RHEUMATISM, a constitutional disease having for its chief manifestations inflammatory affections of the fibrous textures of joints and other parts, together with a liability to various complications. Two forms of rheumatism are recognized, and will be now briefly described, namely, the acute and the chronic, the latter either resulting from the former or arising independently. In addition to these, a disease which has received the name of chronic rheumatic (or rheumatoid) arthritis, and which presents many resemblances to chronic rheumatism, although the relation between them is questionable, may be noticed here.
ACUTE RHEUMATISM, frequently called RHEUMATIC FEVER, is mainly characterized by inflammation affecting various joints, with a tendency to spread in an erratic manner, and accompanied with much pain, febrile disturb-ance, and perspiration.
The nature of this disease has been extensively discussed by pathologists and physicians; but, although numerous, and many of them ingenious, theories have been advanced and supported by evidence drawn from experimentation as well as clinical observation, it cannot yet be said that any one of them has gained general acceptance. It has been held that rheumatism is produced by an excess of lactic acid in the system in connexion with morbid states of the nutritive functions. Support to this view was given experimentally by Dr Richardson, but experiments by others have led to a different conclusion. Again, it has been held that the disease is a textural inflammation due to chill acting upon the parts, either locally through the circulation or through the agency of the nervous system, whereby the nutrition of the joints and other structures is lowered. Another view regards it as arising primarily in a profound disturb-ance of the heat-regulating mechanism of the body by chill, which specially affects the muscular system, causing heat to be generated without work, one of the consequences being that impressions of pain are conveyed to the brain by the articular nerves instead of those of work performed (see PATHOLOGY). The view has been held, too, that rheumatism is to be referred to a germ or parasite, or a miasm? analogous to the poison of malaria.
Without attempting to discuss the relative probability of these and other theories, it may be stated that those which point in the direction of a nutritional change in the special tissues affected (the fibrous) as the result of chill or other depressing cause operating through the agency of the nervous system appear more consonant with the pathological evidences of the disease itself than those which would refer the morbid process to the influence of any poison circulating in the blood.
There are certain points of importance in connexion with the causation of this form of the disease which are generally agreed upon. Thus an hereditary tendency is recognized as among the causes predisposing to acute rheumatism. The extent of this has been variously esti-mated, but it would appear to be well established that it shows itself in about one-fourth of the cases. Age is another important predisposing condition, the acute form of rheumatism being much more a disease of youth than of later life. The period of adolescence, from sixteen to twenty, is that in which probably the greater number of the cases occur; but even in early childhood the disease may manifest itself, or at any period of life, although it is rarely observed in old age. Persons much exposed to all kinds of weather are specially liable to suffer, and hence the disease is more common among the poorer classes. Any depressing cause acting upon the general health, such as overwork or anxiety, or any habitual drain upon the system, such as overlactation, in like manner has a similar effect. Climate, too, is a factor of great importance, for, although not unfrequently met with in temperate or even warm climates, the disease is unquestionably of more com-mon occurrence in cold and damp regions. Attacks of acute rheumatism are brought on in most instances by exposure to cold, by getting wet through, sometimes also by excessive fatigue such as in walking long distances, especially if in addition there have been overheating of the body and subsequent chill. Persons who have once suffered from this disease are very liable to a recurrence on a renewal of the exciting cause, and even apparently independently of this from such causes as digestive disturbances.
An attack of acute rheumatism is usually ushered in by chilliness or rigors followed with feverishness and a feeling of stiffness or pain in one or more joints, generally those of larger or medium size, such as the knees, ankles, wrists, shoulders, &c, which soon becomes intense, and is accompanied with severe constitutional disturbance and prostration. The patient lies helpless in bed, restless, but afraid to move or to be touched, and unable to bear even the weight of the bed-clothes. The face is flushed, and the whole body bathed in perspiration, which has a highly acid reaction and a sour disagreeable odour. The tempera-ture is markedly elevated (103° to 105°), the pulse rapid, full, and soft; the tongue is coated with a yellow fur; and there are thirst, loss of appetite, and constipation. The urine is diminished in quantity, highly acid, and loaded with urates. At first the pain is confined to only one or two joints, but soon others become affected, and there is often a tendency to symmetry in the manner in which they suffer, the inflammation in one joint being shortly followed by that of the same joint in the opposite limb. The affected joints are red, swollen, hot, and ex-cessively tender. The inflammation seldom continues long in one articulation, but it may return to those formerly affected. In severe cases scarcely a joint large or small escapes, and the pain, restlessness, and fever render the patient's condition extremely miserable.
An attack of acute rheumatism is of variable duration, sometimes passing away in the course of a few days, but more frequently lasting for many weeks. Occasionally, when the disease appears to have subsided, relapses occur which bring back all the former symptoms and prolong the case, it may be for months. Again, after all acute symp-toms have disappeared, the joints may remain swollen, stiff, and painful on movement, and the rheumatic condition thus becomes chronic.
