680 ANNALS OF THE RHEUMATIC DISEASES

factor, LDH cells, and protein were investigated. The surgeon who shares the ward with me who does a tre-
clinical evaluation and temperature measurements were mendous amount of tapping hydroceles and I used his
performed before treatment and on five occasions during rather horrid-looking apparatus. Dr. Popert's grains of
the 6-week follow-up, laboratory estimations being done rice would flow through these wide-bore cannulae with
at the beginning and end of the trial. the greatest of ease. I am sure this is why I can get such
From the above investigations we concluded that there large quantities. I have done this lavage over a period of
time in a closed drainage system using the pie-sterilized
was no difference in the temperature curves in either drainage bags which are now freely available.
group and this was confirmed statistically. Pain im-
proved to a statistically significant degree in both groups.
Joint mobility-measured in terms of knee flexions per PROF. J. J. R. DUTHIE (Edinburgh): I am against the idea
30 sec.-showed a statistically significant improvement that just because a joint has fluid or debris in it one must
at all follow-up stages in the lavage patients but not in clean it out. I have on several occasions seen joints,
the controls; testing between the two groups showed no which might appear suitable for drainage, settle down
significant difference. Similarly, as regards the range of spontaneously.
I think that the trial reported here shows lavage to be
movement, there was no difference between the two of no benefit.
groups. The laboratory investigations were also in-
conclusive. Viscosity increased in both groups but not
significantly more in the lavage patients.
Although there is benefit from joint irrigation, the Rheumatoid Heart Disease. By JULIAN KIRK and
statistical difference between the treated and control JOHN COSH (Royal National Hospital for Rheumatic
groups is such that there would appear to be no indication Diseases, Bath): Heart disease in a patient with rheuma-
to adopt joint lavage as a routine out-patient procedure. toid arthritis is usually due to coincidental and unrelated
pathology. However, true rheumatoid heart disease
Discussion.-DR. A. J. POPERT (Droitwich): In the last exists in two main forms, although its identification may
5 years I have carried out lavage in about sixty patients be uncertain without knowledge of the morbid anatomy.
and have formed some impression of the usefulness of this The main specific form is a granuloma, having some
procedure. It has always seemed to me that the crux of
treatment in rheumatoid arthritis in a patient whose joints similarities to the classical subcutaneous nodule, which
are radiologically normal, should be to restore the joint may develop in valves, myocardium, or epicardium.
to normality and keep it so. I think it is impossible for a Aortic or mitral valve damage or impairment of con-
joint which contains "rice grains" ever to return to duction may result. Such lesions are found in patients
normal; such a joint is likely steadily to degenerate. If with chronic sero-positive rheumatoid disease of some
you have a patient whose joint cartilage is radiologically years' duration.
normal but whose disease is active and you use lavage as
part of a comprehensive regime aiming at inducing a The other main form, pericarditis, is commoner, but of
remission of the disease, then to clear the joint of this no specific histology. Although described in 30 per
debris must, it seems to me, help to protect that joint cent. of rheumatoid patients coming to autopsy, peri-
from future degeneration. carditis is not often noted clinically as its manifestations
DR. F. M. ANDREWS (Reading): I have been using joint are slight. It may arise at any stage of rheumatoid dis-
lavage procedures somewhat similar to Dr. Popert's. I ease, is often symptomless, and may accompany rheuma-
have been impressed by the extraordinary quantity of toid pleurisy. If an effusion is formed, it is usually not
fibrinous material that one could in fact obtain from big, and tamponnade is rare. It results in partial or even
joints by such techniques, although radiographically they total obliteration of the pericardial sac by light fibrous
may well be normal. I have recently obtained 200 g. adhesions, and occasionally leads to frank constrictive
from one particular knee that was chronically swollen pericarditis requiring surgical relief; examples of rheuma-
and similar quantities from three others. I cannot toid pericarditis have been studied, ten of them found
but agree with Dr. Popert that it must in fact be a good during a careful review of 100 consecutively admitted
thing to be rid of these deposits even if the particular trial patients with chronic rheumatoid arthritis.
described does not reveal by the techniques used, any
particular advantage to the lavage treated group.
DR. LINDSAY: May I ask Dr. Andrews and Dr. Popert Discussion.-DR. J. H. GLYN (London): I had a very
what size needles they were using? Clearly one cannot interesting case which was written up in the British
extract a large amount of fibrinous material through a Medical Journal (1963) of a man who came into the chest
small bore needle. I should like to know if their patients wards of our hospital with a spontaneous pneumothorax
were aspirated as out-patients or under theatre conditions. and who subsequently developed constrictive pericarditis
which needed surgical resection. He came under my
DR. A. J. POPERT (Droitwich): These were all hospital care because very shortly afterwards he developed signs
