subsidence and final disappearance of the pain. The fugitive kind,
already alluded to, may, however, be present more or less during
several weeks.
DIAGNOSIS.--Errors of diagnosis between muscular rheumatism and a
variety of other disorders are common. Laymen especially are only too
apt to attribute pain felt in muscles at once to rheumatism of these
muscles--a term which is badly abused. Some of these errors are of no
great interest, but others are of the highest importance, for they may
cause the onset of a serious disease to be overlooked. The principal
affections to be borne in mind with reference to diagnosis are the
following: organic diseases of the spinal cord (notably tabes
dorsalis), causing peripheral pains as an early symptom; functional
disorder of the same part, as hysteria or spinal irritation;
intra-thoracic inflammation; the onset of an exanthem; the pains
produced by the chronic poisoning of lead and mercury; neuralgia;
painful spasm of muscle from deep-seated inflammation or suppuration.
It is sufficient to indicate these various sources of fallacy, which,
if remembered, can generally be guarded against by a consideration of
the special features characteristic of each one.
TREATMENT.--The indications for the treatment are mainly two--viz. to
relieve the pain and to counteract the diathetic condition generally
present. The relief of the pain is accomplished in various ways,
according to the seat of the trouble. In severe cases it is proper to
resort to the hypodermic use of morphia, to which may be advantageously
added some atropia. When the pain is seated in large muscles, the
injection will produce better results if thrown not merely under the
skin, but into the substance of the muscle. Sometimes perfect rest in
bed is necessary to secure the required immobility; in other cases this
can better be secured by plaster or firm bandages. Soothing anodynes
are extremely useful locally, and counter-irritants also may be used
with benefit. Liniments give us a convenient form of application. The
best are those containing a considerable proportion of chloroform with
either aconite or belladonna, or both. The repeated application of
tincture of iodine often gives great relief. Galvanism sometimes proves
a rapid cure. Continuous heat is nearly always grateful, and may be
applied either in the dry form or by means of soft warm linseed
poultices with or without a {77} percentage of mustard. When these are
discontinued, care should be taken to protect the affected muscles from
cold by keeping them enveloped in flannel or woollen coverings.
Whilst these local measures are being adopted the constitutional
disorder should also receive attention. A diaphoretic action should be
set up. For this purpose the hot-air or Turkish bath at the outset
would seem to be sometimes really abortive. Of medicinal means amongst
the most reliable are liquor ammonii acetatis and Dover's powder.
Pilocarpine occasionally proves useful. The fixed alkaline salts are
also sometimes beneficial, such as the acetate and citrate of potassium
and, at a later stage, the iodide of potassium. In a certain number of
cases of muscular rheumatism the sodium salicylate acts promptly and
well. This drug will succeed well in proportion as the evidence of the
rheumatic constitution is well marked, as shown by the tendency on
other occasions to attacks of acute articular rheumatism.
Persons who are subject to muscular rheumatism should be made to wear
warm clothing, avoid draughts, guard against strains and twists, and in
other respects to be careful of their general hygiene. Obstinately
recurring cases will very often receive benefit from a visit to some of
the natural springs known to possess antirheumatic qualities.
The chief varieties of muscular rheumatism, divided according to the
locality affected, require some separate description.
1. Lumbago, or myalgia lumbalis, is that common form which attacks the
lumbar muscles and the strong aponeurotic structures in connection with
these. It is more frequently than any other form attributed to some
effort of lifting or sudden twist of the trunk, but in many cases it
owes its origin directly to exposure to cold. The pain comes on
suddenly and renders the person helpless, the body, if he is able to go
about, being held stiffly to prevent any movement or bending; if
severe, he is absolutely compelled to observe complete rest in bed. The
muscles, when handled, appear slightly sore, but no local point of
acute tenderness can be found. This fact, with the characteristic
shrinking from any movement, distinguishes lumbago from neuralgia and
from abscess. Pain in the loins, more or less severe, is such a
frequent accompaniment of disorder of several organs and parts that
careful examination should always be instituted lest some serious
organic disease with lumbar pain as a symptom be mistaken for a simple
lumbago. The most important of these are perinephritis, lumbar abscess,
spinal disease, abdominal abscess, and disease of the rectum and
uterus.
