corn-meal or oat-meal gruel, milk, and barley-water, or even pure milk.
Where persons will not take milk the various thin animal broths to
which good barley-water or arrowroot or well-boiled rice has been
added, jellies, sago and other starchy puddings, may be allowed.
Suitable drinks are--plain water, Seltzer and Apollinaris water,
carbonic-acid water, lemonade. This low, unstimulating diet should be
observed until all fever and articular inflammation have subsided, the
tongue become clean, and the visceral inflammations declined, and a
return to solid food, and especially to animal food, should be made
cautiously. Eggs are to be regarded as of very doubtful safety in this
disease. As a very general rule, ales, wines, and the stronger
alcoholic liquids are objectionable, but they may be required under the
same conditions as in other fevers. Should the salicylates depress the
heart, old wine or whiskey may be given with advantage.
During convalescence the patient should not be permitted to leave his
bed for several days after complete removal of the fever and articular
pain, and for the first four days he should occupy a sofa or
easy-chair. Premature walking may induce relapse. An occasional
alkaline or sulphur bath, if cautiously taken, sometimes appears to
complete the recovery. If endocarditis have existed, a longer rest is
desirable, more especially in severe cases, in order that the
reparative process going on in the lately inflamed valves may not be in
the least disturbed.
Chronic Articular Rheumatism,
synonymous with rheumarthritis chronica, rheumatisme articulaire
chronique simple (Besnier), polyarthritis synovialis chronica (Heuter),
is defined here as a chronic idiopathic inflammation of one or a few
articulations, which is more prone to become fixed than the acute form,
and which, notwithstanding its protracted duration, produces no
profound structural alterations in the joints.
ETIOLOGY.--It may be the direct sequel of a single attack or more {70}
commonly of several attacks, of acute, or more especially of subacute,
articular rheumatism. But it is generally a primary affection,
occurring in persons who have not had either acute or subacute
rheumarthritis, yet owning the same causation as these, and
occasionally in its course exhibiting acute or subacute symptoms. The
specially predisposing conditions are inheritance; repeated attacks of
subacute or acute articular rheumatism, which in accordance with
general laws impair the resisting power of the affected joints;
prolonged residence or employment in cold, damp, or wet rooms or
localities; repeated exposure to bleak, cold currents of air or to
frequent wettings of the body or lower limbs. For these reasons it is
most common amongst the poor, who are especially exposed to the
influences just mentioned; and amongst them cellar-men and sailors,
washerwomen and maid-servants, are very liable to the disease. It is
chiefly an affection of advanced life, or at least of mid-age, and is
rare in youth. The first attacks, and especially exacerbations, are apt
to be induced by the direct action of a draught of cold air or by
unusual exposure to cold and damp air, especially when the body has
been fatigued or overheated. In many cases no distinct exciting cause
can be traced.
The morbid anatomy of simple chronic articular rheumatism will vary
with the severity and duration of the disease. The alterations are such
as chronic inflammation of a non-suppurative character might be
expected to produce in the joints by one who had learned those
characteristic of acute rheumarthritis. In the simple chronic form the
proliferating process involves chiefly the synovial membrane, the
capsular and other ligaments, and the periarticular tissues; to a less
degree the cartilages, and to a much less degree, and exceptionally,
the osseous surfaces. The synovial membrane is thickened, slightly
injected, and its fringes hypertrophied and more vascular than
normally. Little fluid usually exists in the joint unless during an
exacerbation, when a moderate amount of thin, cloudy serum may be
present; generally only a trace of thick, turbid fluid, containing
oil-globules, and in severe cases débris of the cartilages, but no pus,
is found. The fibrous capsule and ligaments become thickened, dense,
and stiffened by hyperplasia; and sometimes the adjacent tendons and
their sheaths, the fasciæ and aponeuroses, undergo similar alterations,
so that the movements of the joints become seriously interfered with.
