RHEUMATISM (from Gr. peDjwx, flux), a general term for various forms of disease, now subdivided more accurately under separate names.
ACUTE RHEUMATISM or RHEUMATIC FEVER is the name given to a disease having for its chief characteristics inflammatory affections of the joints, attended by severe constitutional disturbances and frequently associated with inflammation of the pericardium and valves of the heart. The acute rheumatism of childhood differs materially from that of adults in that the articular manifestations and constitutional disturbance are usually much less severe, whereas the heart and pericardium are especially liable to be attacked. It will be advisable, therefore, in discussing the symptoms, to deal separately with the rheumatism of adults and that of childhood. There are certain points of importance in connexion with its causation which are generally agreed upon. It is essentially a disease of childhood and early adult life, being most commonly met with between the ages of ten and twenty-five and comparatively rarely after forty. Heredity is unquestionably an important predisposing cause. Climate is also a factor of considerable importance, cold and damp with sudden and wide fluctuations of temperature being especially conducive to an attack. While perhaps more common in Great Britain than elsewhere, it is met with in most parts of the globe. Exposure to cold and wet, and especially a chill after free perspiration and fatigue, are among the most common exciting causes of an attack.
Of recent years much evidence has accumulated tending to show that rheumatism is a specific infective disease due to a micro-organism, and this is now generally recognized. There is still, however, some difference of opinion as to the nature of the micro-organism by which it is produced. In 1900 F. J. Poynton and Paine isolated from eight cases of acute rheumatism in children a minute diplococcus similar to that previously described by Triboulet and by A. Wasserman, which inoculated into rabbits produced lesions of the joints and of the heart indistinguishable from those met with in acute rheumatism. They have since obtained the same micro-organism from a further large number of cases of acute rheumatism, and their results have been confirmed by Walker, Beattie and others. They therefore claim that this micro-organism, to which they have given the name Diplococcus rheumaticus, is the specific cause of acute rheumatism. The objections which have been raised by other competent observers against this view are: (i) That this diplococcus is not found in all cases of acute rheumatism. (2) That certain other micro-organisms when inoculated into animals will produce joint and heart affections similar to those produced by the aforesaid Diplococcus rheumaticus . It would be out of place here to enter into the merits of this controversy; suffice it to say that the objections raised do not appear to be cogent enough to invalidate the conclusions arrived at by the authors of the germ theory. The matter is, however, still to a certain extent sub judice.
In adults the affection of the joints is the most striking feature. The attack is usually ushered in by a feeling of chilliness or malaise, with pain or stiffness in one or more joints, generally those of large or medium size, such as the knees, ankles, wrists or shoulders. At first the pain is confined to one or two joints, but others soon become affected, and there is a tendency to symmetry in the order in which they are attacked, the inflammation in one joint being followed by that of the same joint on the opposite side. The affected joints are swollen, hot and excessively tender, and the skin over them is somewhat flushed. The temperature is raised, ranging from about 101 to 103 F., the pulse rapid, full and soft; the face is flushed, the tongue coated with a thick white fur, and there is thirst, loss of appetite, and constipation.^ The body is bathed in a profuse perspiration, which has a characteristic sour, disagreeable odour. The urine is diminished, acid and loaded with urates. The attack is of variable duration, and may pass off in a few days or last for some weeks. Relapses are not uncommon when convalescence appears to have been established. Among the complications which may arise are hyperpyrexia, or rapid and extreme rise of temperature, which may run up as high as 110 F., when death will speedily ensue unless prompt and energetic treatment by cold baths or icepacks is resorted to. Affections of the heart, pericarditis (inflammation of the fibro-serous sac investing the heart) and endocarditis (inflammation of the lining membrane and the valves of the heart), which are so frequently associated with rheumatism, should be regarded as part of the disease, rather than as complications of rheumatism. They are far more common in children than in adults, and it is the damage to the valves of the heart in children by rheumatism which lays the foundation of much chronic heart disease in later life.
