As she did not escape recurrent attacks of soreness in her bunion, while at the same time there were achy feelings in her foot, she took up the careful study of the dietary for gouty patients which she found in the books in her husband's library. So many things have seemed possibly deleterious for gouty people that it is not surprising that after a time nearly everything worth eating except a few cereals and milk and eggs had to be eliminated and she began to suffer from inanition. Then, after a time, came constipation, due to the insufficient amount of residue in her intestines, and this, partly by physical action but largely by mental suggestion, still further diminished the appetite for food, and a loss of over twenty pounds in weight was the result. The weakening of the general muscular system consequent upon this loss emphasized the trouble with the foot and the painful condition at the base of the big toe became more marked.
The supposed necessity for more exercise in the open air led her to walk long distances and in order to prevent her feet from hurting her, as she thought, she wore roomy shoes, distinctly too large. This is one of the common mistakes of people whose feet bother them, and it is just the wrong thing to do, since a snug, well-fitting shoe provides both support and protection. It is not surprising that the attacks of sub-acute bursitis became more frequent and more painful.
It was then that I saw her, and, as I feared to disturb the family harmony by suggesting that the whole trouble was a bunion and flatfoot, I compromised by saying that, while there might be some gout, there was undoubtedly flatfoot, and if she would wear the proper sort of shoe and stop limiting her diet so strenuously, and cease suggesting to herself that she had a progressive gouty affection that would lead to deformity and decrepitude, she would soon be much better.
It required tact to make her look favorably on this advice, after all that she had gone through during months of limited diet and enforced exercise. Though not quite convinced, she was ready to try the new method. She began to be better as soon as she was fitted with a pair of shoes that supported her arch and as soon as her increased nutrition began to make itself felt. At the end of two weeks she was able to give up the remedies for constipation that she had been using for nearly a year, while at the end of four weeks she had regained ten pounds of weight and felt much better.
Several years have passed since I saw her professionally and occasionally I hear from her only to be told what a great measure of relief it afforded her and how much better she has been as a consequence of a few simple directions with regard to her feet. I have seen at least a dozen of cases of so-called gout in educated people which followed almost exactly the same course and yielded promptly to the same treatment. The hardest symptom about these cases to cure is the cherished mental conviction that they are the victims of constitutional disease, either gout or rheumatism, to which all their symptoms are attributed. They are cases for psychotherapy more than any other form of therapeutics and need for a considerable period to have repeated assurances of the entirely local character of their affection.
Bunions and Flatfoot.—The etiology and preventive treatment of a bunion has always seemed to me to bear a closer relation to a flat foot than to anything else. The flatfooted man has nearly always a tendency to bunions. The {417} explanation of this is not difficult if one traces the relation between the tendons that run around the arch to the big toe. The usual etiological explanation, however, is that in youth short shoes were worn which initiated a tendency to divert the big toe inward toward the other toes. But there are many reasons against this explanation. Anyone who tries will find that it is practically impossible to wear shoes that are so short that the big toe is crowded back. Women are more apt to shorten their shoes than men, yet women suffer both from flat feet and from bunions much less than men. The reason for this seems to be that the forward position with the elevation of the heel of the shoe supports the arch and gives the shoe a shape more fitted to the normal foot than is found in the masculine flat-heeled shoe. Besides, this form of shoe maintains its shape better, and then, too, women are not so prone to wear old so-called comfortable shoes as are men.
The mechanism of the formation of the bunion in many cases seems to be, that the large toe, instead of lying straight along the inner edge of the foot, is pushed or pulled toward the other toes. If this process began from the wearing of pointed shoes, especially if such shoes did not have a straight line on the inside, conditions within the foot would soon tend to emphasize it. If the adductor hallicis once gets the habit of contracting rather strongly, as it is likely to do through the irritation set up by the yielding of the arch, it will be hard for its opposing muscles to counteract it. More important than this, however, is the fact that the tendon of the flexor longus hallucis runs along the inner border of the foot and is particularly affected by the yielding of the arch. For it works at a decided mechanical disadvantage under the new conditions and is stretched in such a way as to pull forcibly and constantly upon the big toe, necessarily turning it more and more outward as the arch continues to yield. The dropping of the arch makes the distance from the heel to the toe longer than before and the tendon pulls the toe as far outward as possible to compensate for this, as the distance to its insertion is thus made somewhat shorter.