2. Pleurodynia, myalgia pectoralis or intercostalis. Here the affected
muscles are the intercostals, and in some cases the pectorals as well.
Spasmodic pain is felt in one or other side of the chest, and is
especially aggravated by the movements of respiration; it is rendered
intense by the efforts of coughing or sneezing. Pleurodynia may be
confounded with pleurisy, the distinguishing features being the absence
of fever and the friction sound of pleurisy. Intercostal neuralgia is
sometimes with difficulty known from pleurodynia, but in the former the
pain is more circumscribed, more paroxysmal, and more easily aggravated
by pressure than in pleurodynia, and when severe there are tender
points in the course of the nerve a little outside of the middle line
posteriorly (dorsal point) and anteriorly (sternal point). Now and then
the hyperæsthetic {78} areas become anæsthetic, and even patches of
herpes may form in the course of the nerve, when doubt can no longer
remain. From periostitis of a rib pleurodynia may be known by the fact
that in the one the tenderness is marked in the intercostal space, and
in the other in the rib itself. Pleurodynia is a frequent accompaniment
of thoracic affections, causing cough, the frequent paroxysms of
coughing tending to induce a painful state of the overworked muscles.
The pain, which may be very great, can often be controlled by fixing
the chest with imbricated plaster or a firm bandage. Dry cups sometimes
answer very well; if more active measures are necessary, then
hypodermic injections of morphia must be resorted to.
3. Torticollis, myalgia cervicalis, stiff neck or wry neck, caput
obstipum. This term includes those cases of rheumatic idiopathic
affection of one or more of the muscles of the side and nape of the
neck, which fixes the head firmly in the median line or else in a
twisted fashion, with the face turned toward the sound side. The
disease can be recognized at a glance by the peculiar manner in which a
person will turn his whole body round instead of rotating his head
alone. It is much more common in children than in adults. The
sterno-mastoid is the muscle chiefly affected, but any of the muscles
of the neck may become rheumatic in the same way, and frequently
several of them suffer at the same time. The most important point at
the outset of an attack of wry neck is to determine whether we have to
do with a true rheumatic (idiopathic) disorder, or whether the muscular
stiffness is secondary to some spinal or vertebral lesion. The
diagnosis is usually founded upon the suddenness of the onset, the
absence of other symptoms of nerve disease, and the rapid course of the
case, terminating in a cure in a few days. There is nothing special in
the treatment of torticollis beyond what has been already said under
the general heading.
Other forms of muscular rheumatism which have received special names
and have been separately described are the following: myalgia
scapularis or omalgia, when the surroundings of the shoulder are
affected; myalgia cephalica or cephalodynia, an affection of the
occipito-frontalis; and abdominal rheumatism, when the external muscles
of the abdomen are involved.
Rheumatoid Arthritis.
SYNONYMS.--Nodosity of the joints (Haygarth); Chronic rheumatic
arthritis, or rheumatic gout (Adams); Arthritis, rheumatismo
superveniens (Musgrove); Goutte asthénique primitive; Arthritis
pauperum; A. sicca; Usure des cartilages articulaires (Cruveilhier);
Arthrite chronique (Lute); Progressive chronic articular rheumatism;
General and partial chronic osteo-arthritis;[216] Arthritis deformans.
[Footnote 216: _Nomenclature of Diseases R. C. Physicians_, London.]
