affects but one joint, and has little tendency to become general; the
joints of the lower extremity, ankle, and knee are most obnoxious; the
local signs of inflammation, redness, swelling, and pain, are feebly
developed, and the child may walk as if nothing were wrong; the disease
is usually subacute; the temperature rarely very high; the perspiration
not profuse; the urine not scanty, and not often loaded with lithic
acid. Cardiac and the other internal complications, except the
cerebral, are more frequent than in adults; endocarditis is especially
frequent, pericarditis and pleuritis not rare. It is almost exclusively
in childhood that acute articular rheumatism becomes associated with or
followed by chorea, and yet the delirium, coma, and convulsions
frequently observed during rheumatic fever in the adult are very rarely
seen in the child. Muscular rheumatism, however, in the form of
torticollis, frequently coexists, and so do erythema nodosum and the
subcutaneous fibrous nodules previously described.
Mono- or Uni-Articular Acute and Subacute Rheumatism.
It is very rarely indeed that acute rheumatism invades a single joint
to the exclusion of the rest; and it is perhaps impossible to be
certain that such an arthritis is rheumatic unless some of the other
symptoms or complications of articular rheumatism supervene, or unless
it have succeeded a polyarticular rheumatism, which it very rarely
does. Mono-articular rheumatism is very generally of the subacute type,
and unattended with fever from the outset, or only a moderate pyrexia
obtains for a few days; there is generally considerable effusion into
the joint, with {50} swelling, pain, and moderate local heat; visceral
complications very rarely arise, but the local inflammation persists
most obstinately for six or eight weeks or three or four months, and
often leaves the joint tender, stiffs, and weak for a long time or even
permanently. In both the acute and subacute forms, before concluding
that the uni-arthritis is rheumatic, we must exclude the probability of
its being traumatic, strumous, syphilitic, gonorrhoeal, neurotic, or,
above all, of the nature of rheumatoid arthritis, which many such cases
really are.
PROGNOSIS.--The disease is rarely directly fatal during the attack, yet
as the frequency of the complications varies unaccountably from time to
time, so the mortality may be exceptionally large or small for even
prolonged periods. It may be said that the average mortality ranges
between 1.16 and 4 per cent. in the experience of modern authors. The
average mortality in the Paris hospitals for four years (1868-69,
1872-73) Besnier fixes at 1.65 per cent.;[122] in St. Bartholomew's,
London, Southey found it for fifteen years (1861-75) to be 1.16 per
cent.;[123] Pye-Smith fixes the rate at 4 per cent. in 400 cases
treated in Guy's;[124] W. Carter gives 2.5 per cent. as the rate during
ten years at the Southern and Royal Southern Hospitals of
Liverpool.[125] The death-rate appears to vary remarkably with age, as
Southey's figures show:[126] under ten years, 3.40 per cent.; between
ten and fifteen, 1.5 per cent.; between fifteen and twenty-five, 1.4
per cent.; between twenty-five and thirty-five, 0.9 per cent.; between
thirty-five and forty-five, 0.8 per cent., the mortality declining very
greatly after the tenth, after the twenty-fifth, and after the
forty-fifth year of life.
[Footnote 122: _Dictionnaire Encyclopédique_, Troisième serie, t. iv.,
p. 463.]
[Footnote 123: _Barth. Hospital Reports_, vol. xiv., p. 4.]
[Footnote 124: _Guy's Hospital Reports_, xix. p. 327.]
[Footnote 125: _The Liverpool Medico-Chirurgical Journal_, July, 1881,
p. 88.]
[Footnote 126: _Lib. cit._, p. 4.]
