Synonym:—Chronic articular rheumatism.
Definition:—A chronic disease of the articulations, which is characterized by slow development and by the presence in the joints of pain, tenderness and disability.
Etiology:—The condition may follow repeated attacks of the acute form of this disease, or it may develop most insidiously in those who are persistently exposed to dampness and cold, or those who are insufficiently clothed. While it is more common in middle adult life, it occurs in childhood, with some slight modifications of its phenomena. It is thought that there is a slight preponderance in favor of the difficulty occurring in females, but this is questionable. Those who live in poorly ventilated rooms, from which the sunlight is excluded, who are improperly clothed and insufficiently fed with poorly prepared food, will be found liable to the disease. This is especially true among those who, with or without these conditions, are careless of their excretory functions, paying no attention to bathing or to the demands of nature in evacuating the bowels or bladder; who confine themselves without physical exercise in close rooms, and engage in persistent, unremitting, monotonous labor. These conditions are similar to those which induce lithemia, and clinically the two conditions are often found to be associated.
Symptomatology:—Pain in the joint or joints which are involved in this disease may be the only symptom at first apparent. There is no redness, no swelling, and the pain may not at this time be greatly increased upon movement, but will increase during the night, and upon the approach of abrupt changes in the weather, and especially upon the occurrence of rainy weather. Later the joints become stiff, and movement is painful, and swelling occurs. Ultimately the tenderness and pain become extreme, and the patient refuses to move the joint. With the swelling there may be also infiltration of the tissues, which will readily pit upon pressure.
In other cases there are deposits in and around the joints, which will at first elicit crepitus on movement, and later will induce immobility. Occasionally the tendons, ligaments and muscles surrounding the joints become involved, and with the calcareous deposits produce deformities of a serious character. There may be, finally, permanent extension or flexion, dislocation or distortions of various kinds. In the developing stage, while movement is painful, the pain decreases if the movement is continued, and the condition of the joints seems to improve, while during rest the joints stiffen and the pain and edema increase. Metastasis is not as frequent in chronic rheumatism as in the acute form of the disease.
Often this condition will run a long course with little impairment of the general health; at other times the stomach and intestinal tract are subject to considerable derangement; the secretions are deficient, the urine scanty and high colored, and headaches are not uncommon, especially with those who are kept awake by the pain in the joints. Ultimately the health becomes seriously impaired and important complications develop, among which chronic endocarditis is the most common.
Diagnosis:—In the diagnosis, other joint disorders will be readily excluded by their characteristic symptoms. The history and gradual development of the symptoms above described will be confirmatory.
Prognosis:—These cases seldom make a complete recovery. The condition, however, while seriously impairing the physical action of the patient, is not a menace to life. The disease may be present from middle life to extreme old age. Complications increase its seriousness.
Treatment:—I believe that those patients have obtained the best results who have persisted for a long period in the use of the botanic alteratives and anti-rheumatic remedies, in the form of infusions or decoctions, conjoined with a strict attention to diet and hygienic surroundings. Macrotys, corydalis, stillingia, polymnia, rumex crispus and aralia are all valuable remedies. These may be selected and tried in accordance with the exact condition of each patient. An infusion of apocynum may be given in teaspoonful doses, or this remedy may be combined with one or more of the remedies above named to excellent advantage. Phytolacca, iris and apocynum will work nicely together, and other specific remedies will be available. Echinacea, apocynum and corydalis will exercise a beneficial influence also; or echinacea, corydalis and macrotys will be found of much service. These remedies may be given with potassium acetate or with small doses of potassium nitrate, which has been a favorite with Professor Whitford for many years.
External applications will be beneficial in selected cases. It is a good plan to keep the joints enveloped always in flannel; heat exercises a favorable influence in relieving pain and in promoting local tissue metamorphosis. The joint may be immersed each day, from fifteen minutes to an hour, in hot salt and water, then wrapped in warm flannels and surrounded with hot bricks or hot water bottles; or a flannel may be wrung from hot salt water, applied around the joint, and covered with oiled silk, to prevent its drying, and then packed in hot bricks or hot water bottles for several hours. The use of counter irritation or blistering remedies has not yielded good results in my cases. I have perfect confidence in the persistent use of a mild faradic current of rapid interruptions, continued for from fifteen to twenty or thirty minutes with each application, once every day, or every two days. I adopted this course in 1880, and have seen beneficial results almost universally from its use since. I am sure as good results have been obtained from the use of small batteries as from complicated, expensive apparatus. I have often advised these patients to purchase an inexpensive battery and administer the current themselves. I have not obtained nearly as satisfactory results from the galvanic current.
A change of climate and an occasional course of hot baths at the various springs, or a course of Turkish baths properly conducted and adjusted to the individual patient, or the hot air treatment, has been productive of good results. I am in favor of excluding meat from the diet of these patients in a large number of the cases. I decide by the condition of the skin and of the urine. If the skin is dry and the patient has a distinctly uric acid diathesis—lithemia—I prescribe the diet advised for the latter condition, excluding coffee and tea, and advising the use of water freely between meals, and a glass of milk at meal time.