with acute rheumatism. Besides sudamina and miliaria rubra, which are
very common as consequences of the excessive perspiration,[101] there
{43} are others which may be themselves rheumatic manifestations. Such
are especially erythema marginatum,[102] e. papulatum, and e. nodosum.
A well-marked urticaria frequently precedes acute rheumatism in a
friend of the writer's; it may occur during its course or soon after
the cessation of the pains. Scarlatiniform eruptions are occasionally
observed, and very rarely punctiform hemorrhages--peliosis rheumatica
or rheumatic purpura. The purpuric symptom may be accompanied by
erythema or urticaria, and may precede, accompany, or alternate with
other rheumatic manifestations. Unlike purpura variolosa and idiopathic
purpura hæmorrhagica, this variety appears to be free from danger.
[Footnote 101: Dr. J. T. Metcalfe of New York many years ago showed me
a case of rheumatic fever in which the sweat-vesicles had run together,
forming, instead of the usual pearly globular vesicles, irregular flat
blebs, some of them equal in area to seven or nine primary vesicles,
filled with transparent fluid, and this fluid could be displaced by
pressure to adjacent parts, as though it lay simply under the
superficial epidermic layer. I have seen several similar cases since.]
[Footnote 102: Dr. Palmer relates a case complicated with erysipelas
and peritonitis in _Boston Med. and Surg. Journal_, 1868.]
Besides a slight local oedema affecting the malleoli, scrotum, eyelids,
etc., or accompanying the cutaneous eruptions just mentioned, a more
decided infiltration of the subcutaneous cellular tissue occasionally
exists in the vicinity of the inflamed joints and tendinous sheaths,
and more rarely extends to an entire limb, which may not only be
considerably enlarged and painful and resemble a milk leg, but may be
red, hot, and tender, and excite suspicion of phlegmonous erysipelas.
Phlebitis, although infinitely less frequent than in gout, has been
observed in acute articular rheumatism.[103] Jaccoud in 1871[104]
mentioned the exceptional occurrence of subcutaneous nodosities in
rheumatism, which he says Froriep first pointed out;[105] but Homolle
states that they had been previously mentioned by Sauvage and
Chomel.[106] Since then several independent observers have met with
this affection, and Drs. Thomas Barlow and Francis Warner of London
have lately written a short valuable paper upon the subject based upon
27 cases which they had separately or conjointly investigated. From
their paper the following account is chiefly derived:[107] These
nodules may vary in number from one to fifty, and in size from that of
a pin's head to the volume of an almond, and are quite subcutaneous,
firm and elastic, painless, and freely movable. They are not usually
attached to the skin, but to the tendons, deep fasciæ, pericranium,
periosteum, etc.; the integument over them is free from heat, redness,
and infiltration, although exceptionally tenderness on pressure and
slight redness may exist over them. They are found most frequently on
the back of the elbow, the malleoli, and margins of the patella, but
occur occasionally on the extensor tendons of the hand and foot, the
scapular spine and iliac crest, the temporal ridge and superior
occipital curved line, the ear, etc. These nodules occur singly or in
clusters, and are often symmetrical; they are very rapidly developed in
crops or in succession, and last sometimes for a few hours, more
frequently from three or four days to four or five months, or even
eighteen to thirty months. The original formations may disappear, and
be succeeded by fresh ones; and sometimes, when no longer perceptible
by touch, they may be found post-mortem. Their development is
unattended by pyrexia, unless pleuritis, pericarditis, or other
condition coexist to which the pyrexia might {44} be referred. These
nodosities do not appear to suppurate or ossify or become infiltrated
with urate of soda, and histologically they resemble organizing
granulative tissue. As regards their pathological associations, Drs.