The danger of the case is usually proportionate to the youth of the
patient, the degree of the pyrexia, the number of the joints involved,
and the number and the character of the complications, the habits, and
previous health of the patient. A fatal issue is most frequently
observed in connection with hyperpyrexia alone, or in combination with
delirium or coma. A rapid rise of temperature and a temperature over
105°, especially if cerebral disturbance coexist, indicate danger; and
so does arrested perspiration while the temperature is high. In a much
smaller number of cases death is due to some other complication,
especially to purulent pericarditis or to that combined with pleuritis
or pneumonia; in not a few cases the prior existence of chronic
valvular disease, with fibroid induration of liver and kidneys, renders
a fresh rheumatic endo- or pericarditis, occurring as part of acute
articular rheumatism, fatal. There is good if not conclusive evidence
that rather sudden death in acute articular rheumatism is occasionally
due either to diffuse myocarditis or to fatty degeneration of the
muscle of the heart. In Greenhow's 2 deaths out of 50 cases treated by
sodium salicylate the pericardium was universally adherent and the
heart's fibre fatty in one and pale and flabby in the other. Sudden
death in this disease is very rarely due to embolism of the pulmonary
artery or of the cerebral vessels, while ulcerative endocarditis is
very exceptionally one of the sources of a fatal issue.[127] But
although acute articular rheumatism rarely kills {51} directly, it
frequently lays the foundation of subsequent ill-health, and ultimately
proves fatal through organic disease of the heart and its many
consequences. However, it is an interesting circumstance that while
acute rheumatic inflammation is prone to damage the heart permanently,
it very rarely, quite exceptionally, impairs the structure or functions
of the articulations. It is almost solely the subacute form that now
and then becomes chronic or renders a joint for a long time painful,
swollen, and crippled in its movements. Whether acute rheumatism,
however intense per se, ever ends in destructive suppuration and
ulceration of a joint is doubted by some authorities, notwithstanding
the cases published by Fuller and others. No doubt some of the cases
were really pyæmic, or perhaps gonorrhoeal; and it must be borne in
mind that acute articular rheumatism occasionally develops pyæmia, and
then an arthritis might be considered rheumatic when truly pyæmic. The
question of acute rheumatic arthritis exciting a chronic rheumatoid
affection will arise hereafter.
[Footnote 127: See an article on the mortality among rheumatic risks by
A. Huntingdon, M.D., in _N.Y. Medical Record_, 1875, p. 195.]
TREATMENT.--Owing to our imperfect knowledge of the real nature of
acute articular rheumatism, its treatment is still largely either
empirical or intended to combat certain prominent symptoms or
complications of the disease. Of the various methods of treatment which
have been employed space will not permit a description; even of those
advocated by authorities of the present hour only very few will be
considered.
The method which is now unquestionably the favorite one in both Europe
and America, and which in its power of promptly relieving the articular
and muscular pains and reducing the fever of acute rheumatic
polyarthritis may without exaggeration be compared to that exercised by
quinia over the paroxysms of ague, is that in which salicylic acid or
salicylate of sodium is given in repeated and full doses. It was in
July, 1875,[128] that Buss first asserted that salicylic acid was a
specific for rheumatism, and in March, 1876,[129] Maclagan, after
having employed salicine from 1874, published his experience of it as a
valuable remedy in the treatment of acute rheumatism, its beneficial
action being "generally apparent within twenty-four, always within
forty-eight, hours of its administration in sufficient dose." Perhaps a
sufficient time has now elapsed to permit of a just opinion of the
power of these new remedies, the salicyl compounds, over acute
articular rheumatism. The facts presented at the discussion recently
held at the Medical Society of London[130] are sufficiently numerous
and authoritative to justify, at least provisionally, some definite
conclusions as to the remedial relations of the salicylates to acute
articular rheumatism.
[Footnote 128: "Die Antepyr. Wirkung der Salycylsäure," _Centralbl. f.
d. Medic. Wissenschr._, 1875, 276.]
[Footnote 129: _The Lancet_, March 4 and 11, 1876.]
[Footnote 130: _The Lancet_, Dec. 17, 24, 31, 1881; Jan. 7, 14, 28,
1882.]
1. The articular pain and the fever of acute rheumatic polyarthritis
are more or less speedily removed by the salicyl remedies (salicylic
acid, sodium salicylate, and salicine); the pains very frequently
persist after the temperature has become normal. Both symptoms were
removed by five days' use of such agents in 50 per cent., and by eleven
days' use in 80 per cent., of 355 cases treated at Guy's Hospital, and
tabulated by Fagge,[131] and by five days' use in 60 per cent., and by
eleven days' use {52} in 66 per cent., of the 60 severe cases treated
and severely criticised by Greenhow.[132]
[Footnote 131: _Ibid._, ii., 1881, 1031.]
[Footnote 132: _Clinical Society's Transactions_, vol. xiii., 1880. See
Dr. Fagge's table iv., _Lancet_, ii., 1881, 1032.]
Again, in 190 cases of acute and subacute rheumatism the average
duration, under salicyl remedies, of pyrexia was 5.5 days and of joint
disease, 5.3 days (Warner[133]); in 156 cases at St. George's Hospital
the average duration of pyrexia was 3.66 days, of pain 4 days
(Owen[134]); in 82 at the Middlesex the average duration of pyrexia was
5 days, of pain 5.6 days (Coupland[135]); and in 55 at the Westminster
the average duration of pyrexia was 7 days, of pain 7.25
days[136]--that is, a general average duration in the whole series for
the pain and pyrexia of 5.4 days.
