Acute Articular Rheumatism.
Synonyms:—Rheumatic fever; acute rheumatic fever; inflammatory rheumatism; acute rheumatism.
Definition:—An acute constitutional disorder, due to general infection, characterized by a sharp high fever and by an acute local inflammation, with the usual concomitants of pain, heat, redness and swelling of the enveloping tissues and synovial membrane of one or more of the joints of the extremities. It is usually sporadic in its appearance and is not considered contagious. Occasionally an epidemic is suggested by the coincidental appearance of a number of cases in one locality.
Etiology:—The exciting cause of the disorder has not been positively determined. The investigations of Poynton and Fayne, confirmed by Walker, Meyer and Beaton, point strongly to the existence of a specific micrococcus, but that this germ is distinct from the streptococcus is not fully proven. The uric acid theory of the cause of the disease is no longer accepted.
The predisposing causes are many. The season and the weather exercise the most apparent influence. The disease is one of cold, damp weather, appearing often in the late fall, but most commonly in the United States in the early spring months or from the middle of February to the middle or last of April. It occurs occasionally in times of extreme rainfall, even if that be during the hottest weather of midsummer. Foreign authorities claim that it is common in extreme dry weather. This is not observed to any great extent in our country, although isolated cases in dry weather are not uncommon. Exposure to cold, with wet clothes, predisposes directly to the disease. Parties working in wet places or with the feet or clothes constantly wet are especially liable to it. The disease very seldom occurs in infancy, but an occasional case will be seen under five years of age. From the age of five to twelve years it is more common, and more frequent among girls than boys, and these cases are very susceptible to cardiac inflammation, more than seventy-five per cent of which are so complicated. Between the years of twelve and thirty-five it is most common and at this period among men rather than women, as their occupation exposes them to the peculiar causes of the disease. Attacks of tonsillitis predispose the patient to-rheumatism, it frequently following that disease immediately. It is so frequently associated with endocarditis that some pathologists claim that the two diseases depend upon the same specific cause. Cases suffering from chronic endocarditis are especially liable to rheumatism, and inversely very many cases of endocarditis follow rheumatism or are coincident with it. This disorder is also apt to occur in children suffering from chorea. In other isolated cases a child who may have suffered repeated attacks of tonsillitis has chronic rheumatism with valvular murmurs in the heart, and at the age of from eleven to fourteen years may develop stubborn and intractable chorea. There is certainly a causal relation between these disorders which is not as yet explained. An attack of rheumatism confers no immunity against future attacks.
Symptomatology:—There is no definite period of incubation in rheumatism. The milder cases occasionally develop somewhat gradually, with malaise, muscular soreness, and perhaps some tenderness in one of the joints. Typical cases, however, may occur with no premonition. The patient is aware of having been subjected to undue exposure, but no symptoms are present, except, perhaps, those of an ordinary acute cold, when suddenly one of the joints, most commonly the ankle or knee, becomes extremely painful and swells rapidly and excruciating sensitiveness with redness develops. Every movement and even the most careful handling causes extreme pain and prevents examination in diagnosis. The local heat seems intense, and the redness soon becomes somewhat dusky in color. Simultaneously a chill occurs and fever is found to be present, which increases with the increase of the local evidences. The temperature seldom rises above 102.5° F. and it is subject to irregular remissions, during which the patient will sweat profusely. During the increase of the temperature the skin is dry and hot and the patient moans and is restless and fretful. The patient is never "comfortably sick" in rheumatism. The fever may terminate by lysis in seven days, but its course is uncertain and extremely irregular. Some of the severest cases terminate within a few days most satisfactorily ; other milder cases may continue even for months. In yet other cases there may be a remission of the fever, with complete abatement of the local symptoms at the original point of attack, when the acute inflammation will abruptly develop in another joint previously unaffected. This may occur until all the large joints of the body have been attacked. In other cases two or more of the joints may be inflamed at once. The disease may attack a solitary joint and no abatement occur in this locality, when another joint is attacked, and this continue until one by one several of the larger joints will be involved to a greater or less degree; or the inflammation may recur in a joint which was previously affected. The order of the invasion of the joints is not regular, but usually the knee and ankle are first involved, with perhaps the wrist, then the shoulder, elbow and hip joints. The phalangeal joints are next in order, then the tarsal and metatarsal joints, the intervertebral articulations, and ultimately the ribs, the sternoclavicular articulations and those of the jaw. Ankylosis is not a usual result of acute uncomplicated rheumatism.