in-patients. The size of the needle varies according to of rheumatoid arthritis, and his latex-fixation test was
the size of the debris that one seems to be dealing with. If strongly positive from the earliest stage. I thought it was
you think there is obviously debris in the joint and a unique sequence of events, but another letter came in
aspiration yields none, you use a larger needle up to a from Australia recording a similar case. Recently I was
certain limit to see if you can obtain debris. asked to write an annotation in the British Medical
Journal, and in the last 10 years there have been reported
DR. F. M. ANDREWS (Reading): These procedures were twenty or thirty cases of rheumatoid arthritis, presenting
carried out on in-patients. It so happens that there is a identically as constrictive pericarditis, followed by sero-
 HEBERDEN SOCIETY 681
positive rheumatoid disease. So it may be worth while I also want to comment on the very interesting case of
considering this as an atypical mode of presentation of the woman in whom you actually saw the development of
rheumatoid arthritis. constrictive pericarditis. I have seen seven cases (des-
DR. COSH: I did not realize that quite so many examples cribed inmy Croonian Lecture this year), but we were not
had been recorded of rheumatoid arthritis presenting able to time the development. Could you tell us more
with constrictive pericarditis. One cannot help wonder- about this; how does it develop and how long does it
ing whether the cardiologists concerned were aware of take ?
joint involvement in its earliest stages. DR. COSH: I did not summarize the course of that
DR. T. BIrrER (Los Angeles): You did not mention one particular patient on this occasion, but it is described
condition which can mimic pericarditis very closely and in the Quarterly Journal of Medicine (Kirk and Cosh
is seen much more frequently in patients with rheumatoid 1969). The patient was under observation for 7 years,
arthritis more frequently than rheumatoid nodules in the coming to the clinic a few months after the onset at age
heart or clinically evident pericarditis, that is amyloidosis. 53. The arthritis was sero-positive and became general-
As there is secondary amyloidosis in close to one such ized and severe, and she was started on steroids a year
patient out of eight, have you done rectal biopsies in the after the onset. After 5 years on steroids she developed
patients of your series, to exclude this possibility? Other a gastric ulcer, and later had a haematemesis. While in
authors have emphasized the incidence of rheumatic fever hospital recovering from this, she developed pericarditis
in rheumatoid arthritis and I wondered about the possi- with effusion and a right-sided pleural effusion which was
bility of rheumatic fever in this series. aspirated. Later a small left pleural effusion formed.
DR. COSH: My impression is that rheumatic fever and Pericardial friction and effusion persisted, but the peri-
rheumatic heart disease are no commoner in rheumatoid cardium was not aspirated. She improved, but within
patients than in the non-rheumatoid population. Prof. 7 months of the discovery of pericarditis she developed
Bywaters came to this conclusion when he reviewed the leg oedema. When this was followed by hepatomegaly
subject in 1950. and jugular venous engorgement, constrictive pericarditis
As for amyloid, we did not do rectal biopsies, and we was recognized, and this was confirmed by cardiac
accepted that the pericarditis was due to the rheumatoid catheterization. A surgical resection of the thickened
process, particularly as there was so often pleurisy as well, pericardium was performed, but the patient unfortunately
so that it did not seem necessary to look further. Thank died the day after operation.
you, however, for pointing this out.
PROF. E. G. L. BYWATERS (Taplow): Surely rheumatoid References
BYWATERS, E. G. L., (1950). Brit. Heart J., 12, 101 (Relationship be-
patients with amyloid very seldom show heart lesions tween heart and joint disease).
(apart from senile amyloid) and it is in primary amyloido- GLYN, J. H., and PRATT-JOHNSON, J. H. (1963). Brit. med. J., 1, 262
sis alone that the heart is involved and constricted. We (Correspondence: Rheumatoid pericarditis).
see a good many rheumatoid patients with amyloid and KIRK, J., and COSH, J. A. (1969). Quart. J. Med., 38, 397 (Pericarditis
they have not been troubled by cardiac deposits. of rheumatoid arthritis).

GAIRDNER FOUNDATION AWARDS, 1969

RHEUMATOLOGY-REHABEILITATION FELLOWSHIP
A new Rheumatology-Rehabilitation Fellowship modalities. One year of training in Internal
programme has begun at Montefiore Hospital, New Medicine or Physical Medicine and Rehabilitation is
York City. Clinical training is provided through required. The programme is equivalent to one year
the direct management of in-patients and out- of medical residency training (American Board of
patients with arthritis and other rheumatic diseases Internal Medicine). Fellowships may be taken up
under the supervision of specialists in Rheuma- in January or July, 1970.
tology and Rehabilitation Medicine. Practical Full particulars may be obtained from Mr.
experience is provided in the treatment and preven- Nathan Zamoff, Education Co-ordinator, Depart-
tive management of both acute and chronic states ment of Rehabilitation Medicine, Montefiore
with opportunities to become proficient in the tech- Hospital and Medical Center, 111 East 2 10th Street,
niques of splinting, bracing, and the use of physical Bronx, New York 10467, U.S.A.

ROYAL COLLEGE OF PHYSICIANS