Rheumatism (from the Gr. rheuma, 'a flux') is a term which has been, and still is, rather vaguely and extensively used in the nomenclature of disease. But there is one very definite affection to which it is always applied; after this has been discussed the other senses in which it is used will be considered.
Acute rheumatism or rheumatic fever is indicated by general febrile symptoms, with redness, heat, swelling, and usually very intense pain, in and around one or more (generally several, either simultaneously or in succession) of the larger joints, and the disease shows a tendency to shift from joint to joint or to certain internal serous membranes, especially the pericardium and the endocardium; rheumatism being the most common origin of pericarditis, as has been already shown in the article on that disease. The pulse is strong and full, there is headache, but seldom delirium, unless in very severe cases; the tongue is covered with a creamy thick fur, the tip and edges being red; the urine is turbid, and abnormally acid; and the skin is bathed in a copious perspiration, with so characteristic a smell (resembling that of sour milk) that the physician can often recognise the disease almost before he sees the patient. The joints are extremely painful, and the pain is much increased by pressure, and consequently by movement which gives rise to internal pressure. Hence the patient lies 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. Sleeping 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. Rheumatism 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 rheumatic diathesis or constitution, and the diathesis may be so strongly developed as to occasion an attack of acute rheumatism, independently of exposure 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 disease than women, but this probably arises from their greater exposure to atmospheric changes on account of the nature of their occupations. The predisposition 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 materies 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; and permanent damage to the affected joints is rare. It is, however, extremely apt to recur, either in the early stages of convalescence, 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 condition, much less common, but extremely fatal, is known as rheumatic hyperpyrexia, and is characterised 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 between blankets (i.e. without sheets), and be clothed in flannel; he must be carefully protected from draughts, and from undue pressure of the bedclothes, 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 be 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, colchicum, 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 Stricker in Berlin and MacLagan in England called attention to another method of treatment which is now almost universally adopted. Though new to Europe it has long been in use elsewhere, for the natives of South Africa have from time immemorial treated the disease by willow-top infusion. This method consists in the administration 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 admitted 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 necessary 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, especially 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.
Osteo-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 (e.g. 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, &c., are also of use. Under any treatment, however, complete recovery is exceptional; but the disease, even when severe, does not much shorten life.
Gonorrhoeal rheumatism is a form of joint-disease closely simulating acute rheumatism which occurs in some cases of Gonorrhea (q.v.). The affection does not, however, flit from joint to joint in the same way, and is not amenable to the same treatment.
Muscular rheumatism is the name usually given to painful affections of the muscles for which no clear cause is discoverable; it usually depends either on defective digestion or imperfect excretion of waste products from the system, and eliminant treatment, by alkalis, purgatives, or diaphoretics, is usually indicated. But it is very doubtful whether the cause is the same as in acute rheumatism.
RHEUMATIC DISEASES OF ANIMALS.—These are less common than the corresponding affections of men. Horses are not very liable to acute rheumatism, but suffer from a chronic variety, which occurs especially in conjunction with influenza. When affecting the limbs it often exhibits its characteristic tendency to shift from one part to another. In cattle and sheep rheumatic disorders are more common and acute than in horses. The specific inflammation sometimes involves most of the fibrous and fibro-serous textures throughout the body, inducing general stiffness, constipated bowels, and high fever. This is rheumatic fever—the chine-felon or body-garget of the old farriers. Sometimes the disease mainly affects the larger joints, causing intense pain, lameness, and hard swellings; occasionally it is confined to the feet and fetlocks, when it is recognised as bustian-foul. Cattle and sheep on bleak exposed pastures, and cows turned out of the dairy to feed on strong alluvial grazings are especially subject to rheumatism in its several forms. Amongst dogs rheumatism is known under the name of kennel lameness, and is very troublesome and intractable in low, damp, cold situations. Blood-letting is rarely admissible except in the most acute cases amongst cattle. In all animals a laxative should at once be given, with some saline matters and colchicum, and when the pain and fever are great a little tincture of aconite may be added. For cattle a good combination consists of one ounce of nitre, two drachms of powdered colchicum, and two fluid drachms of the Pharmacopœia tincture of aconite, repeated in water or gruel every three hours; half this dose will suffice for horses. With a simple laxative diet dogs should have a pill night and morning containing five grains of nitre and two of colchicum. Comfortable lodgings, a warm bed, horse-rugs on the body, and bandages on the legs will greatly expedite a cure. In chronic cases, or after the more acute symptoms are subdued, an ounce of oil of turpentine and two drachms each of nitre and powdered colchicum should be given for a cow, half that quantity for a horse, and one-fourth for a sheep. Hartshorn and oil, or other stimulating embrocations, diligently and frequently rubbed in, will often abate the pain and swelling of the affected joints.