Neither my space nor time will permit of a history of this disease; it
must suffice to say that Sydenham in 1766-69 appears to have first
tersely described it and distinguished it from gout; that in 1800,
Landré-Beauvais in his inaugural thesis made some observations upon the
disease under the title of primary asthenic gout; that in 1804,
Heberden, and {79} more especially Haygarth, in 1805, pointed out some
of the more striking clinical features of this disease, and
distinguished it from both gout and chronic rheumatism under the title
nodosity of the joints. The latter author, in the work mentioned,
claims to have written a paper upon the subject twenty-six years
previously, although it was not published; and to him belongs the merit
of having so described the disease as to have given it a place in
nosology. Incidental allusions were made to the affection in 1813 by
Chomel, in 1818 by Brodie, and by Aston-Key in 1835; in 1833, Lobstein,
and about the same time Cruveilhier, pointed out some of the more
striking characters of the morbid anatomy of the affection. But it is
to Adams of Dublin that we are indebted for the most complete account
of the anatomy and of many of the clinical features of the
disease--first in a paper read before the British Association in 1836,
next in his article on "The Abnormal Conditions of the Elbow, Hand,
Hip, etc.,"[217] and finally in his able monogram "On Rheumatic Gout"
in 1857. The contributions to this subject since that date have been
very numerous as well as valuable from the leading countries of Europe,
and I must not here attempt to assign to each investigator his proper
portion of the work.
[Footnote 217: Todd's _Cyclop. of Anat. and Phys._ (1836-39).]
It may be here remarked that Landré-Beauvais and Haygarth described
more particularly that form of the disease which, beginning in the
small joints of the extremities, tends to extend to the larger joints
in a centripetal way, and to involve many of them--peculiarities which
have given rise to the epithets progressive polyarticular chronic
rheumatism, peripheral arthritis deformans, and which is the form of
the disease usually described by physicians as rheumatic gout,
rheumatoid arthritis, nodular rheumatism, and by the other names just
mentioned. On the other hand, Key, Colles, Adams in his earlier paper,
and R. W. Smith described the disease as it affects the larger joints,
hip, shoulder, or knee, to one or two only of which it may be confined;
and as this variety is frequently observed in elderly persons, and in
them often involves the hip, it is often spoken of as senile arthritis,
malum senile articulorum, morbus coxe senilis, mono-articular arthritis
deformans, partial chronic rheumatism, and has been described by
surgeons rather than by physicians. However, even when beginning in the
hip or shoulder, the disease is apt to involve several of the
intervertebral articulations, and not unfrequently to extend to other
joints than the one first affected, and even to the peripheral joints.
Its progressive and general nature is thus evidenced, whether it invade
from the beginning a single large joint or several symmetrical small
articulations. Finally, on this topic Charcot has insisted that
Heberden's nodi digitorum contributes a special form of the disease
under consideration, and proposes to call it Heberden's rheumatism or
nodosities.[218]
[Footnote 218: _Lectures on Senile Diseases_, Syd. ed., 1881, p. 137.]
Rheumatoid arthritis presents the clinical varieties or groupings of
phenomena just mentioned, at times quite distinctly appreciable from
one another, but sometimes more or less blended, yet even then
manifesting in their periods of invasion and early stages an adhesion
to all of these typical groupings. Charcot has especially dwelt upon
these: 1st, the general or polyarticular and progressive form; 2d, the
partial or oligo- or mono-articular form; 3d, Heberden's nodosities.
{80} 1st. The symptoms and clinical history of general or polyarticular
and progressive rheumatoid arthritis. This is the most common form of
so-called chronic rheumatic arthritis, the classical rheumatic gout, or
rheumatisme noueux, and it may declare itself, as Garrod and Fuller
pointed out, very rarely in an active or acute form, or, as it usually
does, in a chronic and insidious form.
The acute form of rheumatoid arthritis closely resembles the milder
varieties of acute articular rheumatism or the best marked examples of
the subacute form of that disease. But it presents the following
particulars, by which it may generally perhaps, but not always, be
distinguished: while the temperature, the thirst, the furring of the
tongue, the frequency of the pulse, the articular pains and tenderness,
etc., are less developed than in acute articular rheumatism, there is
wanting the profuse and continued perspiration, the early involvement
of the endo- or pericardium in the inflammation, and the prompt
prostration of the strength so commonly witnessed in that disease. On
the other hand, while the rheumatoid affection may involve the larger
joints--knees, ankles, elbows, and wrists--it almost certainly
implicates the smaller joints of the fingers, and often of the toes.