In childhood the affection of the joints is usually slight, and may be confined to a little pain or stiffness in one or two joints, and is sometimes attributed by parents to " growing pains." The constitutional symptoms are also ill-marked and tliere are no acid sweats, the temperature is not as a rule very high, the tongue not heavily coated, and the child does not appear to be very ill. The heart and pericardium are, however, especially liable to attack, and this may be so insidious in its onset that attention is not called to it till considerable damage has been done to the heart. It is of importance, therefore, that in children the heart should be frequently examined by a physician, when there is the slightest suspicion of an attack of rheumatism. Chorea or St Vitus's dance is a common manifestation of rheumatism in children. Subcutaneous fibrous nodules, attached to tendons or fibrous structures beneath the skin, are a special feature of the rheumatism of childhood. They are painless, and vary in size from one-eighth to half an inch in diameter. They are not very common, but when present indicate that the rheumatism has a firm hold and that cardiac complications are to be apprehended.
The patient should be placed in bed between blankets, and should wear a light flannel or woollen shirt. The affected joints should be kept at rest as far as possible, and enveloped in cotton-wool. Salicylate of soda or salicin, first meat' suggested by Dr Maclagan in 1876, appear to exercise a specific influence in acute rheumatism. They have a powerful effect not only in reducing the temperature, but in relieving the pain and cutting short the attack. Frequent and fairly large doses of salicylate of soda should be administered for the first twenty-four hours: the dose and interval at which it is given should then be gradually reduced till the symptoms subside. In conjunction with this, alkalies such as bicarbonate or citrate of potash should also be administered. The effect of the salicylate should be carefully watched, and the dose reduced if toxic symptoms such as delirium, deafness, and noises in the ears occur. These drugs are of less service in the rheumatism of children than in that of adults, as they do not appear to exercise any specific influence in arresting the cardiac inflammation to which children are specially liable, though they have a marked effect on the joint affections. Aspirin has recently come into use as a substitute for salicylates, and may succeed when salicylates fail.
Subacute rheumatism. This term is sometimes applied to attacks of the disease of a less severe type in which the symptoms, though milder in character, are usually of longer duration and more intractable than in the acute form. It is difficult, however, to draw a hard-and-fast line between the two, but the term may perhaps be most appropriately applied to the repeated and protracted attacks of cardiac rheumatism in children.
CHRONIC RHEUMATISM. This term has been somewhat loosely applied to various chronic joint affections, sometimes of gouty origin or the result of rheumatoid arthritis. Strictly speaking, it may be applied to cases in which the joint lesrons persist after an attack of rheumatism, and chronic inflammatory thickening of the tissues takes place, so that they become stiff and deformed. It is also appropriate to certain joint affections occurring in later life in rheumatic subjects, who are liable to repeated attacks of pain and stiffness in the joints, usually induced by exposure to cold and wet. This form of rheumatism is less migratory than the acute, and is commonly limited to one or two of the larger joints. After repeated attacks the affected joints may become permanently stiff and painful, and crackling or creaking may occur on movement. There is seldom any constitutional disturbance, and the heart is not liable to be affected.
MUSCULAR RHEUMATISM. By this is understood a painful affection of certain groups of muscles attributable to inflammation of their fibrous and tendinous attachments. It is commonly brought on by exposure to cold and wet, and especially by a chill after violent exercise and free perspiration when the clothes are not changed. Any movement of the affected muscles gives rise to severe and sharp pain which may induce a certain degree of spasm and rigidity at the time. The pain usually subsides and passes off completely while the patient is at rest, but occurs on the slightest movement of the affected muscles.
The chief varieties of muscular rheumatism are:
1. Lumbago, in which the muscles of the lower part of the back are affected so that stooping, particularly the attempt to rise again to the erect position, induces severe pain.
2. Intercostal rheumatism, affecting the muscles between the ribs, so that taking a deep breath and certain movements of the arms give rise to pain.
3. Torticollis or stiff neck, affecting the muscles of one side of the neck.
Treatment. Salicylates, which are of service in acute rheumatism, are not so reliable in the chronic varieties, but are sometimes of service. Aspirin, salicin, quinine and iodide of potassium may be more successful, but other active treatment is usually required. The application of heat in the form of poultices or fomentations, counter irritation by mustard leaves or blisters, are indicated in some cases. In others massage, hot douches, or electricity may be required. Mineral waters and baths of various health resorts are often of great benefit in obstinate cases, such as those of Buxton, Bath, Harrogate, Woodhall Spa, etc., in England, or of Aix-les-Bains, Wiesbaden, Wildbad, etc., and many others on the continent of Europe. Wintering abroad in warm, dry and sunny climates may be advisable in some cases when this is practicable.