After an attack of rheumatism, the patient is much reduced in strength and pale-looking for a considerable time, but should no complication have arisen there may be complete recovery, although doubtless there remains a liability to subsequent attacks. This disease derives much of its serious import from certain accompaniments or complications which are apt to attend its progress. Among these may be mentioned excessive fever (hyper-pyrexia), which is sometimes developed in a sudden and alarming manner, the temperature rising quickly to 108°-110° or more, and thus endangering life. Indeed in most of such instances death speedily follows unless prompt treatment be resorted to. Another danger is the occurrence of serious head symptoms in the form of delirium or excitement, which may exist in conjunction with hyperpyrexia or independently. Chorea or St Vitus's dance is also an occasional accompaniment of acute rheumatism. Besides these, other complications pertaining to the respiratory organs, such as pleurisy, pneumonia, bronchitis, &c, sometimes arise in the course of the disease, as well as certain disorders of the skin. But the most frequent and important of all are those affecting the heart. These cardiac affections are regarded by some as an integral part of the rheumatic disease rather than as results of it, especially as it would seem that occasionally they are the only local manifestation of the attack.
Pericarditis (inflammation of the investing membrane of the heart) and endocarditis (inflammation of the lining membrane of the heart) are the two most common forms which these heart complications assume, and it is the latter which is specially important as tending to lay the foundation for valvular heart disease (see HEART). It is the liability to these inflammatory heart affections that causes special anxiety during the earlier stages of an attack of acute rheumatism, when it would appear they are more apt to occur. The risk of cardiac complications seems to be greater the younger the patient, and doubt-less the foundation of organic heart disease is often laid in early childhood, when, as is now well known, rheumatism is by no means uncommon.
The name subacute rheumatism is sometimes applied to attacks of the disease of less severe type than that now described, but where yet the symptoms exist in a well-marked degree. Cases of this kind may be of even longer duration and more intractable than the more acute variety, although probably the danger to the heart is less.
CHRONIC RHEUMATISM appears occasionally to be deve-loped as the result of the acute form, but is more frequently an independent constitutional affection, and is usually a complaint of later life. The causes associated with its occurrence are habitual exposure to cold and damp; hence its frequency among outdoor workers. It is also apt to arise in persons debilitated by overwork or privation. Certain poisons introduced into the system are often attended with symptoms of chronic rheumatism, e.g., lead, syphilis, &c. This disease is often hereditary. It differs from acute rheumatism in being less frequently attended with fever and constitutional disturbance and less liable to dangerous complications, but on the other hand it is much more apt to produce permanent alterations in the joints and parts affected. The joints tend to become swollen both from effusion of fluid and from chronic inflammatory thickening of the textures, and the result is stiffness and sometimes complete immobility. But in addition the sheaths of muscles and of nerves are apt to be affected by chronic rheumatism, causing much suffering. This form of rheumatism is less migratory in its progress than the acute, and tends to remain fixed in a few joints, often in those which are specially exposed to atmospheric influences or to overwork. The chief symptoms are pain and stiffness in movement, more particularly when the efforts begin to be made, becoming less after the limbs and body have been in exercise. Creaking or crackling noises accompany the movements. The pain is apt to be increased during the night, and is besides markedly influenced by the state of the atmosphere, cold and damp aggravating it.
This form of rheumatism, although not directly dangerous to life, tends to lower the health and render the patient more vulnerable to other morbid influences. Besides this, by long continuance it may lead to great deformity and disablement of the frame, in some instances resulting in a condition of utter helplessness.
Treatment.Few diseases have had so many remedies recommended for their alleviation, and vaunted as specifics, as rheumatism; and, when it is remembered how many are the theories of the nature of the malady, it is obvious that even as regards principles the methods proposed must be numerous and diverse. Nevertheless, there are certain well-recognized systems of treatment which in most instances will be found to be of benefit. The treatment differs in the two forms of the disease. As regards acute rheumatism the general management of the case from the outset requires attention. The patient should be placed in bed between blankets, and should wear a flannel shirt, the front and arms of which should be opened to admit of the examination of the heart and of the joints. Move-ments of all kinds should be as far as possible avoided. The affected joints should be enveloped in cotton wool, kept in position by a light bandage. Sometimes the bathing of these parts with warm water containing opium or other sedative affords relief. The local application of blisters in the neighbourhood of the painful joints, as pro-posed by Dr Herbert Davies, is in some instances followed with benefit, but is obviously applicable only where the rheumatism is limited in its extent. The same may be said of the local application of electricity to the joints. Constitutional remedies are of undoubted value in this disease, and the number of available agents for this purpose is so large that mention can only be briefly made of some of the more approved. For long the alkalis, especially the salts of potassium, were the chief remedies resorted to, and for them it was claimed that they shortened the attack, relieved pain, and prevented heart complications. They are certainly very valuable in many instances. Of late a new series of substances has been tried with great success, namely salicin (first suggested for acute rheumatism by Dr T. J. Maclagan), salicylic acid, and salicylate of soda. These remedies, which are known to have a powerful effect in reducing febrile temperatures, appear to exercise a special influence in acute rheumatism, not merely by lowering the fever, but by relieving pain and cutting short the attack, thereby lessening the risk of complications. From 20 to 30 grains of these drugs every two hours require to be given for about twenty-four hours in order to produce the desired effect, and the quantity is reduced as the acute symptoms subside. Although they do not succeed in all cases, and sometimes give rise to symptoms (delirium, sickness, &c.) which necessitate their suspension, it will be admitted by most physicians that cases which appeared likely to be of a severe character have under this treatment been cut short in a few days, and that even where this result was not attained the pain and other distressing symptoms were materially alleviated. Tonics, such as iron and quinine, have also been employed in acute rheumatism, but their advantage is more apparent in the convalescence, when there are anasmia and debility, rather than in the height of the disease. The pain and sleeplessness may render necessary the administration of opiates, but in many instances both are completely overcome by the remedies previously mentioned. In the dangerous complication of hyperpyrexia the cold bath (in which the water is quickly cooled down from 94° to 68°) has frequently been suc-cessful in speedily lowering the temperature and saving life. Persons who have suffered from acute rheumatism should ever afterwards be careful to avoid exposure to damp and chill, and to protect the skin by suitable underclothing.