Barlow and Warner found evidences of rheumatism in 25 out of 27 cases;
a morbid condition of the heart existed in all of them, and chorea in
10 of them. Two of the conclusions formulated by the authors just
mentioned are of great importance: that these subcutaneous nodosities
"may be considered as in themselves indicative of rheumatism, even in
the absence of pain;" that, while unimportant in themselves, they are
"of serious import, because in several cases the associated heart
disease has been found actively progressive." Dr. Dyce Duckworth has
reported two cases in which these nodules occurred in adults, lasted
eighteen months in one, and were still present in the other case after
thirty months, and were attached to the skin and periosteum. In one of
them the nodules were very painful and ached more in cold weather, and
the patient had no history of rheumatism or of chorea, although her
mother and one sister had.[108] In Dr. Stephen Mackenzie's case the
woman was the subject of tertiary syphilis, and had no personal history
of rheumatism or chorea, and she was free from heart disease; but her
family history was not given.[109]
[Footnote 103: _Phlebite Rheumatismale Aigue_, Paris, 1869, par M.
Lelong. In _Revue de Méd._, t. i. 492-499, 1881, a case by Dr.
Launois.]
[Footnote 104: _Pathologie Interne_, ii. 546, 1871.]
[Footnote 105: _Die Rheumatische Schwiele_, Weimar, 1843.]
[Footnote 106: _Lib. cit._, p. 628.]
[Footnote 107: _Trans. International Medical Congress_, London, vol.
iv. pp. 116-128, 1881. In this paper, and in an article by MM. E.
Troisier and L. Brock, to be found in _Revue de Médecine_, t. i.
297-308, 1881, are references to the authors who had written upon it.]
[Footnote 108: _Brit. Med. Journ._, i., 1883, 868.]
[Footnote 109: _Ibid._, i., 1883, 867.]
The course and duration of acute polyarticular rheumatism vary very
much, and are apparently influenced by several circumstances, such as
the severity or the mildness of the articular affection, as well as of
the constitutional disturbance; the presence or not of complications;
the state of health of the patient about the time of the attack, and,
probably, the existence or not of a proclivity to the disease; and
whether the disease present the continued or the relapsing type. As a
tolerably general rule, when the constitutional symptoms are acute, the
skin hot, the perspiration free and very acid, the urine of high
density, color, and acidity, and several of the articulations are
swollen and very painful--when no serious complication, and especially
no severe cardiac affection, exists, and when the patient is endowed
with a fair constitution and with organs not damaged by previous
disease, the course of the fever is tolerably short and continuous, and
the recovery more or less prompt. Amongst the most reliable evidences
of approaching recovery in such cases is the tongue becoming clean and
losing its red color and the urine increasing considerably in quantity,
but containing a large proportion of solid matter, as indicated by a
high density.
On the other hand, a large proportion of cases run a more irregular and
protracted course, and more or less marked relapses succeed real but
temporary improvements, the local disturbance affecting fresh joints or
reappearing in those previously attacked, and the general symptoms
resuming renewed activity. The duration of the active symptoms in these
cases is considerable, seldom under six weeks, and frequently occupying
seven, eight, or more. In these protracted cases the symptoms, as a
rule, are usually rather milder, the perspiration not as profuse or
sour, the urine of less density and acidity, the articulations less hot
and painful, than in the previously described group. Sometimes, indeed,
the perspiration and the urine are of neutral or even faintly alkaline
reaction. It is not only the unexplained tendency to relapse which
protracts these {45} cases, but sometimes in addition an established
proclivity to the disease--the rheumatic habit--or a condition of
previous unsound or frail health.
Such cases occasionally pass into the subacute form, or the mild
febrile symptoms gradually and finally decline, and the joints may
either remain tender, swollen, and stiff some time longer, or these
signs of recent inflammation may soon disappear and leave the
articulations merely weak.
Many cases of acute rheumatism embody several of the features of the
two groups just described, and no definite course or duration of acute
articular rheumatism can be accurately laid down.
The course and duration of acute polyarticular rheumatism have received
a good deal of attention of late years. But Dr. Austin Flint[110] was
one of the first to study the natural history of the disease
uninfluenced by active treatment, and he was followed in 1865,[111]
1866,[112] and 1869[113] by Sir William Gull and Dr. Sutton, who
treated a series of cases without medicine, unless mint-water be so
regarded. The mean duration of Flint's 13 cases from the date of attack
to convalescence, excluding one in which pericarditis and pneumonia
occurred, was a fraction under twenty-six days. It is unfortunate that
the number of cases was so small, and that 11 of the patients were
females, who appear to be especially subject to the milder and more
protracted attacks of the disease. A larger number, with an equal
proportion of the sexes, would probably have given a different result.