Q. F. H. B.)
RHEUMATOID ARTHRITIS (OSTEO-ARTHRITIS, ARTHRITIS DE- FORMANS), terms employed to designate a disease or group of diseases characterized by destructive changes in the joints. Though it is only in comparatively recent times that the disease was definitely recognized as separate clinically from either rheumatism or gout, it is certain that it prevailed in ancient times. Characteristic changes in the bones have been found in remains in tombs in Egypt attributed by Petrie to 1300 B.C., and ancient Roman as well as British graves have held bones showing distinct traces of the diseases. Of early medical writers, Paulus Aeginata observed the lesions and seemed to consider them distinctive. Landre Beauvais in 1800 published a description of the disease under the title of Goulte aslhenique primitif. The first endeavour, however, to separate rheumatoid arthritis as a distinct disease was made by William Heberden in 1803; while in 1805 John Haygarth recognized the difference between it and rheumatism, and suggested the term " nodosity of the joints." A wide divergence of opinion during the igth century as to its relation to rheumatism and to gout gave rise to the unfortunate term " rheumatic gout." The name arthritis deformans-wa.s suggested by Virchow in 1859. Various causes, such as nervous origin, inherited arthritic diathesis, a relationship to rheumatism or gout, and reflex irritation, have been put foward as giving rise to the disease, but in the present state of medical knowledge two are most favoured. The first ascribes the disease to an infective process arising from micro-organisms. Several observers have found bacteria in the synovial fluid and membranes of affected joints, Max Schuller finding both bacilli and cocci, while in 1896 Gilbert Bannatyne, Wohlmann and Blaxall isolated a micro-organism, a bacillus with a bipolar staining, which they stated to be almost constantly present in the joints of patients with true rheumatoid arthritis. The second view is that the disease is the result of a chronic toxaemia produced by absorption of toxines from the intestine, with perhaps some error in metabolism. In many cases there seems to be a distinct evidence of a local infection, injury being a determining factor, and some families seem to have joints which are specially liable to degeneration. The disease may begin at any age, for there is no doubt that persistent cases have been met with in quite young children; but it usually begins in early middle-age, and statistics seem to confirm the impression of the greater liability of females. Conditions which tend to lower the general health seem to act as a predisposing cause to rheumatoid arthritis, e.g. mental worry, uterine disorders and various lowering diseases,' prominent among which are influenza and tonsillitis. In a number of cases in women the onset occurs about the time of the menopause.
The method of onset varies according to the form. There are four well-marked types (i) the peri-articular form, in which the most marked changes are in the synovial membrane and peri-articular tissues, and the cartilage may be involved to a lesser degree. In this variety is found every grade of severity. The onset may be acute, resembling an attack of rheumatic fever, for which it may be mistaken; the joints, one or more, are swollen, tender and painful to the touch; the temperature elevated to 100; 101; but unlike rheumatic fever, sweating and hyperpyrexia are uncommon. The acute stage may then subside, a slight thickening remaining in the capsule of the joint, and the contours of the limb scarcely regaining the normal; or the attack may gradually develop into the chronic form. The pain varies greatly, and is not necessarily in ratio to the amount of arthritis present. Various joints may be involved, the spinal vertebrae not infrequently sharing in an arthritis; the most usual joints to be attacked, however, are r the knee and shoulder. When the knee is attacked there is commonly effusion into the joint. Muscular atrophy is usually present, but varies greatly in its extent. In most cases it is present to a much greater degree than can be accounted for by disuse of the muscles. The skin has in these cases a curious glossy appearance, and pigmentations may be noticed. In chronic forms the onset is gradual, one joint becoming painful and swelling, and then the others successively; in these slow forms the outlook for the recovery of the joint is not so good as in the acute, and some cases may proceed to extreme deformity with little or no pain. Gradually the shape of the joint is altered ; this is in a great measure due to synovial thickening, and partly to the presence of olsteophytes in the joint. When the affected joint is moved a distinct crepitation can be felt. The muscles about the joint atrophy often to an extreme degree, and contractures supervene, flexing the leg upon the thigh if the knees should be affected, and the thigh upon the abdomen should the hip be affected. In extreme degrees the patient may become a complete cripple. Later, in many cases a quiescent stage of the disease is reached, the patients cease to suffer pain, and are inconvenienced only by the deformities in the limbs, in which a considerable degree of motion may be retained. Remarkable deformities are seen in hands in which a considerable amount of usefulness still remains. Dyspepsia and anaemia are frequently associated with arthritis. Monarticular arthritis more particularly affects the aged; and when it affects the hip is known as morbus coxae senilis.