The yielding of the arch lengthens the foot and puts the tendons of all the flexors on the stretch. All of them have a tendency to bend the toes, and as this action is constant, gradually the tendons of the extensors become over-stretched and these muscles are not capable of exerting their full force in overcoming the action of the flexors. The flexor longus digitorum has a tendency to cause a bending of the small toes, and as it also runs across the foot it pulls the toes somewhat inward, that is, toward the big toe. This crowding leads to hammer toes and over-riding. The big toe, however, is maintained in a state of extension by its firm, full contact with the sole of the shoe and with the floor when walking barefoot. The one direction in which it can yield rather readily is outward toward the other toes because this shortens the distance between the end of the toe and the heel. The pressure put upon the flexor longus hallucis will have a tendency to cause this, for it is over-stretched by the yielding of the arch and keeps constantly pulling on the big toe until that member has a distinct flexion outwards.
This makes the metacarpo-phalangeal joint prominent and then nature proceeds to protect it by a water cushion, a special bursa due to the formation between layers of connective tissue of a pocket in which some serum is constantly present. One can scarcely admire enough this provision of nature by {418} which she protects prominent bony points whenever they are subject to much irritation or to such use as would cause injury to important structures below. If continued pressure continues to be irritating, however, the water cushion proves unavailing and an inflammation of the overlying skin occurs with occasionally a spreading of infectious agents from the surface into the serum pocket below. This serum is such a good culture medium that an acute abscess is likely to form—the acute bursitis of the surgeons.
Rarer Foot Troubles.—Besides bunions, a number of other deformities of the feet occur as a consequence of the yielding of the arch. All the toes are likely to bend rather acutely, and the points of them are pressed against the shoe, while the knuckles, so to speak, are made prominent and are more likely to be subject to corns than would otherwise be the case. Besides, the displacement of the big toe toward the little toes leads to a crowding of the toes together, and this gives rise to soft interdigital corns and to a lowered resistive vitality which may be the predisposing factor to slight infections of various kinds that will make the patients miserable. Such affections may appear negligible, a matter for the chiropodist, and not deserving the physician's attention; but they mean so much for the comfort of the patient and the prevention of exercise through sore feet reacts so deleteriously on the general health that these minor ailments become important and merit careful attention. Dr. Emmet tells the story of the old family servant, always grumpy and complaining, who, when he had the many blessings of life pointed out to him, confessed that the Lord had been very good to him, but said, "The Lord knows He takes it out of me in soft corns."
Hammer Toes—Clam Toes.—Nature has provided a wonderful mechanism in the arch of the foot and the anatomical relations of the toes to support the weight of the body firmly, gracefully, and comfortably; yet any yielding of any part of it leads to a disturbance of its delicate mechanical relations and, consequently, to ever-increasing deformity. Hammer toes are typical examples of what such a disturbance may lead to. One of the toes becomes pressed downward between two others. This over-stretches the extensor muscles and tempts the unbalanced flexors to contract. As the extensor muscles become, after a time, unable to work in the constantly bent toes, they atrophy to some extent and then the flexor muscles pull the toe farther and farther down until there is no possibility of its being straightened at all. Now, if the flexor tendons are cut and the toe straightened the atrophic extensor muscles will not hold it in that position, and when the flexors grow together the old condition will reassert itself. In the meantime, muscle changes in the neighboring toes have also taken place. With no resistance on one side of them, they become bent sidewise over the hammer toe, and so their muscles on one side are overstretched and on the other side become contracted. After a time it is impossible to correct this series of deformities which are being constantly increased and emphasized by the weight of the body above.
Present-day Shoes.—In recent years we have heard much more than heretofore about foot troubles. As the old-fashioned shoes were carefully made by skilled shoemakers to fit the feet of one individual and not to conform to some supposed ideal pedal extremity, they supported the feet much better than do the modern cheap machine-made shoes. These custom shoes lasted a long time, and, after they were once molded to the foot, the wearer was not {419} disturbed for many months by the process of having to become accustomed to another shoe. The many advertisements in quite recent times of foot powders and other artificial relief for the foot show that people are suffering much more than before, or, at least, are less able to bear the discomfort. These powders, however, are not likely to do good in the long run, since they tempt the wearers to stand the discomfort against which they do furnish a certain amount of soothing. It is much better, however, for the sufferer to find the cause of the discomfort and to remove it if possible, for otherwise it will lead to constantly growing displacement of bones and muscles and may eventually even bring on actual and ever-increasing deformity. [Footnote 35]
[Footnote 35: How much deterioration of the tissues of the foot may
be brought about by improper footwear and, above all, by sedentary
life and the substitution of the trolley car for the exercise of
walking, is well illustrated by the functions that are lost. The
child can use its adductor and abductor muscles for the toes quite
as well as for the fingers. Those who go barefooted retain those
muscular powers. Some time we will be able to influence young folks'
minds enough to keep them from sacrificing all the more delicate
muscular powers of their feet to the fashion of small or curiously
shaped shoes. Armless men learn to use their feet almost as hands,
they write, pick up small articles, oven play musical instruments.
