Arthritism

ARTHritism (from Greek arthron-joint), a term introduced into common usage by the French school of pathologists and clinicians (Bouchard, Lancereaux, Comby, Bazin and others) to denote the undeniable fact that there are numerous individuals who show a particular predisposition to a whole range of diseases, which in their manifestation seemingly have little in common and occur either in isolation or in various combinations or successively, both in the same individual and among many members of the same family. These diseases are as follows: gout, diabetes, obesity, stones of the biliary and urinary tracts, premature atherosclerosis, rheumatism, migraine, neuralgia, bronchial asthma, eczema and some dermatoses (e.g., herpes; therefore some authors instead of A. use the term "herpetism"). The term A. itself apparently derives from the fact that among the listed diseases there are also joint diseases, and what is common to all these conditions, according to the teaching of these authors, is that the basis of all of them lies in metabolic disorders with a character of its reduction-braditrophy, in Bouchard's terminology. Subsequently, however, the concept of A. became more vague and A. came to include the most diverse constitutional anomalies. In the popular classification of pathological constitutions (diatheses) by Müller (Miiller), the so-called neuro-arthritic diathesis, appearing alongside others-exudative and lymphatic-hypoplastic-is characterized by five whole groups of disorders that succeed each other or are fantastically combined with each other depending on the age of the individual. Here are found: 1) such metabolic disorders as abnormal thinness or obesity, uraturia, phosphaturia, acetonuria, glycosuria, kidney and bladder stones, gout, diabetes, cystinuria, alkaptonuria, oxalaturia, arteriosclerosis, arteriosclerotically shrunken kidney, otosclerosis, presenile cataract, certain types of glaucoma; 2) phenomena of this kind, classified as arthritic, such as chronic or recurrent muscular rheumatism (lumbago, torticollis, etc.), arthritis chronica deformans of non-infectious and non-gouty origin, i.e., without urates in the urine (malum coxae, Heberden's nodes, arthritis in women during the climacteric period, etc.); 3) from skin diseases-moist, impetiginous and pustulo-vesicular eczemas, urticaria, prurigo, hyperhidrosis, tendency to chilblains (perniones), seborrhea, acne, furunculosis, psoriasis, neurodermatitis, lichen simplex, Quincke's edema; 4) in the group of nervous phenomena-various psychopathic and nervous disorders, especially neurasthenia and hysteria, excessive mental excitability, night terrors, habitual headache, migraine, neuralgia, sexual abnormalities; idiosyncrasies to food substances and to odors, tendency to sharp manifestations of anaphylaxis (serum sickness); too early mental development, but later-failure to fulfill brilliant talents or one-sided giftedness (Wunderkind), ischias (functional), asthma; in old age depressive states; finally, 5) tetany, eclampsia infantum, laryngospasms and tetany,-and possibly some cases of epilepsy (see Diatheses). There are objections to understanding arthritism in such a broad sense and doubt has been expressed about the rationality, in particular, of including a number of nervous phenomena in this constitutional anomaly, although, on the other hand, the addition of the word "neuro" to the adjective "arthritic" to some extent justifies such an understanding. Furthermore, it is pointed out that disorders of an endocrine nature, such as tetany and sexual deviations, may be in arthritism a secondary phenomenon caused by deep metabolic disturbances. Finally, the most important thing: Müller's neuro-arthritism in some of its features coincides with another diathesis-exudative, which refers to phenomena such as allergies (see) and tendency to dermatoses. The most characteristic features of A., in any case, are metabolic disorders, while the connection of all other features of the neuro-arthritic diathesis with these latter is either more or less clear and simple, or already much more difficult to account for; finally, sometimes it may turn out to be simply accidental. Neuralgias of gouty origin, for example, for a number of cases admit a very simple explanation from the point of view of the precipitation of uric acid salts in the places where nerve roots exit from the spinal cord.