(2) The atrophic form of arthritis is not very common. The chief anatomical change is due to atrophy in the bone and cartilage. The disease occurs at an earlier period in life than the peri-articular form, from which the initial symptoms do not markedly differ; but the disorganization in the joint is greater, dislocations frequently occur, and ankylosis of the joints follows. This is the most serious form of arthritis.
(3) In the hypertrophic form the anatomical changes include the formation of new bone as well as changes in the cartilage. This new-bone formation may lead to progressive ankylosis in the joints. Should the , vertebral column be affected a rigid condition of the spine known as spondylilis deformans (" poker back ") may ensue. What are termed " Heberden's nodes " are small hard knobs about the size of a pea frequently found upon the fingers near the terminal phalangeal joints; they rarely give rise to symptoms. Popularly ascribed to gout, these nodes are in reality a manifestation of arthritis.
(4) A variety of arthritis occurring in children is known as Still's disease; in which the swelling of the joints is associated with swelling of the lymph glands and of the spleen. The onset is often acute, with fever and rigors; sweating is profuse and the joints are enlarged and painful. There may be much muscular wasting and limitation of movement in the joints, and anaemia is associated with the disease.
The treatment of rheumatoid arthritis is rarely curative, once the disease has been permanently established; and it is therefore important to begin treatment before destructive changes have taken place in the joints. In the acute febrile form, which is frequently taken for rheumatism, the essential treatment is rest to the affected joints, with the application of oil of wintergreen; the joint should not be fixed but supported. In the more chronic forms medicinal treatments are usually of little value. Potassium iodide is useful in some cases by promoting absorption of the hypertrophied fibrous tissue, and guaiacol if administered for a sufficiently long time is said to be capable of arresting the disease, diminishing the size of the joint and helping movement. Where anaemia accompanies the disease iron and arsenic are of value. The general health of a patient suffering from rheumatoid arthritis must be maintained, and he should live upon a dry soil. Visits to Aix-les-Bains, Buxtdn, Bath or Droitwich, with their baths and shampooings, often prove useful, particularly when combined with gentle massage. It is a mistake to keep the joints entirely at rest in the chronic forms, as this tends to the formation of coritractures and ankylosis. Moderate exercise without undue fatigue is desirable. Patients should go early to bed and have plenty of rest, sunshine and fresh air. It is important that the diet should be nourishing and plentiful, and should there be intestinal putrefaction fermented milk is useful. As regards the local treatment, it will be well in the majority of cases to determine by the X-rays the exact state of the affected joints. Radiant heat, vibration and hot-air baths are among the best treatments. The active hyperaemia induced by hot air favours restoration of movement and alleviates pain, but where there is pronounced destruction of bone and cartilage full restoration of a joint cannot take place. Systematic exercises of the joints tend to prevent the atrophy of the adjacent muscles, and Bier's passive hyperaemia induced by the temporary use of an elastic bandage has the same results. Should an X-ray photograph reveal the presence of spurs or loose bodies in the joints interfering with free movement their removal is called for. Sometimes the breaking down of adhesions under an anaesthetic is necessary, and gentle passive and later active movements of the joints should follow if freedom of use is to be gained. Recently treatment by radium has taken a definite place in the therapeutics of chronic arthritis, its analgesic properties seeming of great benefit. (H. L. H.)