(INFLAMMATORY RHEUMATISM)
=Definition.=—An acute, febrile, non-contagious disease; it is
infectious, although there is some controversy as to its exact nature;
characterized by a multiple arthritis and a tendency to involve the
heart.
=Osteopathic Etiology= and =Pathology=.—The prevailing thought is that
the disease is an infection due to a diplococcus. This micro-organism
is called by others micrococcus rheumaticus and streptococcus
rheumaticus.
“Rheumatic fever occurs most frequently in the temperate zone, among
people who live under conditions which are unhealthful and which
especially induce focal infection. It is most prevalent in the young
and in the more exposed male of all ages. The excess of lymphoid tissue
in the pharynx and nose of the young explains the frequency of the
incidence of the focal infection and the subsequent rheumatism. The
frequent association of the onset of rheumatic fever with lowering of
the body temperature by exposure to cold and a wetting is explained by
the increased specific virulency of the bacterial cause acquired by a
low temperature and the coincident lessened resistance of the patient
due to the exposure. The frequent absence of evidence of acute focal
infection at the onset of the systemic disease is not an evidence
that no focus exists. The latent chronic streptococcus infection of
tonsillitis, pyorrhea alveolaris, sinusitis, etc., may suddenly acquire
increased virulence and specific pathogenic affinity with varying
degrees of focal tissue reaction. This transmutation of type and
pathogenicity certainly occurs in the focus of infection. The removal
of the tonsils and other sites of focal infection has been followed by
complete recovery of prolonged, subacute and chronic types of arthritis
and has unquestionably prevented recurrent attacks of rheumatic fever
to which the susceptibility is increased by one or more attacks. The
occurrence of rheumatic fever after the removal of an apparent focus
may be due to secondary systemic latent foci in lymph nodes proximal to
joints, in the neck or elsewhere. The streptococci of these secondary
foci may take on new virulence and specific pathogenicity, from the
same causes which induced like changes in the pathogenic bacteria of
the primary focus.[67]”
Osteopathic lesions play an important role, both in their relationship
or bearing upon the tissues of a possible site for a focal infection
and upon systemic conditions that derange general bodily tone. This has
been definitely confirmed in those cases of rheumatism where correction
of the osteopathic lesions, with attention to hygienic measures, have
resulted in recovery. This is a feature of osteopathic etiology and
therapy that can hardly be over-emphasized, for an intact innervation,
circulation and chemism of the organism is basic to both preventive and
curative therapy. Rheumatism, like most diseases, is of local origin
and if tissues and structures can be kept up to the normal, infectious
or the other pathologic processes can rarely become active.
=Pathologically=, the synovial membrane is hyperemic. The muscles and
ligaments are inflamed. The fluid is serous with more or less fibrin
and leucocytes. In severe cases slight erosion of the cartilages is
found. Acute rheumatism is rarely fatal; when death does occur it is
generally due to the complications which arise.
=Symptoms.=—The onset is usually sudden; although it may be preceded
by slight fever, aching in joints, chilliness, and sore throat. It
generally involves the larger joints and is almost always multiple;
it has a tendency to move from one joint to another. The pain in the
joints usually develops rapidly with slight chilliness and a rapid
rise in the temperature from 102 to 104 degrees F. The pulse is
frequent, often disproportionately to the fever. There are profuse
acid sweats, often causing sudamina. There is loss of appetite and
thirst is present. The urine is scanty, high colored, very acid, and
deposits urates upon standing. The tongue is coated and the bowels
are constipated. The joints are reddened, swollen, extremely painful
and tender to the touch. Every movement, jarring of the bed, or the
pressure of the bed clothes is agony to the patient. The blood is
greatly deranged, anemia develops rapidly and there is well marked
leucocytosis. The duration varies from a few days to several weeks.