In some cases this irritative hyperplasia specially involves these
periarticular fibrous structures, and these, undergoing retraction,
produce marked deviations, subluxations, and deformities of the
articulations very like those observed in rheumatoid arthritis,
although the osseous components of the joints are unaffected. Jaccoud
gave to such cases the title of chronic fibrous rheumatism.[211] It is
worth noting that Jaccoud's, Charcot's,[212] and Rinquet's[213] cases
of so-called "chronic fibrous rheumatism" developed out of acute
articular rheumatism, while Besnier's was primarily chronic. In simple
chronic rheumatism, if protracted, the cartilages also proliferate,
lose their semi-transparency and polish, and become opaque and white;
they are often rough and traversed by fissures, and occasionally
present erosions; and these erosions {71} are either naked or covered
with a layer of newly-formed connective tissue, which may occasionally
produce fibrous adhesions between the articular surfaces. Points of
calcification occur in the cartilages and tendons in very chronic
cases. Instances are observed in which the bones exhibit, to a slight
degree, the alterations found in rheumatoid arthritis, and are probably
transitional between the two affections. The muscles which move the
affected articulations in severe cases are often atrophied, and the
wasting imparts to the joints an appearance of considerable
enlargement.
[Footnote 211: Vide Jaccoud, _Clin. Méd. de la Charité_, 23e Leçon,
Paris, 1867.]
[Footnote 212: Besnier, _Dictionnaire Encyclopéd., etc._, t. iv., p.
680 _et seq._]
[Footnote 213: _Du Rheum. Artic. Chronique, etc._, par Martial Rinquet,
Thèse, Paris, 1879, pp. 28-33.]
SYMPTOMS AND COURSE.--Simple chronic articular rheumatism presents many
varieties. In the milder forms the patient experiences trifling or
severe pain in one, or less frequently in two or more, joints, more
especially in the knee or shoulder, or both, attended with want of
power in the member or with stiffness in the affected articulation. The
pain frequently is likewise felt in the soft parts, muscular and
tendinous, near the joints, and is usually increased by active or
passive movement; it is not always accompanied by tenderness, and
rarely with local elevation of temperature or swelling. The wearying
aching in the joint is of an abiding character, but is very liable to
exacerbations, especially at night; and these come on just before
atmospheric changes, such as a considerable fall of temperature, the
approach of rain, variations in the direction of the wind, etc., and
they usually continue as long as the weather remains cold and wet. A
very common symptom is a creaking or a grating which may be felt and
heard during the movements of the joint.
The above symptoms may rarely prove more or less constant by night and
day for years, but far more frequently, at least at first, they last an
indefinite period and disappear to recur again and again, especially in
the cold and changeable seasons of the year. Although in the earlier
attacks, and often for a long time, no alteration of structure is
perceptible in the painful joints, yet in some instances slight
effusion into the articulation may be observed during the
exacerbations, or the capsule and ligaments may at length become
slightly thickened, or the muscles may waste and produce an apparent
enlargement of the joint; and this prominence of the articular surfaces
may be increased by retraction of the tendons and aponeuroses--a
condition which causes real deformities (deviations, subluxations,
etc.) of the articulation and impairs more or less its movements. In
very chronic cases a fibrous ankylosis may be established.
These last-mentioned conditions often entail great and long-continued
suffering, and may even cause some anæmia and general debility; but
very frequently the general health and vigor continue good,
notwithstanding the permanent impairment of the functions of one or
several of the large articulations, and the liability to exacerbations
often amounting to attacks of subacute rheumarthritis from changes in
the weather, fatigue, or exposure.
Besides the above varieties may be mentioned a not infrequent one
consisting of a series of attacks of subacute articular rheumatism
recurring at short intervals, involving the same joints, and attended
with slight elevation of temperature, febrile urine, perspiration, and
moderate local evidences of synovitis, heat, pain, tenderness,
swelling, and effusion into the affected joints. This is an obstinate
variety, and is often associated with rheumatic pain in the muscles and
fibrous tissues of the affected member.
{72} Simple chronic articular rheumatism, like the acute form, is most
apt to affect the larger articulations, knees, shoulders, etc., but it
frequently also involves the smaller ones of the hands and feet.
Although usually polyarticular, it is prone to become fixed in a single
joint, but even then it may attack several other articulations, and may
migrate from one to another without damaging any.