[Footnote 110: _American Journal of Med. Sciences_, July, 1863.]
[Footnote 111: _Ib._, vol. xii.]
[Footnote 112: _Medico-Chirurgical Transactions_, vol. lii.]
[Footnote 113: _Guy's Hospital Reports_, 2d Series, vol. xi.]
Gull and Sutton have published the natural histories of 62 cases--viz.
of 41 in their first series, of 8 more in their second, and of 13 more
in their third. The average duration of the acute symptoms was, in the
first series, 8.5 days, in the second, 9 days, and in the third, 10
days, giving an average of 9.1 days for the duration, after admission
to hospital, of the acute symptoms of acute polyarticular rheumatism
when there is no very severe cardiac disease. In their third paper,
based upon 13 new cases and 12 of those published in their two previous
communications, they conclude "that rheumatic fever uncomplicated with
any very severe heart affection tends to run its course in nineteen
days, calculating from the time the rheumatic symptoms first set in to
their termination."[114] Yet an analysis of the 23 of the 41 cases
contained in their first series[115] respecting which the duration of
the rheumatic symptoms before admission and from admission to complete
convalescence is given, shows that the period occupied from the setting
in of the rheumatic symptoms to convalescence was in the 13 male
subjects 25.8 days, and in the 10 female 42 days, or, including both
sexes, the average duration was 32.8 days--_i.e._ 6.8 days longer than
Flint's result.
[Footnote 114: _Med.-Chir. Trans._, lii. 82.]
[Footnote 115: _Guy's Hospital Reports_, xi. 435.]
As Gull and Sutton had especially pointed out the class that tends to
assume acute characters and recover more quickly than any other, and
the class that runs a protracted course and tends to relapse, it is
somewhat remarkable that they did not tabulate the cases belonging to
those classes separately, and show distinctly their differences in
duration and {46} modes of convalescence. This has been attempted by
Southey,[116] but, unfortunately, his conclusions, as will hereafter
appear, have not been confirmed by other observers.
[Footnote 116: _St. Bartholomew's Hospital Reports_, xiv., and _ib._,
xv.]
Finally, in this connection, after carefully weighing ten subjects of
acute articular rheumatism during their illness and until they had
regained their usual weight, A. Roussel[117] found that the time during
convalescence occupied in regaining the weight previously lost was
inversely proportional to the duration of the attack.
[Footnote 117: _Essai sur la Convalescence du Rheumatisme Artic.
Aigue_, Paris, 1881, 66.]
Subacute Articular Rheumatism.
Under this head Charcot, Besnier, and Homolle describe an affection
which corresponds closely with one variety of the disease commonly
called rheumatoid arthritis, but the writer employs the term with the
same significance as most modern English authors (Garrod, Sutton,
Flint, Maclagan). It is milder yet more enduring than the acute form,
but their symptoms are identical in kind. It is usually subacute from
the outset, although occasionally succeeding the acute type. The
febrile disturbance is but slight, rarely reaching 101°, and the
perspiration is less abundant; there is less pain, heat, and tenderness
in the joints, and only a few of them are involved together; but
although the articular affection moves from joint to joint, it persists
for weeks or months in several of them or in one only, improving and
relapsing generally without apparent reason. However, it does not
seriously damage the articulations, and they ultimately quite recover.
Mild cardiac affections also occur, but less frequently, and the
serious disturbances of the cerebral and respiratory systems are very
seldom met with. The gradations between subacute articular rheumatism
and the acute form on the one hand, and the simple chronic form on the
other, are almost innumerable. Marked anæmia is as much a feature of
subacute as of acute articular rheumatism, and its victims are often of
unhealthy or asthenic constitution, and subject to recurring attacks of
the disease on but slight provocation. The return of warm weather often
relieves such cases.