-The connection between gout or diabetes and the arteriosclerotically shrunken kidney (toxic effect on tissues in one case of uric acid salts, in the other of glucose) is not difficult to understand, but it is already more or less difficult to specifically clarify the connection between these metabolic disorders and, for example, allergies. Some of the French authors (Richardiere, Sicard), who had begun to lose the strictly defined contours of the concept of A., in later times try to return to the former more restrictive meaning. At the same time, with the development of the doctrine of internal secretion, a tendency emerged to seek in the field of endocrinology the patho-chemical substrate of the metabolic anomaly underlying A., with some authors (Leopold Levi, Rothschild) considering this substrate to be insufficiency of the thyroid gland, others-deviations of a pluriglandular nature (Enriquez, Sicard). There is no doubt that the endocrine glands do indeed play a significant role in protein metabolism, in particular purine, as well as in fat and carbohydrate metabolism. Given the complexity of correlational relationships and the multitude of factors involved in the aforementioned processes, one could easily understand, from this point of view, the possibility of the occurrence of various, characteristic of A., symptom complexes against the background of general instability of the neuro-glandular apparatus. The pathogenetic essence of A. continues to remain far from clarified. Considering it established that in diabetes the body's ability to oxidize sugar is reduced, Bouchard transfers a similar pathogenesis to other arthritic diseases grouped around diabetes; he considers it probable the hypothesis that in obesity there is insufficient combustion of fat, in gout-a disordered metabolism of nitrogenous substances. Bouchard took the insufficiency of oxidative processes due to the reduction in alkalinity of body fluids as the basis for all these pathological processes. While complete oxidation gives off easily removable carbonic acid from the body, incomplete oxidation leads to the accumulation of non-volatile acids in the body (acid dyscrasia of previous authors). Later, slowed oxidation began to be explained by enzymatic insufficiency or, finally, by disruption of the nervous regulation of these enzymatic processes. The school of Brouardel and Glenard considers the primary insufficiency of liver cells as the first cause of A. The slowing of metabolic processes underlying the braditrophic diathesis, however, could not be detected by systematic studies of basal metabolism, which as a rule proved normal in all the indicated diseases. Even in obesity, a decrease in basal metabolism is determined as an exception, only in its endocrine forms. Haig associated the anomalies of the arthritic diathesis with an increased content of uric acid in the blood (lithaemia of English authors). However, except for gout, for other forms of arthritism hyperuricemia is not characteristic. On the contrary, Uffenheimer in some children-arthritics found a disturbance of uric acid metabolism. The acidosis of the blood, considered by Bouchard to be characteristic of the arthritic diathesis, also cannot be recognized as a regular symptom, since it is found only in severe diabetes and uremia, but not in other arthritic conditions. From the point of view of differentiation of diseases, the general concept of A. can even be considered as a step backward in the progress of medicine. Thus, the division of gouty and rheumatic A.s, based, among other things, on the study of uric acid metabolism in gout (Garrod, Umber), is largely smoothed out by supporters of the doctrine of A. (Lancereaux, Trousseau, Charcot). German authors in general relate completely negatively to the doctrine of the French and English about A., considering this doctrine theoretically justified and too vague (Brugsch, Umber). Nevertheless, the denial of the clinical significance of A. is premature. Besides the statistically confirmed heredity of its manifestations, without accepting the "diathesis" the etiopathogenetic explanation of such diseases as, for example, liver stones (compare the latest theories of Aschoff, Rovsing) is incomplete. The sometimes observed alternation of symptoms of asthma and gout, diabetes and gout (diabetes alternans), urticaria and gout and others in patients also speaks for the existence of the indicated diathesis. The experimentum crucis of the hungry years gave the same therapeutic effect for all arthritic conditions. The latest observations in the field of disorders of intermediate metabolism in various arthritic diseases reveal unexpected analogies (e.g., uric acid metabolism of gouty type in lead poisoning).

Thus, with a sufficiently critical approach, the concept of arthritism as an incompletely clarified metabolic disorder, combining clinically related forms of disease, continues to retain a certain raison d'etre. Regarding etiology, one must first emphasize heredity, homologous or heterologous, in the sense of manifestation of various of the above-mentioned afflictions. Bouchard cites the example of a family in which kidney stones in males were inherited for 600 years. But a certain role in this respect must also be attributed to the living conditions of the individual, such as: nervous exhaustion, chronic alcoholism, lead poisoning, sedentary lifestyle, lack of movement, excessive nutrition, especially meat. Under these conditions, one must also see the most important indication for the prevention and therapy of A.