The course of the disease is usually one of deterioration during
persistent or recurring attacks, and in many cases the intervals of
relief become shorter and less marked; the joints become weaker and
stiffer; and although the pain may not increase and the general health
may not be seriously impaired, yet the patients may continue for many
years or the rest of their lives severe sufferers, unable to work, and
often hardly able to walk even with the aid of a stick. Occasionally,
after several years of pain and weakness, a sudden or slow improvement
may set in and the patient become free from pain and lameness, and only
experience some stiffness in the movements of the joints after several
hours of rest, and slight thickening of the ligaments and capsule of
one or more articulations. The duration of the disease is indefinite;
the danger to life trifling.
The complications of simple chronic articular rheumatism are held by
many, and especially by those who regard the disease as constitutional
or diathetic, to be the same as those of the acute form, and that they
may precede, follow, alternate, or occur simultaneously with the
articular affection. All admit that they are observed much less
frequently in the former than in the latter. Other pathologists either
deny the occurrence of the visceral complications (Senator, Flint) or
do not mention them (Niemeyer). It is not denied that cardiac disease
may be found in chronic articular rheumatism which has succeeded the
acute form, and which may then be referred to the acute attack. The
tissue-changes then set up may not have produced at the time the
murmurs indicative of endocarditis, but these tissue-changes may have
ultimately roughened the endocardium, puckered a valve, or shortened
its cords, so that cases of chronic articular rheumatism having a
history of an acute attack cannot be safely included when inquiring
into the influence of the chronic form upon the heart or other internal
organ. Attention has not been sufficiently given to ascertain the
frequency of the occurrence of these complications in primary chronic
articular rheumatism, and reliable evidence is not at hand. It is not
unlikely that the chronic form may slowly develop cardiac changes, as
the acute form rapidly does; but when the advanced age of the persons
most liable to chronic rheumatism is borne in mind, it must be admitted
that valvular and arterial lesions (endarteritis) are observed at such
periods of life independently of rheumatism, and referable to such
causes as repeated muscular effort, strain, chronic Bright's disease,
senile degeneration, etc. Somewhat similar observations are applicable
to the attacks of asthma, of subacute bronchitis, of neuralgia, and of
dyspepsia, which are frequently complained of by sufferers from simple
chronic rheumarthritis. Such affections are common in elderly people in
cold and damp climates; they may be mere complications rather than
manifestations of rheumatism, or outcomes of the confinement and its
attendant evils incident to chronic articular rheumatism, as is
probably the relationship of the dyspepsia. There is {73} no doubt of
the frequent coexistence of muscular rheumatism with this variety.
DIAGNOSIS.--Simple chronic articular rheumatism may be confounded with
rheumatoid arthritis, with the articular affections of locomotor ataxia
and other spinal diseases, with chronic articular gout, with syphilitic
and with strumous disease of the joints. The reader may consult the
observations made on four of these affections in connection with the
diagnosis of rheumatoid arthritis. A few additional remarks are called
for in distinguishing chronic articular rheumatism from chronic
articular gout, which is often a very difficult problem. Both are apt
to be asymmetrical in distribution, to have paroxysmal exacerbations,
to recur frequently without damaging the articulations, to have been
preceded by acute attacks of their respective affections, and to be
uncomplicated by endo- or pericarditis. But chronic rheumarthritis has
no special tendency to attack the great toe; it is more persistent than
gouty arthritis; it does not, even when of long standing, produce the
peculiar deformities of the articulations or the visible chalk-like
deposits in the ears or fingers observed in chronic gout. The etiology
of the two diseases is dissimilar. There is no special liability to
interstitial nephritis in articular rheumatism, nor is urate of soda
present in the blood in that disease.
In chronic strumous or tubercular disease of a joint the youth, the
personal and family history, and sometimes the evident defective
nutrition, of the patient; the moderate degree of local pain compared
with the considerable progressive and uniform enlargement of the joint;
the evident marked thickening of the synovial membrane, either early or
late according as the disease has originated in the synovial membrane
or in the bones; the continuous course, without marked remissions or
exacerbations, of the disease; the rarity with which more than one
joint is affected; and the tendency to suppuration, ulceration, marked
deformity, and final destruction of the joint,--will prevent the
disease from being mistaken for chronic rheumatism.