=Complications.=—The temperature may rise to 106 or 109 degrees F.;
this is often associated with delirium, great prostration and a feeble,
frequent pulse. Endocarditis, pericarditis, myocarditis, pneumonia,
pleurisy, iritis, chorea, convulsions and meningitis may occur. Coma
may develop without preceding delirium or convulsions; this is very
serious and may prove fatal. Subcutaneous fibrous nodules attached to
tendons and fascia sometimes develop. They vary in size and are most
common in children and in young adults, occurring most frequently in
the fingers, hands and wrists. They are also sometimes seen about
the elbows, knees, scapulæ and spines of the vertebræ. They usually
last a few days, sometimes for months, and generally develop during
the decline of the fever. Cutaneous affections, such as urticaria,
erythema, nodosis, purpura and sweat vesicles sometimes appear.
=Diagnosis.=—This is seldom very difficult; there are, however,
several affections which resemble acute articular rheumatism. In
=septic arthritis= its association with some other septic process
and the tendency of the inflammation to end in suppuration with more
or less destruction of the joints, will determine the diagnosis.
Septic arthritis may develop during the course of pyemia, puerperal
fever, or acute osteomyelitis. =Gout= is rarely mistaken for acute
rheumatism. Gout occurs later in life and usually affects the greater
toe; history and mode of onset will usually render the diagnosis
easy. In =gonorrheal rheumatism= the history of recent infection, its
obstinate character and being generally connected with a single joint
from the start are diagnostic. It especially affects the knee. Heart
complications are rare. =Rheumatoid arthritis= begins in the small
joints; then attacks them all, leaving permanent deformity. There is
no fever or sweats and the heart is not affected. Acute arthritis of
infants usually attacks the hip or knee. The effusion becomes purulent.
=Prognosis.=—Recovery is the rule, but the prognosis nevertheless, must
be guarded. Relapses and recurrences are common.
=Subacute Rheumatism.=—In this form both the local and general symptoms
are of a milder type and are more prolonged than in the acute form. The
temperature seldom rises above 101 degrees F. The inflammation of the
joints is not so severe and fewer joints are involved. It may last for
weeks or months, and then it may pass into the chronic form. Usually
though, when the course is prolonged, the joints return to their normal
state.
=Treatment.=—Place the patient in a room that is well ventilated and
maintain a temperature of about 70 degrees F. Avoid draughts of air.
The bed should be soft and smooth and blankets should be used. The diet
should consist largely of milk, and let the patient drink freely of
water. Oatmeal, barley water, egg albumen and meat juices may also be
used.
Treatment should be given along the entire spine, especially if the
rheumatism changes from one joint to another; otherwise treat the
innervation directly to the affected joint. Correct any derangements
that may be found along the spinal column and carefully relax the deep
back muscles. Particular attention should be given to the bowels and
kidneys. Also, treat the liver most thoroughly during each treatment.
The liver is many times considerably enlarged and tender in rheumatism
and a thorough treatment of it seems to favor a more rapid cure.
Carefully treat the affected tissues. If you cannot treat over the
joint, then manipulate the tissues above and below the joint; and
usually after a few minutes’ manipulation the swelling is somewhat
relieved so that direct treatment of the joint can be given. It is best
to wrap the inflamed joints in flannel if the pain is severe. Besides
treatment of the innervation of the joint, hot applications will be
helpful. Some claim that cold compresses are of aid to the inflamed
joints.
=Complications= are to be treated separately. Besides the ordinary
fever treatment for the fever, the cold bath is very effectual. After
=convalescence= has been established, the patient should be carefully
protected for several days from cold and damp. For any stiffness that
may persist, manipulation and hot baths will be quite sufficient.
H. M. Still[68] writes “If the fever is not over 103 degrees I do not
try to reduce it.... After treatment in a majority of cases, the fever
is reduced within twenty-four hours unless complications have set in.
These are usually of the heart, so no matter how mild the attack, keep
this in mind. If the action is irregular and weak, stimulate it two or
three times a day. If it is rapid and high fever, go to the vasomotor
centers and reduce fever, then inhibit the heart action and keep the
excretions active. If the joints are affected I always move them gently
no matter how great the inflammation. As yet I have never had a case of
rheumatism in which cardiac lesions or ankylosed joints were a sequela.”
If the tonsils are evidently badly diseased and osteopathic treatment
does not clear them up do not hesitate to have them removed.