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spondylitic type where sacroiliac and large joints are involved and (iii) rheumatic like rheumatoid arthritis which is an additive arthritis and not fleeting, whereas rheumatoid arthritis in the old is always symmetrical and peripheral joints are most commonly involved.

The disease may present as a chronic illness, an acute over a chronic illness or acute excerbations after remissions. In the acute stage, there is fever, severe pain with limitation of movements of the joints involved, synovial thickening, effusion and swelling. This picture subsides with treatment. Pain is only action oriented during remission. In late stages, cartilage is totally damaged, defects in circulation leads on to rarefaction and cyst formation at the ends of long bones. Synovial thickening extending over articular surfaces is called panus. Deformities such as the button hole deformity, swan neck deformity, ulnar deviation of fingers are pathognomonic of Rheumatoid arthritis. Autoamputation occurs due to (i) arterial blood deficit and (ii) purely vasomotor disturbances. Raynaud's phenomenon also occurs in some cases. Systemic extension may lead to diabetes, hypothyroidism, hypertension and ischemic heart disease.

Latex fixation test is positive in 42% of the cases. Rest are seronegative. Seronegativity can occur in Rheumatoid arthritis itself when all immune complexes get deposited in joints.. E.S.R. is raised. VDRL is mildly positive. IgM fraction is increased. Aspiration fluid is cloudy, has high protein and increased IgM globulin. Polymorpho- nuclear leucocytosis is reported. The sugar content of fluid is low.

Treatment

Response to drugs varies from individual to individual. Trial and error method is to be employed. Aspirin and analgin do not help. Phenylbutazone and oxyphenbutazone relieve pain effectively, provided, the drug is accepted by the patient. Gastric irritability misreported as increased appetite by the patient leading onto loss of appetite, abdominal pain, vomiting and haematemesis are the usual adverse effects of the drugs. Sodium and water retention lead onto puffiness of the face and oedema. Diuretics have no place in treating water retention. Reassurance along with a reduced dosage or stopping the drug is usually effective. These effects are not dose related.

40% of patients respond well to Indomethacin which stimulates prostaglandin synthesis. Dose related gastro-intestinal side effects as vomiting, diarrhoea and abdominal pain limit the acceptability of the drug. Concurrent administration of antacids does not relieve these effects. The drug is administered in doses of 25 mgms to 200 mgms per day. Indomethacin is also used in the treatment of nephrotic syndrome, polyradiculopathies and transverse myelitis.

Ibuprofen 200 to 400 mgms per day though claimed very effective has not been found to relieve pain much. Ketoprofen is another preparation. Naproxen has a limited response and is costly too. With Oviran (CIBA) initial relief of pain is dramatic.

A combination or 25 mgms of Indomethacin per day and 100 mgms of Butazolidone per day is effective. Chloroquine 300 mgms per day gives constant relief from pain.

Gold Chloride administered as 50 mgms per week until a total dose of 2 mgms and 50 mgms once in 3 to 4 weeks for a prolonged period causes remissions. Complication

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