An investigation into the use of the standard radiographic hand in the classification of chronic arthritis and certain diseases associated with a disturbance of calcium metabolism

Abstract

(1) Acute cases of Arthritis give no radiological indication as to their nature and therefore it is obvious that a pure radiological classification is impossible. In the chronic state, radiology is able to give exact information about the condition of the joint and a classification on this basis is the most rational and accurate method. From the foregoing conclusions, one is reduced to a compromise. A combination of the two methods of investigation, aetiological and clinically, on the one hand and radiological on the other, will yield the most suitable field for future classification. The acute cases will have a provisional diagnosis. If the Arthritis clear up and leaves no structural change in the joint, then the provisional diagnosis will remain the final diagnosis. On the other hand, if the joint shows radiological changes later on in the course of the disease, the provisional clinical diagnosis is confirmed or corrected and placed in the exact radiological group. (2) It will be apparent from e consideration of this work that where the Arthritis is present in the hands, radiology can classify it into one of five groups, namely, Osteo-Arthritis, Rheumatoid Arthritis, Infective Arthritis, Gout, or a mixed type. 'adhere the Arthritis affects a major joint, the diagnostic hand can, very often, give the key to the diagnosis. This is particularly valuable in cases of gout. These five groups are exact, and can be used as a basis for the estimation of treatment. At present, in spite of a working classification in Hospital cases, a large personal factor in diagnosis exists. One physician will label one type of case under a certain group, and another physician will label the same case under a different group. It is obvious that no progress can possibly be made in assessing the value of any treatment until some- thing more exact is found. Radiology supplies this want. (3) A standard radiograph of the hand should always be taken in every case of Arthritis. This will often give considerable help in diagnosis by supplying unexpected information and .also, in confirming the diagnosis of any other joint involved. (4) It will be seen from the tapies of classification that no mention is rude of Infective Arthritis in the British Medical association Report. This group comes under the heading of Secondary Rheumatoid. I have endeavoured to show that true rheumatoid Arthritis is a disease with metabolic changes, and the close resemblance to Grave's Disease and other conditions associated with Calcium upset, places it in a category by itself. In Rheumatoid Arthritis an obvious focus of sepsis is rarely found. It's close association and resemblance to the allergic diseases has also been shown. In Infective Arthritis of the focal or metastatic type, some virulent micro -organism, usually the streptococcus, is discovered. The morbid anatomy of Rheumatoid Arthritis and Infective Arthritis is different. In the one, you have a lymphocytic reaction and in the other there is a oolymorpho-leucocytic reaction, respectively. Clinically, in Rheumatoid Arthritis, there is a polyarthritis and that invariably arising in the small joints of the hand; in Infective Arthritis, one joint only is usually affected. The X -ray of the hand supplies the information on which the differential diagnosis between these two conditions can be made. The appearance of the arthritic joint may be clinically identical, but, in Rheumatoid Arthritis, there is a general bone calcium disturbance while in Infective Arthritis, it is purely local, (i.e.) is limited to the component bones of the affected joint. (5) There are many cases of chronic Osteo-Arthritis which are, in reality, cases of chronic gout. Although no acute attack of gout has made one suspect this possibility, there is no doubt that a gouty diathesis often exists undetected. The radiological signs, if present, are conclusive and will enable one to give a more specific treatment. The classical acute gout and the gross tophaceous type are to-day very uncommon but the more insidious type is of very frequent occurence. Those cases of chronic osteo-Arthritis where gross destruction of cartilage exists, usually have an underlying gouty diathesis. As true degenerative Arthritis does not produce true bony enkylosis some other factor must co-exist; this other factor is gout, and the destruction is brought about by the deposit of uric acid crystals in the cartilage and periarticular structures. ( 6) The distinguishing radiological features between an estabiisrzed osteo-arthritis and an established Infective Arthritis in a major joint are not as definite as the other types. If a single major joint is affected then the classification will depend upon the .t -ray appearances of the hand. Should the dtandard hand show no typical Osteo Arthritic changes, then the major joint will be classified an as Infective Arthritis. If, on the other hand, there are osteo-Arthritic changes in the standard hand, then the major joint will be classified as an OSTEO-Arthritis. ( 7) In leprosy, degeneration and regeneration can occur simultaneously in neighbouring joints and, therefore, some local factor must be at work as well as general infection or neuro-trophic disturbance. (8) In the past one has assumed that by finding a normal blood calcium all must be well with the calcium metabolism. The mechanism which controls the mineral content of the blood is so delicate and complicated that adjustments are soon made between production, execretion and absorption. Therefore, the blood may be in a state of equilibrium at the expense of some other tissue. I have shown that there are many diseases where there is an abnormal condition of the bone calcium and yet the blood calcium gives no indication of this. The standard hand is a much more reliable guide in the detection of genera] calcium imbalance. It can also be used as a guide to treatment