Complicated rheumatoid disease.

Rheumatoid arthritis is a disease not only of bone, ligament, and joint, but also of the patient as a whole. It has not only articular manifestations, but general ones also, so that loss of weight, anaemia, and low-grade ill-health are very much a part of the clinical picture. How often have we heard a patient say, " My arthritis is better than it was, doctor, but I feel worse in myself," or vice versa. Along with this prolonged disorder of body goes, inevitably, psychic (or spiritual) distress. A prolonged painful illness will find the weak spots in anyone's psychic armour, so that depression and anxiety are an everyday and regular part of the disease in many, if not most, cases. Suffering may occasionally make saints ; more often it makes tense short-tempered sinners. Grace Stuart, herself a sufferer from rheumatoid arthritis, in her book The Private World of Pain quotes the late Reverend Dick Sheppard as saying to Laurence Housman, " I like pain: it brings me nearer to my Master." But later, racked with more severe and continuous pain, he wrote in a moment of despondency to his friend, " I do not love suffering, so you must not worry about me in that way. I dislike all that talk about how lovely it is to suffer. I think it is a rotten process which has nothing whatsoever to do with God. . .. I know it may do me good-that is, if I take it decently, but I know it is as likely to embitter mankind as to convert him." And Somerset Maugham: " I know that suffering did not ennoble, it degraded. It made men selfish, mean, petty, and suspicious. It absorbed them in small things. It did not make them more than men ; it made them less than men." Nevertheless, after 20 years of close contact with the rheumatoid sufferer, I have seen many more saints than sinners emerge from their suffering, and I am daily amazed at the fortitude with which these patients accept their daily painful and unpleasant lot. This, then, is our first aspect of the complicated picture of rheumatoid arthritis; the patient's emotional reaction to a prolonged, painful, and at times seemingly hopelessly progressive disease. The physician who sets out to treat this condition must put time aside to deal with the patient's individual problems and must blend sympathy and practical and timely advice with intelligent use of analgesics and occasionally psychotropic drugs. In many patients this aspect is the greater one and the more important. I have said on many occasions previously that therapy in rheumatoid arthritis is not so much a treatment as a way of life. The sufferer may often be lucky and have a natural remission from disease activity, but equally often she continues to have daily pain, weakness, and stiffness for many years. Almost all this time is spent at home, the patient and her disease being far from physician and physiotherapist. She is alone with her arthritis in her private world of pain. Over 90% of a rheumatoid sufferer's life is touched only by her physician's advice and his drugs, and in some cases by the results of orthopaedic surgery. There have been a hundred