[Footnote 133: _Ibid._, p. 1080.]
[Footnote 134: _Ibid._, p. 1081.]
[Footnote 135: _Ibid._, i., 1882, 10.]
[Footnote 136: _Ibid._, ii., 1881, p. 1080.]
Further, 36 per cent. of Fagge's cases and 58 per cent. of Greenhow's
were relieved of both the above symptoms on the fourth day; 24.8 per
cent. of Fagge's and 50 per cent. of Greenhow's on the third day; and
13.5 per cent. of Fagge's and 26.6 per cent. of Greenhow's on the
second day. In Clouston's 27 cases, treated in private, 66.6 per cent.
were free from pain and 59 per cent. from fever within three days, and
85.2 per cent. were devoid of pain and 72.7 per cent. of fever within
four days.[137] Finally, all who have had much experience of this
method of treating acute rheumatism will agree that the first or second
dose frequently relieves the articular pains like a charm, and the
local swelling then frequently subsides in from sixteen to forty-eight
hours.
[Footnote 137: _The Practitioner_, i., 1882.]
2. Relapses are more frequent--probably considerably more
frequent--under treatment by salicylates than under other methods.
Thus, the average of relapses in eight different tables of cases
treated by the salicyl remedies ranged from 16.6 per cent. to 35 per
cent., giving a general average of 26 per cent.;[138] while under other
methods in three different tables the average ranged from 5.4 per cent.
to 27.6 (this last under the full alkaline), giving a general average
of 16 per cent.[139] Relapses appeared to recur less frequently in
those cases which yielded to the salicylates within five days than in
those which took from six to eleven days to yield, in the ratio,
according to Fagge's figures, of 26.6 per cent. for the first, and 29.4
per cent. for the second day; and, according to Hood's, as 18.4 per
cent. to 24.4 per cent. There does not appear to be any regularity in
the order of occurrence or recurrence of relapses, nor is Southey's
definite statement that in "relapsing cases the temperature is nearly
or quite normal on the eighth evening, and a slight relapse occurs on
the thirteenth morning," borne out by the statistics produced at the
London Medical Society. Moreover, W. Carter's cases[140] have not
confirmed Southey's precise statement respecting the gradual remission
of the temperature on the eighth and ninth days of illness in the
continued or non-relapsing, uncomplicated forms. Irregularity and
inconstancy are the typical features of articular rheumatism. The
relapses under the treatment by the salicylates have been referred to
the premature disuse of those remedies, but they do occur
notwithstanding {53} the continued employment of them. It is a general
opinion that exposure to cold, errors in diet, and an early return to
work are frequent causes of relapse; and Broadbent refers the increased
liability to relapse under the salicyl compounds to the rapidity with
which those remedies relieve the acute symptoms of articular
rheumatism, in consequence of which sufficient care is not observed
either by the patients or their nurses, and they are exposed to some of
the above exciting causes of relapse. All the above causes do probably
play their part so long as the materies morbi (if that really exist
either as a chemical principle or as a germ) has not been wholly
eliminated or destroyed. Indeed, the short intervals which frequently
obtain between the primary invasion of the so-called relapses, and the
failure of the salicyl compounds to prevent peri- and endocarditis,
render it probable that what are commonly spoken of as relapses are not
due to a new infection, as in the case of the relapse of typhoid fever,
but to the recrudescences of a disease not yet terminated, but over
some of the manifestations of which--the articular inflammation and the
pyrexia--the salicylates exercise some control.
[Footnote 138: Fagge's, 26.2 per cent.; Greenhow's, 35; Warner's, 33.6;
Owen's, 30.2; Hood's, 18.8; Coupland's, 35.3; Broadbent's, 16.6;
Powell's, 18.7; total, 214 ÷ 8 = 26 per cent.]
[Footnote 139: Hood's, 5.4; Warner's, 14.9; Owen's, 27.6; total, 47.9 ÷
3 = 16 per cent.]
[Footnote 140: _The Liverpool Med.-Chirurgical Journal_, July, 1881, p.
101.]