Some people have special muscular faculties, as, for instance, the
power to displace certain tendons and bring them back with a snap
which makes a distinct sound. The Fox sisters, to whom we owe the
origin of modern spiritism, confessed that this was the way they
produced their spirit rapping. Some mediums can, it is said,
dislocate the tendon of the flexor longus hallucis onto the edge of
its grove and then bring it back with a snap. Others can produce
partial toe dislocations which by muscular power are suddenly
reduced with a dull noise like the sound of a gloved hand rapping
beneath the table.]
Prophylaxis.—The most important means of prophylaxis in these cases is to have patients who must assume the standing position for some hours each day, exercise their legs rather vigorously. If teachers, lecturers, and the like, have to stand for a long time, it is important that on the way to and from their occupations they should not have to stand up in cars nor assume cramped and uncomfortable positions. It would be better for them to walk rapidly for several miles rather than ride in a standing or a constrained position. If they are convinced of the necessity for exercise, there is much less likelihood of the development of the severer discomfort that is sometimes very discouraging. It is particularly difficult to make women understand this; yet, once they have found how much relief is afforded by vigorous exercise, they are likely to overdo it and thus run the risk of incurring ills quite as serious as those consequent upon not taking enough. In nervous people the nagging discomfort of a yielding arch will sometimes (just as eye strain does) produce reflex headaches, constipation, lack of appetite, and apparently predispose to the frequent recurrence of migrainous headaches. I have, in not a few cases, seen these conditions relieved by rational treatment of the foot condition.
Circulatory Disturbances Due to Flatfoot.—An interesting direct consequence of flatfoot is the disturbance of the venous circulation, which is likely to bring about some swelling of the feet and nearly always considerable coldness and numbness, particularly in the winter and, above all, on damp days during cold weather. The swelling of the feet makes the patient think—sometimes at the suggestion of his physician—of kidney trouble or heart trouble, and sometimes it is hard to persuade him that there is nothing serious the matter with these important organs. The disturbance of the circulation further leads to numbness, to some anesthesia, and to paresthesia. Corns and especially callouses grow more readily between the toes, and patients who are prone to read about such ailments may conclude that they are suffering from hypesthesia {420} and hyperesthesia due to some serious progressive organic nervous disease. I once had a woman patient discourse learnedly to me about these things who was sure that she had the beginning of some incurable spinal disease. Locomotor ataxia was the least she might expect from her description of her feelings. What I found was flatfoot. Raising her arch cured her.
The cold feet and the numbness, to call them by simple Saxon names which will not disturb patients, may sometimes keep them awake. In the chapter on Insomnia we suggest that the best thing for this is to secure a return of the circulation either by exercises, or by wearing a flatfoot brace during the day, or by putting the feet in water as hot as can be comfortably borne and keeping them there for a quarter of an hour. Of these means exercise is the best. Raising up on the toes after the shoes are off and coming down on the outside of the foot strengthens the muscles, pulls the bones of the arch firmly together and encourages the circulation. For beginning flatfoot this is a curative measure and it is the natural mode of treatment for the coldness and numbness of the feet. Rubbing, also, is good for the feet in order to restore the circulation, but patients are inclined to rub downwards while they should rub upwards in order to help the hampered venous circulation. The thin-walled veins are more likely to be compressed by any disturbance of tissues than are the firm-walled arteries, and it is to help the veins that our remedial measures must be directed.
Secondary Consequences.—The secondary consequences of flatfoot are interesting. It is surprising how many people who frequently suffer from sprains of the ankle have some yielding of the arch as a predisposing factor to that condition. Two classes seem to suffer frequently from sprained ankle—those with yielding arches and those with high insteps. Apparently there is weakness in the excess in both directions. Very flatfooted people apparently do not suffer so frequently from sprained ankles as those in whom there is only an incipient yielding of the arch. They seem to have learned to walk more circumspectly. Perhaps, too, their well-known tendency to toe outward lessens their liability to turning on their ankle. The effects of sprains of the ankle in people with weak foot last, as a rule, longer and leave more weakness after them than they do in ordinary cases. This, of course, might be expected, but it is surprising how often the significance of beginning flatfoot fails to be noticed even by the physician. I have seen rather frequently cases of so-called chronic rheumatism in which there is a series of stories of sprained ankle because of the assumed weakness of the ankle from supposed rheumatism, when the whole case can be summed up in a yielding arch.