In chronic rheumatism the remedies are innumerable. This form of the disease is less under the power of medicinal agents than the acute, although much may be done to alleviate the suffering produced by it as well as to limit its extension. Salicin and the salicylates so useful in acute rheumatism are not found as a rule to be of much service, while on the other hand alkalis in combination with sulphur, iodine, arsenic, and tonics, such as iron, quinine, cod-liver oil, &c, are the most serviceable remedies. Turpentine is also recommended. Friction of the affected parts with stimulating or soothing liniments, counter-irritation with blisters, iodine, or the button cautery are useful local applications, as is also galvanism. Hot baths or Turkish baths may occasionally be used with advantage. The mineral waters and baths of various well-known resorts are of undoubted benefit, especially those of Buxton, Bath, Strathpeffer, or Harrogate in Great Britain, or those of Aix-les-Bains, Wiesbaden, Homburg, Ems, Wildbad, Aix-la-Chapelle, and many others on the Continent. Changes to warmer climates during the colder season where practicable are also to be recommended, as well as every other measure calculated to improve the general health.
RHEUMATOID ARTHRITIS.This term (syn. chronic rheumatic arthritis, arthritis deformans) is employed to designate a chronic inflammatory affection of joints, involving specially the synovial mar-cranes and articular cartilages, of slow development and progressive character, resulting in stiffening and deformity of the parts.
This disease is held by some to partake of the nature of both rheumatism and gout (hence occasionally termed rheumatic gout); others regard it as simply a variety of chronic rheumatism; while in the opinion of several eminent authorities it is an independent constitutional affection occurring in persons with a strumous or tubercular tendency. It does not appear to be hereditary. It is more common in women than in men, and occurs at all ages. It is closely connected with conditions of ill health ; and hence its frequent occurrence among those whose blood is impoverished by insufficient food, by hardship, or by any drain upon the system. It occasionally follows an attack of acute rheumatism; hence the supposed connexion.
The disease in most cases is slowly developed, and shows itself first by pain and swelling in one joint (knee, wrist, finger, &c), which soon subside and may remain absent for a considerable time. Sooner or later, however, another attack occurs either in the joint formerly affected or in some other, and it is noticed that the affected articulation does not now regain its normal size but remains somewhat swollen. The attacks recur with increasing frequency, gradually involving more joints, until, in course of time (for its progress is very chronic), scarcely an articulation in the body is free from the disease. Thickening of the textures, with stiffness, is the result, and often considerable deformity from the joints being fixed in certain positions. The muscles of the affected limbs undergo atrophy and contrast strikingly with the abnormally enlarged joints. Painful inflammatory attacks often occur in the affected joints, and the patient is much reduced in strength by the constant irritation of the disease. In the young the hands are very liable to suffer, and the disease gradually extends to involve other parts; while in old persons it is apt to fasten upon one joint, often the hip, and is not so apt to spread. The chief changes in the joints are (1) in the synovial membrane, which is at first simply inflamed and contains fluid, but ultimately becomes much thickened, and (2) in the articular cartilage, which tends to split up and become gradually absorbed, leaving the articular ends of the bone exposed. The osseous surfaces thus brought into contact become hard and polished by friction. These changes and others affecting the ligaments are apt to produce partial dislocation as well as stiffening of the joint, rendering it deformed and useless. This disease often lasts for many years, sometimes continuing for a lengthened period without much change, but tending gradually to progress and to render the patient more and more helpless. It is not attended with the complications of rheumatism, and is not inconsistent with long life, but its weakening effects upon the system and the ill health with which it is usually associated render the subject of it more liable to the inroads of other diseases. Rheumatoid arthritis is less
amenable to treatment than rheumatism, the remedies for which are not found to be of much value in this disease. Most success is obtained if it is recognized early and measures are taken to strengthen the patient's general health. The best medicinal agents are iron, quinine, cod-liver oil, arsenic. Chalybeate mineral waters, such as those of Schwalbach, Spa, Pyrmont, &c, are often of service. Locally blisters or milder counter-irritation to the affected joints, as well as the employment of galvanism, may be advantageously resorted to. (J. O. A.)