There is apt to be greater effusion into the synovial capsules
(McLeod's capsular rheumatism) and into the synovial sheaths and bursæ
about the affected joints than in ordinary acute or subacute
rheumatism; further, the inflammation does not migrate from joint to
joint, but obstinately persists in several of them, and more especially
in the wrist and in the metacarpo-phalangeal joints of the index and
middle finger, perhaps also in the ankles and in the
metatarso-phalangeal articulation of the great toe. Instead of
disappearing in four to six weeks, the articular inflammation
continues, although the pain may abate very much, and the capsules of
the joints continue swollen and rather tense. The muscles of the
extremities waste, and are the seat of painful reflex spasms which
interfere with the movements of the joints; and although the patient is
capable of moving about, and is free from all febrile disturbance, one
or several of his joints remain permanently swollen, painful, and
crippled. Perfect restoration of all the affected joints seldom if ever
occurs. In common with other observers, I have met with this acute form
most frequently in young women twenty to thirty years of age--several
times in connection with recent delivery or rapid child-bearing, or
lactation; once after what was regarded by the medical attendant as an
attack of acute rheumatism occurring not long after labor. It has been
observed in children, and is not uncommon after forty. These patients
usually suffer in their general health--become weak, pale, depressed in
spirits, and lose flesh. In several cases of this form marked intervals
of improvement have occurred; the local disease has ceased to progress,
and tolerable comfort has been experienced, perhaps, till pregnancy,
delivery, or lactation again determined a fresh outbreak of the
disease. Sometimes, however, this acute form steadily advances, and in
a year or two establishes changes in the cartilaginous and osseous
structure of the affected joints. Such a case I met in a lady of
twenty-one who had had a good deal of anxiety as a mathematical
teacher, and whose illness set in during vacation while at the seaside.
It proved obstinately progressive for several years, until several of
the larger joints, as well as the smaller, were badly crippled.
{81} The primary chronic form is much the more frequent, although
between it and the acute variety there are many intermediate grades.
For weeks or months the patient may experience numbness or formication
and rheumatic pains in the limbs, perhaps with a sense of stiffness in
the joints, especially felt after rest or the day after unusual
fatigue. Then one or more joints--most frequently the
metacarpo-phalangeal of the fingers--become painful, swollen, tender
when touched, and inordinately hot; these symptoms may subside under
rest or treatment, and after weeks or months recur, either without
known cause or from exposure, fatigue, or some impairment of the
health. Usually, the original joint is again affected, but frequently
one or two more of the same on the other hand suffer likewise. More or
less complete remissions of the pain and local inflammation now tend to
take place from time to time and alternate with exacerbations or fresh
attacks of the local disturbance, and the disease extends, as it were,
centripetally and more or less symmetrically to the wrists, then to the
elbows, and then to the shoulders, or from the toes to the ankles and
thence to the knees--although there is no invariable sequence of this
kind--and next to the hands; the knees are specially liable to
invasion. Of Haygarth's 34 cases, in 2 the knees alone suffered, and
"in all or nearly all the rest the hands, chiefly the fingers, were
probably affected." In Charcot's 45 cases the début took place in the
small joints of the hands and feet 29 times; in the hands, feet, and
one large articulation, 7 times; in one large joint, and later in the
fingers, 9 times. Even in this primary chronic form there is usually in
the earlier stages some effusion into the joints; the soft parts of the
articulation are thickened and swollen; obscure fluctuation in the
smaller and very distinct fluctuation in the larger joints may be felt.