Exercises.—If the arch has not yielded much, it is often unnecessary to prescribe flatfoot braces or arch supports of any kind, unless perhaps at first. After the first soreness has passed off, exercises may be employed to strengthen the muscles. As we have said, the patient should rise on his toes and then come down slowly on the outside of his feet. He may be instructed to sit with his feet—not his legs—crossed, the feet resting on their outer edges. He may be shown how even various slight movements of his toes, almost without moving his shoes at all, will strengthen the muscles that pass around the arch, which, thus strengthened, will hold the bones of the arch firmly together and prevent further yielding. There is, at the present day, a tendency to recommend too freely the wearing of flatfoot braces or arches. After all, these are {421} only crutches and should not be worn unless absolutely necessary. If the arch can be strengthened—as it can be in many cases—so as to bear the body weight without discomfort, then this is much the better treatment. If the arch is restored the feet are in a more natural condition, while artificial support leaves the muscles without that exercise which will preserve their functions. Flatfoot braces may be necessary, but only if absolutely necessary should they be advised, and palliative measures, such as exercise, manipulations, and rubbings, should be given a fair trial after the unfavorable suggestions as to his foot condition have been removed from the patient's mind.
Significance of Foot Troubles.—We have devoted much space to foot troubles—more, perhaps, than will seem justified to the minds of many physicians. We have done so, however, because of the firm conviction that the feet are the source of more discouragement and depression of mind than any other part of the body. Life very often takes on another aspect when foot troubles are relieved. In the old, progressive deformities of the feet consequent upon mechanical disturbance are probably the source of more discomfort, and by their interference with exercise and outing, the cause of more ill-feeling and even disturbance of health than any other single factor. Even life may be shortened by the confinement or limitation of movement consequent upon bad feet. Above all, the idea that any constitutional trouble, or hereditary disease, is at the bottom of their affliction must be removed, and then these patients are encouraged to live their lives more fully and with more happiness for themselves and others. Hence this long chapter.
Arthritis deformans has unfortunately been called by several names besides the descriptive term which, in the present state of our knowledge, is the most suitable for it. We do not know its cause. We do not well understand even the predisposing factors in its causation. Hence, the term arthritis deformans, which declares simply that it is an inflammatory condition of the joints producing deformities, exactly fits it. It has often been spoken of by such names as "rheumatic arthritis," or "rheumatoid arthritis," and, above all, by the unfortunate term "rheumatic gout." Many of the worst suggestions that attach to the word rheumatism are founded on these ill-chosen designations. Arthritis deformans was supposed to be connected with rheumatism or with gout, or perhaps to be due to a combination of the two. In a majority of the cases there is no history of either true gout or rheumatism to be obtained from the patient, and where a rheumatic or gouty history does occur, it is either quite indefinite or it is clear that arthritis deformans developed in a gouty or rheumatic subject, that is, following genuine gout or rheumatism, just as it might develop in any other individual without any causal connection between it and the other affections.
Supposed under the old theory to be a constitutional, probably a blood disease, patients who saw the ugly, crippling deformities produced by it and {422} then heard the word rheumatism used in connection with it were prone to think of this as the terminal stage of all the severe rheumatic conditions. As a matter of fact no evidence that we have shows that the disease has any connection with chemical modifications of nutrition or metabolism; nor, above all, has the so-called uric acid diathesis or any other superacidity of the blood any etiological connection with it. It has always seemed to me to be clearly a nervous arthropathy, as the lesions are almost without exception more or less symmetrically distributed. The joints that suffer are commonly the smaller ones in corresponding positions on opposite sides of the body, and they run a definite atrophic course sometimes with the preceding phase of hypertrophy that is so characteristic of the trophic lesions of an affection produced by a disease or defect of the nervous system. This symmetrical distribution constitutes the best possible evidence that arthritis deformans is not a nutritional disease and, above all, is not due to chemical changes in the blood.
The affection exists in at least three forms and there is a growing persuasion that there are even more varieties of it that will have to be separated by clinical observation.
There is a good study of the three types of the disease in Guy's Hospital Reports, Vols. 56-57, London, 1902. The article is entitled "Acute Rheumatoid Arthritis," but there seems no reason for applying the word rheumatoid to the group, especially since there is no proved connection with rheumatism and no similarity, except in the case of acute deforming arthritis in which at the beginning it may be difficult to differentiate the two affections.
