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.