3. Authorities are generally agreed that the salicyl compounds do not
arrest or control rheumatic inflammation of the endo- or pericardium or
pleura, or subdue the pyrexia, if these complications in well-marked
degree exist; and there is strong evidence to show that they do not at
all constantly prevent the disease from involving those organs, even
after the articular affection has subsided under their use. Inestimable
as is the benefit conferred by these remedies in promptly relieving the
articular pain and fever, they do not secure the great desideratum in
the treatment of acute articular rheumatism--protection of the heart.
In 352 cases treated with salicylate of soda at the Westminster
Hospital, heart disease developed in 13.6 per cent.; in 267 treated
without the salicylate, heart disease developed in 14.2 per cent.
(Warner's cases).[141] In 350 cases treated with salicylates at Guy's,
heart complications obtained in 68 per cent., while in 850 treated
without them, the cardiac complications occurred in 58.8 per cent.
(Hood).[142] Gilbart-Smith collected a large number of cases from
several of the London hospitals, and analyzed them with the following
results: Of 1727 cases of acute rheumatism treated before the
introduction of the salicyl compounds, the proportion of cardiac
complications was 54.4 per cent.; in 1748 cases treated subsequently to
their introduction, the cardiac affections obtained in 63.4 per cent.;
and in 533 cases treated by the salicyl compounds, those affections
obtained in 68.4 per cent.[143]
[Footnote 141: _The Lancet_, ii., 1881, 1080.]
[Footnote 142: _Ibid._, ii., 1881, 1120.]
[Footnote 143: _Ibid._, i., 1882, 136.]
These facts certainly seem to prove that the salicyl compounds do not
prevent the occurrence of the visceral complications or manifestations
of acute articular rheumatism; and if space permitted instances might
be quoted from many authors in which either endo- or pericarditis or
pleuritis or pneumonia or other visceral manifestation had set in after
the patient had been taking the salicylates long enough to have
produced their usual physiological effects; some of these will be
mentioned under the next section.
It may be objected that in the above estimates sufficient attention has
not been paid to the period of the disease at which the treatment by
the {54} salicylates was begun, the time it was continued, the doses
given, the age of the patient, the severity and other characters of the
illness, such as whether acute or subacute, first or second attack,
complicated or not.
4. It must be admitted that there are a few facts which render it very
probable that the salicyl compounds do really reduce the frequency of
these complications, and thus give some protection to the heart in
rheumatism. Of Powell's 32 cases, 19 = 60 per cent. had heart disease
when admitted; and of the remaining 13, 6 = 46 per cent. developed
cardiac disease after admission and while under the salicylates.[144]
Of Dr. Jacobi's[145] 150 cases, 78 = 52 per cent. were admitted with
unsound hearts, and of the other 72, only 5 = 6.9 per cent. developed
cardiac disease after beginning salicylate treatment. Of Southey's 51
cases, 24 = 47 per cent. were admitted with diseased hearts; and of the
remaining 27, only 4 = 14.8 per cent. developed a cardiac affection
subsequent to beginning treatment by the salicylates.[146] Of the
Boston Hospital cases, 38 per cent. were affected with heart disease at
entrance, and only 4.76 per cent. afterward. No heart affection was
developed in any of Clouston's 27 private cases--a result he attributes
to the early period at which the remedies are given in private
practice. But the number is too small to permit of any conclusion being
drawn, and 4 of the cases were examples of recurrence of the disease at
short intervals (three and four weeks) in the same patient, in whom
there appears to have existed no proclivity to cardiac complication,
for he had had four attacks before he came under Clouston's care.
Moreover, his cases were mild, but 16 of them being acute, and of these
only 3 attaining a temperature of 103° and upward. Finally, Herman[147]
estimates the percentage of heart affections that developed after
beginning the salicylates in the London Hospital at 18.7 per cent., and
after other treatment at 30 per cent. Omitting Clouston's, the general
average of the above results is, that in 49.2 per cent. cardiac disease
existed before the patients began the salicyl treatment, and that in
18.2 per cent. it developed after that, while 30 per cent. of cardiac
disease developed after other methods of treatment were begun.
[Footnote 144: _Lancet_, i., 1882, 134.]
[Footnote 145: _St. Thomas's Hospital Reports_, New Series, viii. 252.]
[Footnote 146: _St. Bartholomew's Hospital Reports_, xvi. 10.]
[Footnote 147: Quoted by T. G. Smith, _Lancet_, i., 1882, 137.]
