas already been discussed in the HeberdenLecture of I939, but not in great detail.Throughout this paper only such differences as

exceed twice their standard errors are regarded assignificant, i.e. unlikely to have arisen by chance.Differences which exceed twice their standarderror would probably occur by chance less thanfive times in a hundred trials.

The differentiation of the type-infectivearthritis and osteoarthritis.

Sex, Age, and Occupation.Infective arthritis appears to affect females far

more than males. 30 per cent of the femalepatients seen belonged to this group, but only15 per cent of the men, i.e. of the I,000 cases, 48were male cases of infective arthritis and 206 werefemale. This difference would be likely to ariseby chance less than once in a thousand times.The average age for the males with infective

arthritis was 49, and for the females 48, and thedifference between the mean age for all types andthe mean age for infective arthritis was- -*48years for males and- I8I years for females,differences which are not significant. In Table IIwill be seen this series compared with Pemberton'sand Monroe's, and it will be noticed that there isa considerable difference in the percentage ageincidence, the patients in this series being as awhole much older, an average age of 47 as com-pared with 32 in Monroe's series. It is not possibleto say why this is.

TABLE II.

Infective Arthritis-Percentage Age Incidence

Pemberton Monroe This series,536 cases. 267 cases. 254 cases.

Under io 2.4 3 nil10-20 I3.4 I5 I 320-30 15'9 24 12 630-40 23 5 20 I8 I

40-50 26 I 25 20 550-60 I3'4 II 28.760-70 4'7 2 I4 570-80 o-6 - 43

Oldest 75 Oldest 72 Oldest 89Av. age 37-4 Av. age 32 Av. age 47

X2 = II4 *I;5P = -oooooooI shewing the three distribu-tions to be dissimilar.

Analysis of occupation showed that in the males7'9 per cent of outdoor workers and 20 8 percent of indoor workers had infective arthritis. Inthe females, the figures were 31 per cent of womenon light duty and 24 per cent of factory workers.It did not appear from this that hard work orexposed conditions favoured the disease. Thesedifferences were tested and found significant.

Osteoarthritis of the peripheral joints (exceptthe hip) affected I2-o3 per cent of males, but27 22 per cent of females.

In this paper osteoarthritis has been divided intogroups, the criteria of division being the presenceor absence of obesity and of hypertension. Severalmore groups were originally added, but proved tohave no significant value, and were subsequentlyallowed to fall back into the main data. Theerythrocyte sedimentation rate was used as theadditional criterion in these groups, and. theinformation so obtained is discussed in the sectionon this subject.Four main groups were left, and facts and

figures from these groups are incorporated here.The Heberden Lecture was also largely concernedwith this subject. The following groups, withtheir abbreviations, are shown in the disease index.

Group A.-Osteoarthritis with normalweight and normal blood pressure

Group B.-Osteoarthritis associatedwith obesity

Group D.-Osteoarthritis associatedwith obesity and high blood pres-sure

Group N.-Osteoarthritis associatedwith high blood pressure

O.A. (A)

O.A. (B)

O.A.(D)

O.A. (N)The following tables (III and IV) show the differ-

ences of sex and age in these groups.

januayy, I945 11

POST-GRADUATE MEDICAL JOURNALTable III shows that in group A there was no

significant difference between the sexes as regardsthe proportion of patients attacked. Combininggroups B, D and N, 18 per cent of the females, butonly 5 per cent of the males, were included, a differ-ence unlikely to be attributable to chance. Treat-ing B, D and N separately, sex is seen to be ofimportance only in regard to the first two, and wetherefore conclude that one respect in whichgroup A differs from the others is that in A sex isnot a factor, but in the others it is.From Table IV it is seen that whether groups B,

D and N are treated individually or combinedthere is no real difference between the averageages of the males and females. In group A, how-ever, the females are on the average nearly fiveyears younger than the males. The average ageof males in A is but little different from that ofmales in groups B, D and N taken together, butfemales in A are on the average 3-23 ± 1-6* yearsyounger than the females in B, D and N groups.Thus the most that can be said of age as a differ-entiating factor is that females in group A are onthe average three years younger than other osteo-

TABLE III.Sex distribution of ostcoarthritis.

Grouped as percentages of all types of rheumatism.

Males Females Difference ± S.E.

Group A .. .. .. 6-48% (21) 9'-7% (62) 2-69% ± I86Group B .. .. .. 1.85% (6) 6-95% (47) 5Io % ± I-5*Group D .. .. .. 1.23% (4) 7'54% (5I) 6-31 % ± 1-5*Group N .. .. .. 247% (8) 3 56% (24) 1-09 % ± 1I2*

Groups B + D +N . .. 556% (8) 18-o5% (122) 12-49% +±24*All four groups . . . 12-03% (39) 27-22% (184) 15-2 % ±2-8*All types of Rheumatism .. I1 O % (324) Ioo-o % (676)

(Figures in brackets denote the number of cases.)TABLE 1V.