The most familiar form is named Heberden's nodes, from the great English physician who first made a special study of it. The affection is characterized by an enlargement of the sides of the distal phalanges with small, hard nodules, "little hard knobs", as Heberden called them, developing at these points. They are more frequent in women than in men. Evidently neither hard work nor exposure nor excesses in eating or drinking occasions them. They occur in all classes, the poor and rich, manual workers as well as professionals. It is rare to find them on one hand alone, though it is not at all rare to find them affecting solely the little fingers of each hand. I have seen several cases where surgical intervention had been attempted on one little finger because of the deformity produced when the node originally appeared. When I asked if there was not some trace of a similar condition on the other hand I was told there was not, yet I have been able to show that the first signs, at least, of a corresponding growth already existed on the little finger of the other hand. In the two cases in which my attention was called to a slight enlargement on one side before anything developed on the other, my tentative prophecy that corresponding nodosities would grow on the other side was fulfilled during the following years.
While this form of the disease is a true arthritis deformans it seems to be entirely separate from the progressive forms which we shall speak of later. The nodes increase in size and occasionally develop on all of the fingers, but usually never spread beyond the phalangeal joints. There is a tradition in the {423} medical profession of England, where this affection has been observed with care for some two hundred years, that sufferers from these nodes commonly live to long life. This is not founded on any theory, but is an actual observation. There is also a tradition, though I cannot vouch for its truth, that the people who are thus affected have some sort of immunity to tuberculosis, or at least good resistive vitality against a rapidly running tuberculous process.
I have had at least a score of Heberden's nodes cases under observation for more than ten years and some of them for nearly twenty years, and have been surprised at the slowness with which the process develops. A year often makes no change in the size of the nodes, and I have seen cases where after five years the photograph showed no difference. The lesions are often exquisitely symmetrical so that the question of the origin of the affection in the spinal cord constantly crops up, for that is the symmetrical influence in the body. There are, however, no other symptoms that point to involvement of the cord in any way. Most of these patients have suffered more from worry about it than from their affection. It is another case of "having many troubles most of which never happen."
Some of my patients are physicians, and all of them have consulted other, some many other, physicians. As a consequence, many of them have taken to various diets, especially eliminating certain foods and liquids with the idea that this might stop the progress of the disease. I have never known any change of diet or any abstinence from liquids or solids that seemed to make the slightest difference, though I have seen a number of cases that were considerably worse than they would have been if the diet had not been tinkered with to such an extent as seriously to disturb nutrition.
The main disturbing feature of the affection is the dread of the development of serious crippling conditions in the hands or in the large joints.
As a rule, after a time the nodes cease to grow, and then a period of remission sets in that lasts for many years and there may be no recrudescence of the affection. This remission is delayed if the patients allow themselves to run down in general health. It is apparently hastened by getting the patients up to normal weight and removing any factors that disturb their general health. If the patients' minds are properly disposed, the neurotic symptoms that sometimes develop as the result of over-solicitude about their condition are done away with, the patients are more comfortable, and even the progress of the disease is inhibited.
The second variety of the affection is a general progressive arthritis which usually begins with fever, redness, and swelling, involving especially the smaller joints. The diagnosis of the disease can almost be made on the fact that its favorite locations are the jaw and the joints of the spine. It is a much more serious affection than Heberden's nodes. In its beginning it often simulates acute rheumatism. It occurs particularly in people who are run down for any reason, in young women who have recently come to the country and are working as domestics, in young men who have recently changed their occupation from indoors to outdoors and are not used to the inclemencies of the weather. On the other hand, it occurs rather often in young persons of {424} both sexes used to living and working out of doors who take up an occupation in a damp interior.
The fever usually runs a lower course than that of genuine acute articular rheumatism, the pain is not favorably affected by salicylates, and the duration of the disease is generally longer. This affection always leaves its marks on the joints and there are always recurrences. It is, indeed, the confusion of this quite distinct disease with acute articular rheumatism that has given the latter affection the bad name it has in many minds as a producer of deformities. Arthritis deformans or general progressive arthritis is always a crippling disease; acute articular rheumatism has for its surest diagnostic sign, when the complete history of the case is known, the fact that it leaves no mark after it except, unfortunately, that so often seen in the heart.
The third type of arthritis deformans is the chronic slow running type which involves many joints before the process is complete. One form of this, commonly seen in old men, called osteoarthritis, is often confined to the hip joint, and often produces considerable deformity. Another form is more common in women. It begins in middle life by deformities in the terminal joints of the fingers and the carpo-metacarpal joints of the thumbs. Bony outgrowth takes place until the joints become almost or quite useless. It spreads from the joints primarily affected to the elbows, the knees and occasionally involves other joints. The disease has no favorable course, but is progressive, and there is great discomfort, marked disability, aches and pains particularly in rainy weather and, finally, the patient may become quite helpless.