The PROGNOSIS in simple chronic rheumarthritis is unfavorable as
regards complete recovery, and it is chiefly while comparatively
recent, and when the sufferer can be removed from the conditions
productive of the disease, that permanent improvement, and sometimes
cure, may be expected. As a rule, the disease once established recurs.
It does not, however, endanger life.
TREATMENT.--All are agreed that hygienic treatment constitutes an
essential, if not the most valuable, part of the curative and
palliative management of chronic rheumarthritis. A dry and uniform
climate is the most suitable, and there is much evidence in favor of a
dry and warm rather than a dry and cold climate. Protection of the body
against cold and damp by means of flannel next the skin, sufficient
clothing, residence in dry and warm houses, etc., is of prime
importance. In fact, all the known or suspected causes of the disease
should be as far as possible removed.
The direct treatment of the disease resolves itself into general and
local, and is essentially the same as that recommended for rheumatoid
arthritis, to which subject the reader is referred. A few observations
only need be made here. Although, like everything else in chronic
rheumarthritis, it often fails, no single remedy has in the writer's
{74} experience afforded so much relief to the pain and stiffness of
the joints as the sodium salicylate; and he cites with pleasure the
confirmatory testimony of J. T. Eskridge of Philadelphia,[214] of whose
28 cases 75 per cent. were decidedly benefited. Jacob of Leeds also
reports some benefit in 75 per cent. out of 87 cases treated by the
same agent.[215] It must be given in full doses, and be persevered
with. Salicylate of quinia should be tried if there be much debility or
if the sodium salt fail. Propylamine or trimethylamine is deserving of
further trial in this disease. From 100 to 200 grains are given in the
day in peppermint-water. Iodide of potassium, cod-liver oil, arsenic,
iodide of iron, and quinia are all and several remedies from which more
or less benefit is derived in chronic articular rheumatism. The
combination of iodide of potassium with guiaiac resin--gr. ij-iij of
each three times a day in syrup and cinnamon-water--is sometimes very
useful. The writer has no experience of the bromide of lithium
(Bartholow). When the skin is habitually dry and harsh a dose of
pilocarpine every other night for a few times will often prove very
useful.
[Footnote 214: _Phila. Med. Times_, vol. ix. pp. 75-77, 1878, and _The
Medical Bulletin_, Phila., July, 1879, pp. 44-48.]
[Footnote 215: _Brit. Med. Jour._, ii., 1879, 171.]
Cod-liver oil, iron, quinia, etc., the various forms of baths and
mineral waters, electricity, and the several local measures recommended
for the treatment of rheumatoid arthritis, are all occasionally very
useful in, and constitute the appropriate treatment of, simple chronic
articular rheumatism. The dietetic management of the two affections
should be the same.
Muscular Rheumatism.
SYNONYMS.--Myalgia rheumatica or myopathia; _Fr._ Rheumatisme
musculaire; _Ger._ Muskelrheumatismus.
DEFINITION.--The affections included under this term are certain
painful disorders of fibro-muscular structures. They are commonly found
in persons the subjects of the rheumatic diathesis, and are
characterized by pain and often spasm, and sometimes a slight degree of
fever. No doubt as our knowledge increases so many attacks connected
with painful states of muscles and fasciæ are eliminated from the
somewhat uncertain group of muscular rheumatism. True inflammation is
not believed to exist, and pathological investigation has rarely shown
any morbid changes in the affected parts. The symptoms, therefore, have
been attributed to some temporary hyperæmia, slight serous exudation,
or neuralgic state of the sensory nerve-filaments. The strongest
support is given to this statement from the absence of any marked
tenderness in such affected muscles as can be sufficiently examined. In
certain cases, undistinguishable clinically, it is quite probable that
a periarthritis is in reality the principal factor in the case. In
others, again, a subacute rheumatism affecting a joint seems to spread
to the adjoining tendinous sheaths, and thus secondarily to attack the
muscles themselves, the affection of which may ultimately remain the
only condition present.
