688 



RHEUMATISM 



is bathed in a copious perspiration, with so charac- 

 teristic a smell (resembling that of sour milk) that 

 the physician con often recognise the disease 

 almost before he sees the patient. The joint.* are 

 extremely painful, and the pain ia much increased 

 by pressure, anil consequently by movement which 

 gives rise to internal pressure. Hence the patient 

 Res fixed in one position from which he dares not 

 stir. 



The usual exciting cause of acute rheumatism is 

 exposure to cold, and especially to cold combined 

 with moisture, and hence the greater prevalence of 

 this disease amongst the poor and ill-clad. Sleep- 

 ing in damp sheets or upon the damp ground, the 

 wearing of wet clothes, and sitting in a cold damp 

 room, especially if the sitter was previously warm 

 from exercise, are examples of the kind of exposure 

 which is apt to be followed by this disease. Rheu- 

 matism is not, however, a universal sequence to 

 exposure to the cold. It only occurs when there is 

 a special predisposition, or, as it is termed, a rheu- 

 matic diathesis or constitution, and the diathesis 

 may be so strongly -developed as to occasion an 

 attack of acute rheumatism, independently of ex- 

 posure to any apparent exciting cause. Acute 

 rheumatism is often associated with Chorea (q.v.) ; 

 but the exact nature of the relation between the 

 two is not known. Scarlet fever is the only other 

 disease which seems specially liable to be followed by 

 acute rheumatism. Men are more subject to the dis- 

 ease than women, but this probably arises from their 

 greater exposure to atmospheric changes on account 

 of the nature of their occupations. The predis- 

 position is certainly affected by age ; children under 

 ten years being comparatively seldom attacked, 

 while the disease is most prevalent between the 

 age of fifteen and forty. Above this age a first 

 attack is rare, and even recurrences are less frequent 

 than earlier in life. Persons once affected become 

 more liable to the complaint than they previously 

 were. The disease is hereditary in a considerable 

 proportion of cases ; and even when it cannot be 

 traced in previous generations the predisposition is 

 very apt to exist in several members of the same 

 family. The exact nature of the disease poison is 

 unknown. Dr Prout regarded lactic acid as the 

 actual materie* morbi, but, though certain facts 

 tend to confirm this view, it cannot be regarded 

 as satisfactorily proved. 



In the great majority of cases acute rheumatism 

 ends in recovery ; mni permanent damage to the 

 affected joints is rare. It is, however, extremely 

 apt to recur, either in the early stages of con- 

 valescence, or after an interval of months or years. 

 The chief danger arises from implication of the 

 heart, which very frequently occurs ; probably in 

 about one-half of those suffering for the first time 

 either the pericardium or endocardium or both are 

 affected. The younger the patient the greater the 

 liability to these complications, which usually result 

 in more or less permanent impairment of the heart's 

 action (see HEART, PERICARDIUM). Another con- 

 dition, much less common, but extremely fatal, 

 is known as rheumntir hjifttrpyrexia, and is char 

 acterised by a very rapid rise of temperature to 108 

 or 110, with head symptoms in the form either of 

 drowsiness or of violent delirium. 



The patient should be strictly confined to bed 

 Ix-tween blankets (i.e. without sheets), and lie 

 clothed in flannel ; he must lie carefully protected 

 from draughts, and from undue pre-smi' ,,f the bed- 

 clothes, and supplied with light nourishment and 

 diluent drinks. Under such conditions, without 

 other treatment, most cases recover in the course 

 of time. Till the last quarter of the 19th century 

 there was no general agreement as to what more 

 should tie done. When bleeding was used for most 

 acute diseases this one was no exception. When 



that practice was abandoned numerous drugs were 

 used, in some cases with apparent success. Quinine, 

 iron, lemon juice, colchiciun, large blisters to all the 

 affected joints, were all recommended ; more in 

 favour than any of these were alkalis in large doses. 

 But in 1876 Strieker in Berlin and Maclagan in Eng- 

 land called attention toanutlier method of treatment 

 which is now almost universally adopted. Though 

 new to Europe it has long lieen in use elsewhere, 

 for the natives of South Africa have from time 

 immemorial treated the disease by willow-top infu- 

 sion. This method consists in the administ ration 

 of Salicin (q.v.), or one of its derivatives (salicylic 

 acid, salicylate of soda, &c.). The last is at present 

 most largely used. It is usually given in doses of 

 15 or 20 grains every two or three hours at first; 

 but its action needs to be carefully watched, as it 

 often causes considerable depression and other 

 uncomfortable symptoms. It is admit ted by almost 

 all observers that it has a remarkable effect in 

 reducing the fever, relieving the pains, and cutting 

 short the attack ; but under this treatment, as 

 without it, relapses are frequent. In rheumatic 

 hyperpyrexia the only treatment that has been 

 found effectual is immersion in a tepid bath as often 

 as the temperature rises to a dangerous point. 

 Convalescence is usually very slow, and it is neces- 

 sary to keep the patient in bed and on low diet for 

 some time after the fever has disappeared to diminish 

 the tendency to relapse. At this stage tonics, espe- 

 cially quinine and iron, are generally useful. 



Chronic Rheumatism. Chronic painful affections 

 of the joints sometimes follow rheumatic fever and 

 are clearly a consequence of it. The name is often 

 erroneously applied to chronic and insidious forms 

 of gout. There is another form of disease to which 

 most of the cases of so-called ' chronic rheumatism ' 

 belong, probably distinct from both rheumatism 

 and gout, popularly so called, though it is often 

 called 'rheumatic gout," which deserves separate 

 mention. 



Otteo-arthritis (chronic rheumatic arthritis and 

 rheumatoid arthritis are among its many other 

 names) is characterised in most cases by a very 

 chronic course, by pain and stiffness in one or more 

 of the joints, with creaking on movement, and by 

 destructive changes of the cartilages of the affected 

 joints, with enlargement of the ends of the bones in 

 their neighbourhood. It is more common in women 

 than in men ; most often begins at or after middle 

 life, though occasionally even in childhood ; and is 

 apt to affect those who are weakly and who have 

 had a life of hard work with defective nourishment. 

 There is no special liability to affection of the 

 heart as in true rheumatism. In the treatment of 

 this ailment hot baths and douches, particularly 

 with certain mineral waters (eg. those of Bath, 

 Aix-les-Bains), and a warm dry climate are very 

 valuable ; a generous diet is essential. Of drugs, 

 cod-liver oil and arsenic are most often serviceable ; 

 but many others, iron, quinine, guaiacum, <.Vc., are 

 also of use. Under any treatment, however, com- 

 plete recovery is exceptional ; but the disease, even 

 when severe, does not much shorten life. 



Gonorr/ifnl rheumatism is a form of joint disease 

 closely simulating acute rheumatism which occurs 

 in some cases of Conorrhea (q.v.). The affection 

 does not, however, flit from joint to joint in the 

 same way, and is not amenable to the same treat- 

 ment. 



Muscular rheumatism is the name usually given 

 to painful affections of the muscles for which no 

 clear cause is discoverable ; it usually dejiends 

 either on defective digestion or imjierfect excretion 

 of waste products from the system, and eliniinant 

 treatment, by alkalis, purgatives, or diaphoretics, is 

 usually indicated. But it is very doubtful whether 

 the cause is the same as in acute rheumatism. 