With the progress of the fever the pulse is soft, full and round and about 190 beats per minute. In cases where the constitutional symptoms are severe and the nervous irritation is marked, the pulse is irritable and more rapid, and where pronounced blood changes, which are not uncommon, occur, the pulse may be very feeble, irregular and rapid. Where the heart is involved the character of the pulse is correspondingly influenced. Copious perspiration may accompany rheumatic fever, so much so as to demand special medication.
There are occasionally cases of hyperpyrexia in rheumatism which should be appreciated and combated. The temperature may rise abruptly, even above 106° F., with great restlessness, nervous excitability and convulsive phenomena, or there may be marked delirium and increasing dulness and stupor. This, however, is rare. Cases with the above phenomena are complicated and are apt to terminate fatally. Insomnia is a common complication during the entire course of this disease, and is in part due to the persistent distress. The kidneys are fairly active, but the urine is concentrated, of small quantity and of very high specific gravity, and it is of pronouncedly acid reaction. Urea, uric acid and the urates, with occasionally the phosphates, are present, all in great excess. A little albumin is often present, which I have attributed more often to the irritation and consequent congestion caused by the elimination of the concentrated solids than to faults in blood pressure. These faults occur, however, to a pronounced extent when heart complications arise and their seriousness is in proportion to the extent of those complications.
Complications:—Nephritis, either acute or chronic, seldom occurs as a direct result.
Pleurisy is a not uncommon complication of rheumatism, and pleuritic pains must be distinguished from those of rheumatic involvement of the articulations of the ribs, or of the muscular structure of the chest walls. Bronchitis and pneumonia may follow rheumatism, but are seldom caused by it.
The heart is affected by this disorder more frequently than any other organ. Hare tabulates 683 cases of acute rheumatism of all ages from St. Bartholomew's Hospital. Of these, 48.78 per cent—nearly one-half—had heart complications. And of 480 cases under thirty years of age, 65 per cent were so complicated, proving that the younger patients are much more liable to heart disease than those older. The disease attacks the endocardium first, subsequently that portion covering the mitral valves, which are attacked in over 90 per cent of valvular complications. Later the heart muscle is attacked, and the myocarditis is soon followed by pericarditis. These are seldom the cause of death during the active period of the rheumatic inflammation. But'when the rheumatism abates the heart lesions persist and assume a subacute or chronic form, and for months and perhaps years are the cause of greatly impaired and enfeebled health, and finally the cause of death, or they may incapacitate the patient for any active labor, and result ultimately in other organic or constitutional disease, as dropsy, or Bright's disease, or both, to which the patient succumbs. In children, dropsy and kidney lesions and other organic or nervous disorders may follow rapidly, and terminate in death within a few weeks or months.
Diagnosis:—Abrupt joint inflammation, with its concomitants plainly marked, and fever, is easily distinguishable from other disorders. Arthritis from other causes must be distinguished by the history and often by the persistent fixed location of the inflammation. Septic arthritis, often taken for this disease, follows other acute disorders, especially the exanthemata. Gonorrhceal rheumatism has a previous history of gonorrhoea and has but little elevation of temperature. Osteomyelitis seldom attacks other than the hip joint, and whatever joint is attacked, the bone is involved, rather than the structures of the joint. Monoarticular rheumatism has a previous history of gout and syphilis.