Preliminary Stage.—An early symptom associated with arthritis deformans of chronic character is likely to be a distinct loss of muscle power, which may be the first symptom in cases that have no acute beginning. The patient notices that he is unable to hold a satchel as he did before, or that quite unaccountably it drops from him. There may be a loss of control over muscles and especially small muscles that attracts the patient's attention. He finds that he cannot hold a book as he used to, or that it is difficult to pick up small objects. He finds it hard to turn a door handle or to pull a cork, although the pulling action may be perfect, but the ability to insert the corkscrew is lacking. These symptoms are prone to be intermittent. They are most noticeable when the patient is tired, or after a damp day, or a succession of damp days, when he is not feeling well. It will usually be found that a joint, the affection of which is missed unless it is carefully looked for, that between the radius and ulna has become affected, and as a consequence there is a difficulty in supination. The lesions are different from those which occur in lead poisoning but at the beginning the symptom complexes may easily be confused.
This form of arthritis deformans, in its earlier and its later stages, is a source of unfavorable suggestion as regards other affections. Its first symptoms may be thought neurasthenic, and if it is so called, those who hear the diagnosis and see the later developments will conclude that neurotic symptoms {425} can lead to serious sequelae. On the other hand, the painful tiredness that is always worse in damp weather may be termed rheumatism and be a correspondingly unfavorable suggestion. Patients who develop aches and pains as a consequence of occupations, or through the relaxation of joint tissues, are most uneasy because of the confusion of the later stages of this disease with rheumatism. This must be recalled by the physician if he would be successful in treating such pains and aches; for not a little of the discomfort is due to an exaggerated mental impression of their significance. This of itself often proves sufficient to keep the patients from the exercise that would relieve many of their secondary symptoms, at least, and serve to make their discomfort more bearable.
Course of Chronic Arthritis.—The course of chronic arthritis deformans is always interesting. It is never as serious as the prognosis at the beginning seems to indicate, and it always has intermissions which, in most cases, become favorable remissions with such improvement that the patients feel encouraged, though they never get entirely well. Six rather typical cases have been under my eyes for from five to fifteen years. In all of them the course was slow and the progress of the disease vague at the beginning; and it was difficult to say how the affection began, or what was its cause, and apparently nothing would stop its advance. After a time all of them became discouraged and began to go the rounds. Almost without exception the physicians told them that they were incurable, and nearly all of them received unfavorable prognoses either directly from the physician or from hints sometimes dropped to friends, or from the attitude of the physician toward them. Much of this discouragement proved unjustified by the actual progress of the disease for many years. While they got but scant encouragement from regular physicians, nearly all of them received hopeful suggestions from irregulars and were, as a rule, for the time being, somewhat bettered by the treatments suggested by these, no matter what they were.
Every one of these six cases, as was to be expected under the circumstances, went through a period of intense discouragement, with loss of appetite, partly from confinement to the house, partly from thinking so much about themselves, partly from lack of exercise and, in general, from their morbid mental condition. As a consequence of the loss of appetite, or, at least, of failure to eat in the midst of discouragement, severe constipation developed in five of the six cases and this further complicated the situation. They ran down very much in weight, and this emphasized the apparent size of the hypertrophic nodosities in their joints and weakened their muscles to such an extent that even under good conditions they found it difficult to move. After a time, usually many months, sometimes a couple of years, something happened to make them realize that while they were crippled and were going to be deformed, they still might find much in life that was not to be despised. Then they began to pick up in weight, their muscles got firmer, their nodosities seemed to disappear because the soft tissues around them filled out, though in most cases some of the material previously laid down actually was or seemed to be reabsorbed, perhaps as a consequence of the patient's better metabolism.
Neurotic Additions.—All of these patients are now in much better physical and, above all, in much better dispositional states than they were during the first year or two at the beginning of their disease. While they allowed {426} themselves to run down in weight they were supremely miserable, with many neurotic pains and aches that were extremely hard to relieve, they had tendernesses and sorenesses on rainy days, usually attributed to their rheumatic conditions but really due to intense depression of the nervous system, with a constant tendency to exaggerate slight pains and aches into torments, and in general were invalids, a burden to themselves and others. They have improved to a noteworthy extent so as to become cheerful, reasonably happy in their power to help others, interested in many things and, in at least two of the cases, accomplishing more actual good for those around them than they probably would if their lives had continued to be the conventional existences that they had been before their arthritis came to them. This reminds one of Dean Stanley's famous expression that life looks different when viewed from a horizontal position. He used the expression with reference to fatal illness, but it might well be applied to any ailment that makes people think seriously and keeps them from occupations only with frivolous things. One of these patients is a source of consolation to many friends, who are much better in health than she is, who bring their troubles to her, and who marvel at her power to make the best of things.