G. Sakharov. Arthritism in children. The existence of A. in adults is generally recognized, while the presence of A. in children for a long time was not acknowledged, and even to this day many pediatricians (predominantly of the German school) doubt this. The reason for this is that A. in children proceeds in a highly distinctive manner, sometimes not at all resembling A. in adults. More pronounced manifestations of A. can be noted in the preschool and school periods. - In infancy, one sometimes observes an apparently groundless tendency to digestive and nutritional disorders, reduced tolerance to food. The child's poor appetite, small amounts of food consumed, and abundant fecal masses are striking. The weight curve is unstable, sometimes slowed due to disruption of salt and water metabolism (hydro-lability). Sometimes instability of temperature is observed, ease of its elevation from minor causes (thermo-lability). Usually, increased nervous excitability and mild spasmodic convulsions are noted. Children in general develop intellectually well, are active, but sometimes show a certain backwardness, inertia. Skin manifestations in infancy occur relatively rarely. - In later age, the number of manifestations of A. increases and their character changes. By external appearance, children with arthritism can be divided into erethic, pastose-torpid, and plethoric-fatty; apparently, the latter forms are predominant. The most common reasons for consulting a physician are either abnormal thinness and pallor or abnormal fullness of the child. Fairly frequent complaint is also increased nervousness of children. Associated with poor appetite and small amount of food are constipations. Often the appearance of groundless vomiting, vomiting during mental excitement and irritation is noted. Attacks of vomiting may have a periodic character and be accompanied by acetonemia and acetonuria, with acetone being excreted by the lungs and urine. In the origin of vomiting, in addition to metabolic disturbance, disorder of the autonomic nervous system plays a role. In other forms of A., besides anorexia, the picture of cardiospasm, mucous-membranous colitis, periodically occurring despite the diet being followed, is observed. Attacks of false appendicitis, formation of intestinal stones, biliary crises accompanied by enlargement of the liver, especially the left lobe, proceeding without fever and severe pain, may occur. A similar phenomenon, in connection with metabolic perversion, is the so-called groundless fever. In other children, skin manifestations are observed; most often urticaria, strophulus, dry forms of eczema (but moist forms may also occur). These skin manifestations may alternate with other arthritic manifestations, for example, with acute edema of the eyelid, occurring suddenly, periodically repeating, and being an equivalent of a gouty attack. In other forms, tendency to local edema of the extremities, acro-asphyxia, coldness, fleeting erythemas, rapid change of facial coloration, sweating are noted. A special variety of manifestations of A. are frequent attacks of inflammation of the tonsils, adenoid growths, with simultaneous enlargement of the spleen. In some children, spasmodic cough, asthmatic bronchitis, and attacks of typical bronchial asthma are observed. There are grounds to see in the phenomena from the side of the circulatory organs a reflection of A.-attacks of tachycardia, arrhythmias, dilatations of the heart, appearance of murmurs. Arthritism in children is also manifested by a tendency to form kidney and bladder stones. - The most frequent and characteristic manifestations of A. are considered to be the nervous and psychic symptoms. Children are always excited, capricious, require special attention. Some of them develop excellently and prematurely; in them, a fondness for music, drawing often shows, talent is revealed early. Others may show phenomena of inertia, delayed development. In some children, the presence of night terrors, attacks of migraines (typical and atypical), eye and ear migraines, false neuralgias is noted. Children are strongly prone to convulsions and masturbation. Rather characteristic is the presence in arthritics of idiosyncrasy to odors and certain food substances. As for the metabolism in A., oliguria, alternating with polyuria, high specific gravity of urine (up to 1.035), increased acidity, large deposit of uric acid salts are observed; at times protein may also appear. During acetonemic vomiting, the urine is sharply acid, contains acetone, acetoacetic and beta-oxybutyric acids; the content of NH₃ and amino acids is increased. Outside of attacks, these urinary phenomena may be absent. The gastric juice of arthritics is distinguished by low acidity, poverty in all enzymes (pepsin, labferment, lipase); while the duodenal juice is rich in trypsin. The development of the child proceeds in a highly peculiar tempo, either in the direction of hypotrophy, abnormal thinness and pallor, or in the direction of obesity and even edema. Sometimes one condition replaces another. No predisposition to acute infections exists. Such children are rather resistant also in respect to tuberculosis. The presence of arthritism often determines the peculiarities of the course of many diseases. As for therapy, a rational environment, sensible upbringing and nutrition are necessary first of all. The basis of the diet should generally be food limitation, a vegetarian regime with restriction of meat, eggs, food rich in purines (goiter gland, liver, brains), cocoa, chocolate, canned goods. It should be noted, however, that one must avoid the stereotyped prescription of a purine-free diet to all. Considering the weak functional activity of the stomach, it is advisable to avoid abuse of bread, soups, abundant protein food. Consumption of vegetables (except beans, spinach, sorrel), fruits is permissible. It is more advantageous to increase caloric value with fats and carbohydrates. In other cases, meat is also well tolerated. Sometimes the prescription of pepsin with hydrochloric acid to arthritics gives good effect. Treatment with mineral water (Borjomi, Vichy) is advisable. The prescription of atophan, acting on the allergic attack, is quite rational. Sometimes good results are obtained from the use of milk calcium or sodium. Sojourn at the seaside, in the country, general massage, baths, moderate gymnastic exercises are beneficial.