recently come into use as a substitute for salicylates, and may succeed when salicylates fail.
Subacule 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 lesions 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 fomentation's, 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, &c., in England, or of Aix-les-Bains, Wiesbaden, Wildbad, &c., 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. (J. F. H. B.)
RHEUMATOID ARTHRITIS (osteo-arthritis, arthritis deformans),
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. Landré Beauvais in 1800 published
a description of the disease under the title of Goutte asthenique
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 rgth
century as to its relation to rheumatism and to gout gave rise
to the unfortunate term “rheumatic gout.” The name arthritis
deform ans was 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
forward 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 Schüller 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—(1) 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 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 osteophytes 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
