Chronic Articular Rheumatism.
Definition.—A chronic articular disease of the joints, developing insidiously, or following the acute or subacute forms. It usually affects two or more joints, and is most likely dependent on the same conditions which give rise to the acute forms.
Etiology.—There are several predisposing causes, such as,—
Age.—This is a lesion almost invariably occurring after middle life.
Sex.—Females are more prone to the disease than males.
Environments.—One's surroundings materially predispose to this condition. Where the dwelling is low and damp, the rooms dark and poorly ventilated, and where poverty necessitates poor and illy prepared food and insufficient clothing, exposing the patient to all kinds of weather, there is a tendency to the disease.
Heredity.—Heredity may also operate in favor of bringing about conditions favorable for its development. "In some cases it has its origin in imperfect digestion and assimilation, which we would readily account for, on the theory that an increase of lactic acid was the cause of the disease.
"In others it seems to have arisen from, and is dependent on, deficient action of the excretory organs, and possibly on some changes in the process of retrograde metamorphosis, by which the broken-down tissues are converted into material fit for excretion; and in others, upon some derangement of innervation." There is but little doubt that the same causes which give rise to the acute and subacute forms are actively at work in producing this form of the disease.
Pathology.—"When the joints have been the seat of the disease, we find them variously altered. In some cases there seems to be nothing but an increase of the synovia; in others the synovial membrane is thickened, especially the false ligaments; in some cases roughened, covered with shreds of false membrane, or adherent, coagulable lymph, and the synovia more or less viscid, shreddy, and in some cases purulent. The articular cartilages are sometimes softened, at others eroded, and in some cases completely destroyed. The articular extremities of the bones are not infrequently enlarged, and the ligaments, tendons, and muscles contracted or relaxed. When affecting other parts, if of long duration, it may so change their structure as to leave little resemblance to their original condition."
Symptoms.—Dr. Scudder so clearly describes the disease that I will quote him in full: "As regards the general health of the patient, we find that it varies greatly in different cases. In some there is a manifest derangement of the stomach, various unpleasant sensations, as of fullness, pain, acidity, flatulence, etc., occurring after a meal, and showing that digestion is not well performed. In such cases we find the patient reduced in flesh and strength, and exhibiting evidence of marked general cachexia. In others, the secretions are manifestly at fault, the kidneys acting poorly, or the skin is harsh and dry, or relaxed and flabby, and the bowels irregular. It is true that we find cases of chronic rheumatism in which we can not detect the slightest lesion, except the local rheumatic disease; what loss of flesh and strength there is being attributable to the continued suffering and loss of rest resulting from it; metastasis occurs in the chronic as well as the acute disease.
"It most frequently affects the articulations, they being swollen, tender, and painful; one or more may be affected at the same time, usually not more than two, and the amount of swelling, discoloration, and pain varies in different cases; sometimes the tenderness and pain are exquisite; at others it is not very marked. The articulation is in some cases entirely useless, motion or pressure giving rise to severe suffering; at others, though lame, it may still be used. In some cases it takes the form of synovial dropsy, it being very evident that the enlargement is almost entirely dependent upon effusion into the joint; at others, the enlargement seems to be dependent upon material within the synovial membrane, but it is not nearly so mobile as before. In other cases there is marked enlargement of the articular extremities, or a dull, heavy, gnawing pain, with great tenderness, when the bones are placed so as to give rise to pressure on their extremities. In other cases the deposit is undoubtedly outside, involving ligaments, tendons, and muscles that pass between the two bones, causing relaxation in some cases, contraction in others, thus giving rise to deformity. In some cases this is very marked, bones being dislocated, or tendons so shortened as to produce unnatural flexion or extension, or to change the position of the bones, as in the case of the knee-joint, the articulation of the tibia being so changed as to produce knock-knee, and turn the toes outward; or, in the case of lumbago, or rheumatism of the dorsal or lumbar portions of the spine, giving rise to spinal curvature and other distortions. If it attacks a group of muscles, we may find them gradually shortening, until a limb is rendered entirely useless, as in the case of contraction of the hamstring muscles, and flexion of the knee, and finally terminating in the almost entire change of the muscular structure."
Diagnosis.—This is usually not difficult, the history of the case materially assisting in determining the disease. In gout, the pain is confined to smaller joints, and the pain is not aggravated by a change of weather.
Prognosis.—This is not favorable so far as effecting a cure is concerned; for unless the disease is seen in its incipiency but little can be expected in the way of a radical cure. However, medication mitigates the suffering and improves the general health. Very few die from the disease.
Treatment.—Where the patient has the means, a change of climate will often prove of great benefit. A visit to Southern France or Italy, or our own Southern California, or the dry, warm atmosphere of Arizona, often works changes that can be accomplished in no other way. A sojourn at Hot Springs, Arkansas; Martinsville, Indiana, or the various mineral springs to be found in the various States, will do more for a patient in a few weeks or months than years of ordinary medication.
Of the various anti-rheumatics, a few deserve especial mention. Apocynum, in the form of a decoction, has been one of the best remedies I have ever used. Where there is edema, slight or aggravated, it has few, if any, equals. Commence with ten-drop doses, gradually increasing the dose to a teaspoonful if the stomach will retain it. The one serious objection to the remedy is its intense bitter quality and the sense of nausea it produces, many patients being unable to retain it. Where there is heart complication, it is one of the best remedies at our disposal.
The alkaline diuretics, potassium acetate, citrate, or nitrate, will be found useful where we desire to stimulate metabolic changes, and thus fit the poison to be better eliminated by way of the kidneys. Dr. Webster speaks highly of rhamnus californica and grindelia squarrosa; of the other many remedies which may be used, I will only add, when the conditions present call for their use, of course administer them. Many cases will need other remedies than the anti-rheumatics.
Wrongs of the stomach need to be corrected, for a rheumatic dyspeptic will not improve so long as digestion is impaired. Wrongs of the kidneys need to be corrected, and so do those of any other organs. Many times, rheumatism continues owing to nerve impingement affecting the capillary circulation, and a removal of the source of irritation results in a rapid recovery.
One of the happiest cures I ever effected was accomplished by correcting a diseased rectum. The patient had been medicated for months, had spent several weeks at Clifton Springs, N. Y., but had failed to receive benefit; the removal of hemorrhoids and papillae with a thorough dilating of the rectum, soon effected a cure. Where remedies fail to give benefit, examine the rectum, urethra, and uterus. If there are sources of irritation in these organs, no improvement will follow till they are corrected.
As to local applications, the old irritating plaster accomplished wonders in the hands of the earlier Eclectics. This rather harsh treatment, however, has fallen into disuse and the various stimulating liniments have taken its place, although I still believe that the old plaster accomplished better results.
The patient should wear flannels at all seasons of the year, and avoid damp, low places. The diet should be largely of vegetables, fruits, and farinaceous foods; he should turn vegetarian, though fish and bivalves may be used in season; Londonderry and Buffalo Lithia waters will do some good. Electricity will give relief in some cases, and will be more frequently used when we learn better the conditions calling for its use.