The prognosis for cure is extremely unfavorable, but the prognosis for a reasonable amount of happiness and a large amount of usefulness is, in my experience, excellent and though, of course, new habits will have to be formed and new ways of looking at life assumed, if this can be quietly and persuasively made clear to the patient early in the case, much of the more or less inevitable suffering that the patient will have to endure may be lessened.
The older the patient, as a rule, the better the prognosis in these cases. As with regard to diabetes, tuberculosis and many another affection, every year after fifty adds to the prospect that the patient's ordinary span of life will not be much shortened and that the symptoms will not be severe. Occasionally the disease develops in patients who have been extremely healthy until they were well past sixty. I have in mind particularly a patient who did not begin seriously to suffer from the disease until she was sixty-eight. Then for two or three years she was very miserable, mainly because she had been very active and she feared that the disease would cripple her. It did bring about a considerable limitation of her activity. Ten years have passed, however, and she is still able to be about, and, though now well on the way to eighty, in good weather she still attends to various duties that take her outside of her home and occupies herself with many interests.
I was never able to tell her that she would be better. I assured her from the beginning, however, that she would never be so much worse as she imagined, and that she would never be actually crippled. During the early stages of the disease, her discouragement and, above all, the diminution of activity, the lack of exercise and occupation of mind and the over-occupation with herself, made her not only mentally miserable but seriously interfered with many bodily functions.
In the treatment of arthritis deformans the most important object is the general health of the patient. Owing to the confinement, the pains, which {427} are often worse at night, cause disturbance of sleep which reacts upon the general health. As a result of depression and discouragement, patients are prone to loss of appetite. This is sometimes looked upon as a symptom of the disease, but it is not a direct symptom except during the acute stage when there is fever, and is due rather to the changed conditions in which the patients live and the mental influences that surround them. If the patient loses in weight, as is so often the case, the effects are likely to be more serious, for the remission is delayed and is less complete in its consequences. Above all, it is important not to disturb the diet of the patient in such a way as to interfere with nutrition. Owing to the supposed rheumatic element, meat, or at least red meat, is occasionally taken out of the diet by the recommendation of the physician. Whenever this is done, harm results. There is a definite tendency to anemia, which will be emphasized by an exclusively vegetable diet, especially in those accustomed to eat meat freely. As a rule, there is much more need to encourage the patient to eat than to limit the diet in any way. Patients must rather be advised to take a generous mixed diet and to consume about as much meat and the same varieties as before. Tinkering with the diet has never been known to do any good for arthritis deformans and often does harm. The drinking of large quantities of water seems to do more than almost anything else to help these patients into a better frame of body and mind. Their neurotic symptoms are, as a rule, even more important than their joint symptoms, and if the neurotic symptoms can be cured, as they usually can without much difficulty, the patients feel much better.
Systematic Exercises.—As soon as the acute stage has passed patients should be encouraged to take some systematic exercise in spite of the discomfort that is associated with it. Unless muscles are moved regularly deformities in bad position will result and there will be crippling which can be avoided in most cases. It is sometimes difficult to secure exercises for the small muscles that are involved and definite occupations are better than artificial exercises. For the fingers, for instance, I find that the best thing is knitting. By this I mean using the old-fashioned knitting needles for the making of stockings, wristlets, jackets, and the like. Crocheting is also of some use, but it does not give employment to as many of the small muscles as knitting. If the knitting is done with old-fashioned yarn from which the lanolin has not all been extracted, some of this substance comes off on the fingers during the movements associated with knitting. This seems to do good by rendering the joints more supple and the muscles more easy of movement. At least the suggestion is very helpful to the patients.
Electricity and Mechano-therapy.—Electricity has been much praised, but whatever good it accomplished has always seemed to me to be confined to the exercise afforded the muscles. Its use, however, serves to keep up the patient's hope.
Mechano-therapy often does good and some of the Zander machines are likely to be useful. Pulleys and weights for the shoulders and arms have their place and resisted movements serve to restore muscles to function which they had lost during the time when the joints were worst. Their use helps to bring the joint into the most available conditions.
Something that has distinct hope in it must always be done for these patients. For this local treatment means more than anything else. Unfavorable {428} suggestions keep flowing in upon him from the failure of medicine, and serve to concentrate his attention on his condition and make him think that nothing can benefit him. Often the physician finds that his patient has been to someone else, who did some simple thing that brought relief of symptoms, at least for a time, and restored his confidence to such a degree that he felt much better for a time at least. These ailments are emphasized by advancing years and, though we cannot prevent decay of tissue, we can keep the patient's mind from inhibiting still further the functions of the impaired tissue.