The subject is one beset with difficulties, and still needs
investigation. It is reasonable to infer that as the salicylates
promptly arrest the articular inflammation and allay the fever of
uncomplicated acute rheumarthritis, they will prevent the visceral
inflammations so apt to develop when the disease runs its course
uninfluenced by treatment; but experience has shown that they do not
control or arrest rheumatic inflammation of the heart or pleura or the
attending pyrexia, although capable of subduing the articular
inflammation and the pyrexia that accompanies it. The most eminent
therapeutists are divided on the subject. Maclagan, while admitting
that the salicyl compounds do not ward off cardiac complications, or
cure them when they exist, maintains that their existence is an
additional reason for giving those remedies freely and in large
doses.[148] Broadbent,[149] while believing in the protective influence
of the salicylates "when brought to bear upon the fever in the first
days of its existence," finds in the presence of any cardiac
inflammation a reason for at once discontinuing those remedies.
Flint[150] believes that rheumatic endo- and {55} pericarditis are more
common since the introduction of the salicyl treatment than when the
alkaline method was relied upon almost entirely, and advises[151] the
administration of alkalies with the salicylates to protect the heart.
Vulpian[152] thinks the protective power in question probable, but not
established; while the latest French authority, Homolle, is of opinion
that "cardiac affections are really less frequent in patients treated
by salicylate of sodium than in others."[153]
[Footnote 148: _Lib. cit._, pp. 266, 275.]
[Footnote 149: _Lancet_, i., 1882, 138.]
[Footnote 150: _New York Med. Record_, 1882, 66.]
[Footnote 151: _Pract. Med._, 5th ed., 1098.]
[Footnote 152: _Du Mode d'Action du Salicylate du Soude dans le
Traitement du Rheum. Artic. Aigue_, Paris, 1881, 11.]
[Footnote 153: _Nouveau Dict. de Méd. et de Chir._, xxxi., 1882, 648.]
5. The occurrence of hyperpyrexia is not always prevented by the
salicyl remedies, even when they have produced their full physiological
effects. Fagge endeavors to explain away the two cases of hyperpyrexia
which occurred under Greenhow and the other two which happened amongst
the cases tabulated by himself, and remarks that if the temperature
should begin to fall under the use of salicylic acid, and then should
change its course and rapidly attain a dangerous height, that would
really show that the drug is sometimes incapable of preventing the
occurrence of hyperpyrexia. This actually happened in one of Powell's
two cases,[154] and the patient died suddenly at a temperature of 107°.
In Greenhow's first case the patient had been taking the salicylate for
four days, and was deaf and delirious when the temperature became
105.8°.[155] Finney reports a case in which drachm iss of salicine were
given daily for two days, and drachm ij on the third day, when
pericarditis set in, and on the fourth day hyperpyrexia
supervened.[156] Haviland Hall records an instance in which the
temperature fell from 103.5° to 100.6° after twenty-grain doses of
salicylate soda, every three hours, taken for two days; on the third
day the medicine was given every four hours; the temperature rose in
the evening to 103.4°, and on the next day it rose rapidly to 108.7°,
and the patient became delirious. Patient recovered rapidly after two
baths.[157]
[Footnote 154: _Lancet_, i., 1882, 135.]
[Footnote 155: _Clin. Soc. Trans._, xiii. 264.]
[Footnote 156: _Brit. Med. Journ._, ii., 1881, 932.]
[Footnote 157: _Lancet_, ii., 1881, 1082. See also two cases in _Med.
Times and Gaz._, ii., 1876, 383.]
Pericarditis is not always present when hyperpyrexia arises during the
administration of salicylic acid; it was absent in Powell's cases, is
not mentioned in Hall's, and did not ensue in one of Greenhow's until
two days after the temperature had reached 105.4° F. However, either
pericarditis or pneumonia is very frequently present when the
temperature is excessive. It is generally admitted that the salicylates
do not control rheumatic hyperpyrexia once it exists.
6. Notwithstanding the prompt removal of the pain and reduction of the
fever by the salicyl compounds, the average duration of acute articular
rheumatism is not very considerably lessened by those remedies. Thus,
of Hood's[158] 350 cases treated by salicylates the average duration of
the illness was 35.95 days as against 38.75 under other methods. The
average time spent in bed by Warner's 342 cases was 19.5 days under the
salicylates, and by 352 patients under other remedies 23.5 days. Both
estimates show a curtailment of the duration of the disease by the new
treatment of three to four days only; which is not a very material
improvement.
[Footnote 158: Calculation from Dr. Hood's Tables 1 and 1_a_, _Lancet_,
ii., 1881, 1119.]