PAINS OF SUBACUTE AND CHRONIC RHEUMATISM.
So firmly is the idea of an essential connection between rheumatism and
neuralgia implanted in the popular mind, and, indeed, in the minds of a
certain portion of the medical profession, that the two complaints are
continually confounded. In the great majority of instances, the mistake
made is that of calling neuralgia a "rheumatism." But the opposite error
occasionally occurs, and a patient is styled "neuralgic" who is really
suffering from chronic rheumatism.
As true neuralgia is an essentially localized disease, there can be no
excuse for mistaking for it the more typical cases of chronic
rheumatism, in which a number of different joints, muscles, or tendons,
are affected, more especially in the advanced stages, when the
characteristic fixed contractions of the limbs and extremities have
occurred. But there are a few cases in which, either with or without a
previous history of acute rheumatism, one, or perhaps two, joints begin
to suffer vague pains, which after a little time begin to shoot down the
course of the limb, and are aggravated from time to time in a manner
which superficially much resembles neuralgia; and when the malady has
reached a certain intensity the pains may be so much more severely felt
in the longitudinal axis of the limb than in the immediate neighborhood
of a joint, that the patient forgets that in reality they commenced
either within a joint (as the elbow or hip), or in the fibrous
structures immediately outside it. Certain localities are much more
frequently the seat of this kind of affection than other parts of the
body; thus it occurs, perhaps in nine-tenths of the cases, in the
neighborhood either of the shoulder (especially involving the insertions
of the deltoid and triceps muscles), of the elbow (particularly
affecting the tendinous insertions of the muscles on the internal aspect
of the forearm), or the hip (extending to the aponeuroses on the outer
and back part of the thigh): in all these cases there is a considerable
superficial resemblance to true neuralgic pains. Nevertheless, the
diagnosis need not present any serious difficulties after the earliest
stages; for there soon arises a very diffuse and acute tenderness of the
parts, and usually an amount of generalized swelling, which, though it
may not be readily detectable by the eye, is sensible enough to the
touch. Movement of the parts is also very painful; but usually not with
the acute and agonizing pain which occurs in myalgia.
It is, however, upon signs which are of a more general character that we
ought chiefly to rely for diagnosis. The fact that the patient has
previously experienced a genuine attack of acute rheumatism, though of
some value, is by no means to be taken as a conclusive argument that the
present attack is of a rheumatic nature. The really important matter is,
that whether the patient has or has not suffered acute rheumatism before
the occurrence of the subacute or chronic form, the latter will always
be attended by more or less of the specific constitutional disturbance
of rheumatism. I would carefully abstain from the assumption that
rheumatism is originally dependent on a blood-poisoning, a theory which
I believe to be most doubtful and very probably false; but there is,
nevertheless, a truly specific character about the general phenomena in
acute rheumatism, and I maintain that similar though less-marked
phenomena are always to be seen even in the mildest and least acute
forms of rheumatism. Thus there will be, invariably, more or less of the
peculiar sallow anaemia, together with red flushing of the cheeks when
the pain is at the worst; and there will be a certain amount of the oily
perspiration which makes the faces of rheumatic patients look shiny and
greasy. No doubt these characteristics will sometimes be very slightly
developed, but I believe that attentive observation will always discover
them in any case which is genuinely rheumatic. One case, in particular,
which has been under my care, very strongly impresses me with the value
of these diagnostic signs, where otherwise the symptoms are obscure:
L. P., aged thirty-one, single, a printer by trade, applied to me,
January, 1863, suffering from what I at first decidedly thought was
cervico-brachial neuralgia, the pain having followed exposure to cold
and wet, situated in the lower part of the neck, the shoulder, elbow and
inner side of the right arm, and existing nowhere else. The character of
the pain was described as at least remittent, if not distinctly
intermittent. The pulse was not more than 78; the tongue was thickly
coated with white fur, but the man did not complain of thirst, and there
were no evident signs of fever. As the pains had only existed for about
a fortnight, it appeared an excellent case for cure by the hypodermic
injection of morphia; and, accordingly this was used in quarter-grain
doses twice a day. After about ten days an attempt was made to do
without the morphia, but the pains returned, worse than before, and
meantime the tongue had remained uniformly coated, and was now very
yellow; the appetite was bad, and there was some increase in frequency
of pulse. It now struck me, for the first time, that the man presented,
in a slight degree, the sallow and red tint and oily features of a
rheumatic patient; it was now found that sweat and urine were distinctly
acid. Acting on this idea, I administered five grains of iodide of
potassium, and thirty grains of bicarbonate of potassium, four times
every twenty-four hours, after giving a moderate saline aperient. The
result was manifest improvement within twenty-four hours, and almost
complete relief of the pain within three or four days (the urine never
becoming distinctly alkaline, however.) As the attack subsided, the oily
appearance of the skin disappeared, and the rheumatic tint was replaced
by mere ordinary pallor, which the patient lost after taking a short
course of steel.
At the time this case occurred to me, I was not aware of the importance,
in doubtful instances, of looking to the temperature; but subsequent
experience has convinced me that in every truly rheumatic case, however
limited in extent, there is a real, though it may be a small, rise of
temperature. The thermometer will be found to mark from 99-1/4 deg. to 100 deg.
Fahr., and this, joined with the appearances above mentioned, and a
strong acidity of urine, will be sufficient to distinguish the complaint
as rheumatic; and the striking effect of such remedies as iodide with
bicarbonate of potash, followed up with sesquichloride of iron, in full
doses, helps still further to distinguish the cases from true
neuralgias. Since the introduction of the full doses of the
iron-tincture in the treatment of acute rheumatism, I have had the
opportunity of treating two of these cases of subacute rheumatism in the
same manner, viz., with the iron from the first, and the results have
been most satisfactory in every way. These cases were independent of a
much larger number, treated in the same way, in which the symptoms of
rheumatism were more generalized and more severe.