THE MORBID ANATOMY OF ACUTE AND SUBACUTE ARTICULAR
RHEUMATISM.--Although opportunities of ascertaining the conditions of
the articulations in acute articular rheumatism are rare, yet it is now
established that the process is an inflammation involving chiefly the
synovial membrane, and to a less degree the cartilages, ligaments,
tendinous sheaths, and in some cases even the bones and periarticular
soft parts. The synovial membrane is more or less injected and reddened
diffusely or in patches, especially where it forms fringe-like folds
and at its line of union with the cartilage. It is somewhat thickened,
opaque, and devoid of its satin-like lustre, and in somewhat protracted
cases covered here and there with a thin, easily detached
neo-membranous formation. Within the articulations will be found from a
few drops to one or two ounces of a viscid, pale, citron- or
reddish-colored fluid, like synovia, but more fluid, and generally
turbid and containing transparent or semi-opaque gelatinous masses or
albumino-fibrinous flocculi. The {47} microscope reveals in the
effusion large detached spherical epithelial cells in various stages of
germination or of fatty degeneration, and a variable number of red
blood-corpuscles and pus-cells. Very exceptionally, the effusion is
mixed with more or less true pus. In two out of the eight fatal cases
reported by Fuller, in which the joints were examined, pus in moderate
quantity was found along with other products in some, but not in all,
of the inflamed articulations, and one of them was complicated with
erysipelas, the other with sloughs over both trochanters. In very
severe forms complicated with hemorrhagic tendencies the inflammatory
products have contained a large proportion of blood. Cornil et
Ranvier[118] insist that even in slight cases of rheumatic arthritis
the diarthrodial cartilage constantly suffers changes arising from
nutritive irritation and proliferation of the cartilage-cells. At first
the cartilage loses here and there some of its polished hyaline
appearance, and the microscope reveals a finely-striated condition of
its structure which gives it a velvety aspect. When the inflammation
has been more severe and of longer duration, so that the deeper layers
have been involved, the unaided eye will perceive local swellings in
which the natural elasticity and resistance of the cartilage are
impaired, and its surface is fissured or villous-like in appearance.
"In certain rare cases of mono-articular acute arthritis true
ulcerations of the cartilage are observed."
[Footnote 118: _Manual d'Histologie pathologique_, Paris, 1869, 406.]
The soft parts in the immediate vicinity of the inflamed joints may be
in some cases more or less congested and oedematous, and the tendinous
sheaths, and even the bursæ mucosæ, inflamed and distended with
inflammatory products like those in the articulations. Charcot,[119]
holding the opinion that arthritis deformans is but a chronic variety
of articular rheumatism, quotes Gurlt's statement that in acute
articular rheumatism "the medullary tissue of the ends of the bones
undergoes a great increase of vascularity, with proliferation of its
corpuscles," and remarks that Hasse and Kussmaul have also referred to
lesions of the bone and periosteum in that disease. But the condition
of the osseous parts of the joints in acute articular rheumatism can
hardly be said to be known, and it is premature to speak positively
respecting it.
[Footnote 119: _Clinical Lectures on Acute and Chronic Diseases_,
Sydenham Soc., 1881, p. 148.]
Finally, in subacute rheumatism the alterations in the synovial
membrane, and especially in the cartilages just described, are likely
to be more marked than in the acute form.
The DIAGNOSIS of acute polyarticular rheumatism is seldom difficult in
adults, but when acute rheumatism localizes itself in one joint or
occurs in infancy or early childhood, a diagnosis, especially an early
one, sometimes cannot be easily established. The considerations by
which acute polyarticular rheumatism may be distinguished from acute
gout, subacute rheumatoid arthritis, and gonorrhoeal rheumatism will be
given in connection with those topics.
Pyæmia has perhaps been confounded with acute articular rheumatism more
than any other disease, but the rheumatic affection, unlike the pyæmic,
is not necessarily connected with any pre-existing condition capable of
causing purulent infection of the blood or system, such as a wound,
fracture, abscess, or a local inflammation of bone, periosteum, vein,
pelvic organ, or a specific fever (variola, relapsing, typhoid, {48}
glanders, etc.); it does not present severe rigors, which recur at
irregular intervals and are attended with teeth-chattering and a high
temperature, 104° to 105°, rapidly attained; its type of fever is not
so intermittent or markedly remittent as that of pyæmia; its profuse
sweating continues although the temperature remains febrile, but that
of pyæmia coincides with the decline of the temperature; unlike pyæmia,
it only very rarely produces profound constitutional disturbance of a
typhoid character, and has no tendency to run a rapidly fatal course in
eight to ten days or in two or three weeks; its visceral inflammations
are chiefly cardiac, pleural, and pulmonary, and tend to resolve; those
of pyæmia are especially pulmonary, pleural, and hepatic, although
frequently cardiac also, and generally produce suppuration and
destruction of tissue. Multiple subcutaneous abscesses and cutaneous
blebs and pustules do not occur in acute articular rheumatism, and its
articular affection differs in many respects from that of pyæmia; many
more joints are involved; the inflammation is erratic, very rarely
fixed, and generally resolves without damage to the articulation; the
affected joint is usually hotter, redder, more painful, and more
sensitive, and the swelling is less diffused, and its outline
corresponds more accurately with that of the synovial capsule.