Average age of osteoarthritis groups in years.Sex Group A Group B Group D Group N Groups B, D and N

Males .. 59*86 ± 17 54.17 ± 2-2 62.0 i 3'8 62-0 ± 3 4 59-39 ± I'90Females .. 55-I 14 55-36 -o 59-7 ± II 612 ± 17 58-33 + 0-72Difference .. 4-'8 ± 2-23* 1-19 ± 2'5 2 3 ± 4 0 o-8 ± 3-7 i.o6 ± 2-0

TABLE V.Differences between Mean Age of all Types combined and the Mean Age for Osteoarthritis.

Sex Mean Age of all types Group A Group Broup DGroup N

Males .. 50 29 years +9'57+ 3 88 + 1171 + I1.71 + 9 IoFemales .. 49'56 years + 5 54 + 580 + 1o-15 + II.65 + 8 77

TABLE VI.

Males Females

Type of rheumatism .---

No. of cases Obesity Rate No. of cases Obesity Rate

I.A. .. .. .. .. 48 206 30 I46O.A. (Groups A, B, D, N . 39 8 20-5 184 94 5II-O.A. Spine .. . 13 0 0 27 7 25-9O.A. Hips .. .. .. 29 34 I 6 400All other types .. .. 95 8 4I 244 42 17'2

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January, I945

RHEUMATISM

arthritic patients. These facts are tabulated froma somewhat different angle in Table V.

A similar analysis comparing osteoarthritis-groups A-N combined-with infective arthritisshows that females were more heavily attackedthan males by both types of rheumatism; in thecase of osteoarthritis chiefly, as has been shownabove, in groups B and D. There was no differ-ence between the mean ages of the sexes in eithertype, but osteoarthritic patients, whether male orfemale, were on the average 9'9 ± 2-3 yearsolder than patients with infective arthritis.The occupation has been examined in detail by

Dr. Lewis-Faning. He shows that taking osteo-arthritis of all parts except hips, 20'4 per cent ofall males were affected. 25 2 per cent of the out-door as compared with I6 2 per cent'of the indoorworkers suffered, a difference of 9g 0 ± 4 5, whichis barely significant. But 31 5 per cent of theheavy outdoor workers as compared with I6- 2 percent of all other types of occupation were affected,an excess of 15 3 ± 5 0, which is statisticallysignificant.

In the females the position was more difficult toassess, but if osteoarthritis of the hips is included(I5 cases), 360o per cent of house and office workersas against 24'I per cent of factory workers wereaffected, a difference of I2.8 ± 6.6, which is justwithin the realm of chance.

Physical Type of Patient

(a) Infective arthritis.Obesity was not a common finding. There were

no obese males, and I4 6 per cent of obese females.On the whole, the patients showed one common

feature-a rather pale, anxious expression, withcold clammy hands, and the great majority tendedto be under weight. These features are not, ofcourse, peculiar to infective arthritis, as theyappear in many other forms of rheumatism, butthey seldom appear in osteoarthritis.

(b) Osteoarthritis.Obesity was a common finding. The figures are

set out in Table VI. In osteoarthritis (Groups A,B, D and N) 20 5 per cent of males and 5I-I percent of females were obese. This includes alltypes of osteoarthritis except those affecting thespine and hips-these are kept separate unlessspecially mentioned. These figures compare withobesity rates in infective arthritis of o per cent formales and I4-6 per cent for females.

It is difficult to find figures to compare as nolarge survey has been made, but Spriggs (1936),said that 6 * 2 per cent of admissions to Ruthin Castle

were treated for obesity. HI-nter (1936) said thatof 912,677 new patients treated at the LondonHospital between 1927 and I936, 26 per cent werereferred to the dietetic department for treatment.It seems probable that the proportion for thepopulation as a whole lies somewhere betweenthe two.

Proportion of cases of Infective Arthritis andOsteoarthritis in which Obesity waspresent.

The question of obesity has been fully dealt within the Heberden Lecture. Apart from obesity,patients with osteoarthritis do not present anyvery typical physical characteristics, although inthe case of women they tend to be of a sub-thyroidand myxoedematous type. Nevertheless, truemyxoedema is not often seen (there were onlythree cases in this series), and therapeutic testswith thyroid extract do not present any verystartling results.The question of the association of osteoarthritis

with the menopause is of some interest, and figuresare given in the section dealing with this and otherimportant associated syndromes. Many authorspostulate a particular form of arthritis associatedwith the menopause. On occasion I have seen

joints at operation showing synovia covered withwhat appeared to be fatty villous overgrowth, andit is true that this does not always appear to beassociated with a generalised obesity. Mentionwill be made later of painful fat, and it is possiblethat this fatty articular overgrowth may bepainful. Apart from these scattered and ratherdubious observations, one cannot be at all sure thatthere is a particular form of menopausal arthrosis.

Joints initially involved in infective arthritis.These have been analysed. For the males,

56-2 per cent of cases showed initial involvementof the small joints, and for the females, 64-6 percent. The clinical impression was that the figureswould be even higher. As more is understood,however, of this subject, it becomes evident thatinfective arthritis does affect the larger joints ina fair proportion of cases.

Joints initially involved in osteoarthritis.For the males, 72-7 per cent showed initial in-

volvement of medium or large joints, and for thefemales, 73 I per cent showed the same feature.

These figures, therefore, show the most significantdifference in the two conditions, and are a pointin favour of the Ministry of Health's method (1924)of separating the conditions clinically, but are nota complete justification.

13January, I945