General Condition.—The patient's general condition must be made as good as possible. For this outdoor air is the most important factor. It increases impaired appetite, makes sleep more restful and easy, and gives one of the best occupations of mind that can be obtained. Of course, changes in the weather will bring discomfort. Where it is possible, such patients must be sent to climates as equable as possible. Such a change of climate during December, January and February will often make them very comfortable, and the distraction of mind, with the possibility of getting out in the mild climate, will diminish their sensitiveness and be more powerful factors in the dissipation of their aches and pains than the climate itself. Where people cannot be sent away from home, the securing of corresponding distractions means a great deal. The one thing necessary for the physician is to keep the patient from brooding upon himself and his ills and to find other occupations of mind for him.
Coccygodynia, or, as it is sometimes called, coccydynia, is a painful affection of the coccyx or bony end of the spinal column. It usually results from trauma, as a fall on the buttocks on an icy pavement, or particularly a fall in coming down stairs in which the main portion of the impact is on the seat. Occasionally it follows horseback riding. It is said to be on the increase among women who ride astride. Occasionally it is reported after severe labor, particularly when the head of the child was very large, or after first labor when the coccyx has been beforehand bent inward somewhat abnormally and is pushed out by the oncoming head. It seems to develop with special frequency in nervous people who have to sit much, particularly if they sit on unsuitable chairs. The chair seat with the ridge in the center which has been introduced in recent years is sometimes blamed. Occasionally, on the other hand, it is said to come from sitting on heavily cushioned chairs, particularly leather chairs which do not allow of much transpiration and cause a feeling of uncomfortable heat.
There are, indeed, so many different causes suggested, sometimes of quite opposite or even contradictory effects, that it seems evident that the main element in the disease is some predisposition to sensitiveness in this region which is exaggerated and emphasized by the cause that is blamed. It occurs particularly in women, though it is occasionally seen in delicate or neurotic men. Sufferers from it sometimes find it impossible to sit for any length of time. {429} Even lying down, especially if they lie on their backs, becomes a source of pain. Various operations, such as the reposition in place of the bent coccyx, or even the removal of the tip of the coccyx, have been suggested. Some reported cures are to be found in the literature. These are mainly surgical cures, however, that is to say, the patient recovered from the operation, was seen for a month or two afterwards, and was then on a fair way to complete recovery. Some of us who have had to treat these cases afterwards for painful conditions apparently due to the scar of the operation, or to a neurotic condition closely corresponding to the old coccygodynia, are not so confident of the value of an operation, though probably in purely traumatic cases surgical intervention is of value.
In most cases the sufferers are women who have little to do, who have much time on their hands to think about themselves, and who usually receive abundant sympathy from friends and relatives. In one case under my observation the death of a husband and the discovery that his estate was much less than had been anticipated, so that his widow had to take up a wage-earning occupation, did more in a short time than all the treatment that had been employed before to relieve her discomfort. She had been quite unable to move around at times, especially in rainy weather, and was something of an invalid during all the winter, but now she was able to go out to work every day and had very little trouble. Her affection originally dated from a fall on an icy sidewalk and her fear to go out in the winter seemed to be dependent on the dread of another fall. She realizes now that practically all her former trouble was due to over-attention to a discomfort which is still present, but which she is now able to forget, except at times when she is alone after there have been worries and troubles that have reduced her power to control her nerves. In young girls an injury to the coccyx by a fall on the buttocks will often leave tenderness for months or even years, but if attention is distracted from this and the patient is not allowed to concentrate her mind on it and does not hear of the awful possibilities of coccygodynia—a mouth-filling Greek name in which we map out our ignorance, and which seems to carry with it such a weight of pathology—she will probably recover completely.
Coccygodynia often resembles hysterical coxalgia or the hysterical arthritises, and seems sometimes to be due to the fact that there is a natural or traumatic abnormal mobility of the coccygeal vertebrae which, owing to concentration of attention, has developed into a neurosis analogous to the corresponding condition in a joint. There are undoubtedly cases in which a real pathological lesion exists, but these are comparatively few. In this, as in other joint and bone affections with vague pains likely to be worse on rainy days, the word rheumatism is often mentioned, but it has no proper place. Treatment that will put the patients into good general condition—never local unless there is objective indication—outdoor air and exercise with reassurance of mind and distraction of the attention are the important therapeutic agents. Patients with much time on their hands do not readily get well, while those who are busily occupied seldom suffer for long.