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.