Treatment:—Fever and pain are the primary indications for treatment in acute rheumatic fever. The first remedy is aconite; the second is bryonia; five drops of specific aconite and ten drops of specific bryonia in four ounces of water should be given in teaspoonful doses every hour for the first three or four days. The specific indications for bryonia are not more strongly marked in any other known disease than in rheumatism. An initial dose of pilocarpine or two or three full doses of jaborandi will determine, not sweating alone, but actual elimination of morbific matter from all the emunctories, and especially from the skin, and will exercise a positive sedative influence upon the temperature. The joint should be wrapped at once in a hot salt solution, by saturating soft compresses and covering them with rubber protective, keeping them wet and hot without change. Instead of the solution of sodium chloride, a mild solution of ammonium chloride is used in some cases with better results. Or libradol should be applied for six hours if nausea is not induced. This is a medicated dehydrating application, with a base made similarly to other plastic dressings, with lobelia, tobacco and other sedatives. It positively abates the pain quickly and relieves the inflammation. A most serviceable application is antiphlogistine, which has the advantage of producing no untoward effects whatever. It may therefore be applied and retained and kepit hot without disturbing the painful joint for twenty-four hours.
Rhus toxicodendron is specific in those cases of this disease, in which the redness and swelling are very great and where the patient is restless and constantly moving."
Macrotys has long been used, and active results are obtained where there is extreme muscular soreness and stiffness of the parts. From twenty to thirty minims in four ounces of water is given in dram doses every two hours.
Belladonna in small doses, given in conjunction with aconite, dispels the extreme local inflammation in the first stage of the disorder, equalizing the circulation. It also supports the heart's action.
Arnica, internally and externally, is an excellent remedy. It is indicated when the joints are sore, with a bruised feeling, very sensitive to the least touch. Ten drops in a four-ounce mixture is given in teaspoonful doses every hour.
The salicylates are specific in a general sense, but are accompanied with so many untoward results that they should be given secondarily to the direct specifics. The sodium salicylate is most commonly used, and while superior in many particulars to the potassium salt, it is repugnant to most stomachs and quickly destroys the appetite. The ammonium salicylate is less depressant than the others of its class, but its taste is objectionable. The lithium salicylate is kindly in its action and exercises a kindly influence upon the kidneys. From one dram to one and one-half drams within each twenty-four hours is the maximum dosage of the salicylates. The oil of wintergreen, from which salicylic acid is produced, is recommended for external application and internal use, and good results are claimed for it. Ten minims may be given in a capsule every three hours. The Eclectic fathers thirty years ago recommended salicin in this disease and it has proven efficacious and is now advised by regular writers. Fifteen grains may be given every two hours. It acts best when the skin and tongue are moist and the tongue is cleaning and when the temperature is declining, rather than rising. It has no untoward results. This class of remedies, like the directly specific remedies, prevent heart complications. They seem to neutralize the irritating factors within the blood. The bicarbonate of sodium is advised in conjunction with the salicylates. We would advise it if there be a broad, thick, pale tongue, coated white, with pale mucous membranes of the mouth, indicating excessive acidity.
Caulophyllum, colchicum and phytolacca are all of some service in rheumatism, but do not occupy their once exalted position. Phytolacca has the special indications of glandular involvement, which must not be overlooked. Sore mouth and sore throat or ulceration of the skin demand this remedy. Lindder advised Colchicum in those cases where there are tearing, lancinating pains, with nervous worry and irritability.
Xanthoxylum was thought to be a specific by the older members of our school, but it has not grown in popularity. Dr. Morrill has used the following formula recently in several cases of acute rheumatism and believes it to be far superior to the salicylate treatment, which he has permanently abandoned for it. He claims that it prevents heart complications; kava kava five drams, macrotys three drams, citrate of potassium four drams, elixir of pepsin to make four ounces. A dram is given every three hours, all necessary precautions being taken against exposure to cold.