The pain may be severe, especially at night, and during the
exacerbations of the disease it varies greatly in its degree and
persistency. The position and shape of the joints are altered, partly
by spasmodic retraction of the muscles, and more or less by the
effusion into the capsules and adjacent bursæ and sheaths, and the
thickening of the soft parts covering the articulations. As the disease
progresses further deformities ensue from the growth of new bone around
the heads of the bones, the absorption of the articular cartilage, the
development of masses of cartilage in the hypertrophied synovial
processes and beneath the synovial membrane at the margin of the bones;
the relaxation of the articular ligaments; and the displacements and
subluxations of the unshapely bones composing the joint. The great
wasting of the muscles of the member affected has some share in
producing its unnatural appearance. In the advanced stage there is more
or less abiding pain, soreness, and stiffness in the affected
articulations, violent cramps are experienced in the course of the
adjacent muscles, and pains either along the nerves or vaguely down the
limbs. Crackings or creakings are to be heard, and grating is to be
felt during the movements of the joints; these movements become more
and more restricted, so that an immobility almost equal to that of true
bony ankylosis is established, this result seldom occurring except
amongst the carpal, tarsal, tibio-tarsal, and the vertebral
articulations. Interlocking of the osteophites formed on and around the
articular surfaces, and in other cases union of these surfaces by the
interposition of newly-formed fibrous tissue, produce a spurious
ankylosis {82} destructive of the articular functions. In the very
advanced stages the feet, ankles, and legs are often considerably
enlarged and the integument thickened by a chronic oedematous
infiltration, or the bones and soft parts are atrophied and the
integument is pale, smooth, and attenuated, resembling parchment or the
condition seen in certain stages of scleroderma and tightly drawn over
the wasted rigid fingers. This primary chronic form is especially apt
to progress steadily for many years, the joints earliest affected
becoming gradually more distorted and crippled, and fresh joints
becoming invaded until there may hardly remain a single sound
articulation in the limbs, or even in the body; and at length the
patient may be unable to feed himself or masticate or raise his chin
from his sternum or rotate his head or stand.
The deformities of the several joints, being largely the result of
muscular contraction, observe certain general types, which, however,
are not peculiar to the disease, but occur in various affections of the
nerve-centres, involving paralysis or spasm or both. Charcot has
carefully described those met with in the hands, and I must refer to
his masterly article upon chronic articular rheumatism for his account
of them.
(1) It must suffice to say here that the predominant features of the
hand in chronic rheumatoid arthritis are the following: The first
phalanx of the fingers is either flexed upon the metacarpus or
extended, and the terminal phalanx in like manner is either markedly
flexed or extended upon the second, or these two phalanges are
maintained in a straight line, while the first phalanx is, as usual,
decidedly flexed upon the metacarpus.[219] In all these varieties the
hand is pronated; there is a great tendency to deviation of the fingers
toward the ulnar border of the hand, although sometimes the deformed
fingers stand out, not unlike a bunch of parsnips. The thumb escapes
longer than the other fingers, and its metacarpo-phalangeal joint is
usually flexed, rarely extended.
[Footnote 219: _Lectures on Senile Diseases_, Syd. ed., trans. 1881.
Figs. 1 and 2, Pl. II., on the hand, give good illustrations of these
deformities.]
(2) The great toe, enlarged at the metacarpo-phalangeal articulation,
is usually drawn to the outer border of the foot, across and above, but
rarely below, the other toes, and the foot is usually abducted and
flattened, the prominent internal border resting on the ground. The
wrist, elbow, and knee-joints are generally flexed; the distal ends of
the ulna and radius, more or less enlarged, project backward; the
semi-flexed tibia is drawn backward on the femur and rotated outward,
thus rendering the internal condyle of the femur prominent and
displacing the patella toward the external condyle, and foreign bodies
may frequently be felt in the enlarged knee- and elbow-joints. Finally,
the extremities of the affected bones will, as a rule, be found
enlarged and misshapen, and nodosities, rims, tips, ridges, and
stalactiform growths of new bone may be felt on them.[220]
[Footnote 220: Figs. 12 to 18 and 22 in Adams's _Treatise on Rheumatic
Gout_ are nice illustrations of these deformities.]