Sometimes acute articular rheumatism is complicated with the phenomena
of pyæmia, as when so-called ulcerative endocarditis obtains.
The acute inflammations which are occasionally observed in one or
several articulations of newly-born infants are generally pyæmic. It is
only in the early stage of acute glanders that the severe muscular and
articular pains sometimes present in that very rare disease in man
might lead to its being confounded with acute articular rheumatism; but
the patient's occupation and history, the early and severe prostration,
the absence, as a rule, of redness and swelling around the painful
articulations, and, in some instances, the early appearance of pustules
and blebs on the skin and of abscesses in the deeper tissues, will
suggest the real nature of the case.
Acute periostitis frequently occurs in children in close proximity
either to one joint, or less frequently to more than one, and may
readily be confounded with acute articular rheumatism. But the
constitutional disturbance in acute periostitis is prompt and severe at
the outset; the swelling increases rapidly, is firmer than that of
arthritis, does not involve the joint proper and its capsule, but, like
the tenderness on pressure, exists above or below the articulations,
especially around the head of the bone; there are no visceral
complications, provided pyæmia has not supervened; the constitutional
symptoms early assume a typhoid character, and unless an early incision
be made a fatal issue soon ensues.
The enlarged ends of the long bones and the pains in the limbs of
rickets might lead to a suspicion of acute articular rheumatism, but
the early age of such children, the absence of pain and swelling in the
joints, the beaded condition of the sternal ends of the ribs, the late
dentition and locomotion, the peculiarly shaped head, and other
evidences of that affection, would prevent a careful observer from
making a mistake. Inherited syphilis in infants, like rickets, may
produce fusiform swelling and thickening at the ends of the long bones,
especially the humerus and femur, and sometimes pain in the joints on
movement; but at first the swelling {49} is confined to the epiphyseal
line, and only later extends to the joint; there is a pseudo-paralysis
of the limb, and but little pain or fever; bony osteophytes may often
be felt under the skin at the line of union of the epiphysis with the
shaft; the epiphysis often becomes separated from the shaft, and
suppuration may ensue around the bone and in the articulation;
sometimes adhesions and perforation of the integument take place,
allowing of the escape of disintegrating osseous and cartilaginous
tissue; and there will coexist either on the skin or mucous membrane
some of the ordinary evidences of inherited syphilis.[120] The acute
and subacute articular inflammations occasionally observed in cerebral
softening and hemorrhage, in injuries and inflammation of the spinal
cord and caries of the vertebræ, may be distinguished from acute and
subacute articular rheumatism by the following circumstances: the
existence of some one of these diseases of the brain or cord, the
articular affection being usually confined to the paralyzed limbs; its
invasion about the time of the setting in of the late rigidity, or even
still later; the absence of cardiac complications and the presence of
other trophic or neuro-paralytic lesions, such as acute sloughings,
rapid atrophy of the palsied muscles, cystitis, ammoniacal urine,
etc.[121]
[Footnote 120: Vide Parrot, _Archives de Physiol. Norm. et Path._, 1872
and 1876; R. W. Taylor, _Bone Syphilis in Children_, New York, 1875.]
[Footnote 121: See J. K. Mitchell, _Am. Jour. Med. Science_, vol.
viii., 1831, and _ib._, 1833; Scott Alison, _Lancet_, i., 1846, 276;
Brown-Séquard, _Lancet_, i., 1861; Gull, _Guy's Hosp. Repts._, 1858;
Charcot, _Archives de Physiologie_, t. i. p. 396, 1868, and many
others.]