ETIOLOGY.--Muscular rheumatism is a very common affection. All ages are
liable to its occurrence, but the part affected varies with the time
{75} of life, children and young adults being much more subject to
torticollis, and older persons to lumbago and general rheumatism of the
limbs. Amongst hospital patients the disease prevails more amongst men
than women, owing doubtless to the greater exposure of the former to
the cold; but amongst other classes the same difference is not seen. It
is observed in all countries, but according to some writers it is
unusually frequent in tropical climates, although there acute
rheumatism is very uncommon. The causes of muscular rheumatism are
mainly exposure to cold and strain or fatigue of muscles. If these two
conditions coexist--_e.g._ standing in a draught of cold air or lying
on the ground when fatigued--the chances of the affection coming are
greatly enhanced. Strain, a twist of the body, or a false step can
actively start an attack of this kind, and by the sufferers themselves
it is constantly attributed to this cause. The part played by this
element is difficult to determine, a very slight strain being often
followed by great pain and distress from the subsequent rheumatic
affection. Some individuals are specially prone to attacks, the
slightest current of air, change of clothing, etc. being sufficient to
determine its occurrence. These persons are often found to have
suffered from rheumatism in some other form, and thus in them we must
consider that the rheumatic diathesis furnishes the reason for their
unusual susceptibility. It only remains to mention the fact that a
disposition to gout seems to favor the development of muscular
rheumatism. In gouty families, therefore, it has been observed to be
common.
SYMPTOMS.--In all cases pain is the prominent, and in many cases the
only, symptom present. In all except the more aggravated attacks pain
is felt only when the affected part is disturbed. In such when complete
rest or fixed immobility is maintained there is comfort, or at most a
somewhat dull, uneasy sensation, but when any contraction of the
muscles in question is produced, whether voluntary or otherwise, severe
often excruciating pain is at once experienced, often giving rise to a
sudden cry or causing the features to be contracted in a grimace. The
suffering ceases almost at once when the muscular contraction is
relaxed. In more aggravated attacks the pain is more severe, and
besides persists, though to a less degree, even when there is no
contraction. In rare cases when the maximum degree has been attained
there is continuous pain, but the affected muscles are persistently
maintained in a relaxed condition by means of true spasm in the
surrounding muscles. Slow passive movement affects the subject of
muscular rheumatism, and may often be accomplished with a little
management without causing pain. If, at the same time, these muscles be
handled by pinching and slight pressure, it will be found that they are
very sensitive to the touch. When some tenderness does exist, it is
slight and is not located in the district of the lower nerve-trunks.
Pressure even sometimes allays pain. The constant effort to avoid pain
gives rise to a feeling and appearance of stiffness, and thus
characteristic attitudes and positions of the head, trunk, or limbs are
voluntarily and persistently maintained. There is no spasm of the
affected muscles; the distortion is the result of stiff contraction of
the associated muscles, which thus forcibly fix the faulty one and hold
it in a state of relaxation. Cramp or spasmodic contraction of a single
muscle of a painful character does, however, sometimes occur in
rheumatic subjects, and much resembles the condition above described.
In {76} the same persons also muscular rheumatism may occur in a much
more fugitive or erratic form, frequently being nothing more than a
slightly painful condition of some group of muscles which have in some
way been exposed to cold. This may last but a short time, and either
spontaneously disappear or be readily removed by exercise or friction.
Muscular rheumatism is generally confined to one muscle or a single
group of muscles. Those most liable to it are the very superficial and
those easily exposed to cold (_e.g._ the deltoid and trapezius),
powerful muscles often subjected to violent strain (_e.g._ the lumbar
muscles), and those aiding in the formation of the parietes of the
great cavities.
This affection very commonly exists without any constitutional
disturbances, but sometimes there are present the symptoms of
pyrexia--slight elevation of temperature and temporary disorder of the
digestive organs--loss of appetite, constipation, and general malaise.