Acute Articular Rheumatism.

This disease affects the joints, as the name implies. It is
indeed an inflammation of a smooth membrane which lines the
joints, called the synovial membrane. At the same time it may
extend to other parts of the body containing this same membrane,
especially the heart. So long as the disease is confined to the
joints it is not immediately dangerous; the peril to life consists in
the possibility that the inflammation may extend to the heart, in
which case there often results serious difficulty, which may cause
immediate death, or may result in permanent disease of the heart.
Perhaps the majority of cases of so-called organic heart-disease
originate in attacks of acute rheumatism.

Symptoms*—Acute rheumatism usually begins with a sudden
attack, which may occur in the night. In some cases the manifesta­
tion of local difficulty—that is, pain in the joints—may be preceded
for a few hours or days by more or less fever. In most instances,
however, the fever and the local pain begin at about the same time;
it may indeed happen that soreness in the joints is felt for some
time before the fever begins.

The commencement of the disease consists in a painful swelling
in one or more joints, the skin around which is red and tender, the
intensity of the pain varies, but in most cases it is quite severe, and
becomes agonizing upon movements of the inflamed joints. Perfect
quiet is therefore requisite as one of the essentials for diminishing
pain. Pressure, too, over the joints is extremely painful, so that
even the weight of the bed clothes is at times unsupportable. Those
joints which are not covered by the muscles — the knee, wrist, elbow
and ankle for example — exhibit considerable swelling; while others,
such as the shoulder and hip, may be equally affected and equally
painful, but show only slight swelling. In some cases several joints
become inflamed at the same time, or in rapid succession, in others
the inflammation usually remains limited to one joint for some time
before spreading to others ; it rarely happens that the inflammation
is permanently limited to a single joint, since several joints are success­
ively attacked, and various ones may be suffering from the inflam­
mation at the same time ; in severe cases it seems as if nearly all the
joints of the body were invaded by the disease during its course. It
is a singular feature in the disease that the corresponding joints
on the two sides of the body, both knees or both elbows for instance,
are simultaneously affected. The relative liability of the different
joints to the disease appears to be, first the knee, then the ankle,
wrist, shoulder, elbow, hip and fingers.

Acute rheumatism is always associated with more or less fever,
and is hence often called rheumatic fever. The appetite is impaired
or lost, there is great thirst, the tongue is thickly coated, the bowels
usually constipated. A special feature is the profuse sweating
which occurs, especially at night; the perspiration evolves a sour
odor. The mind is usually not impaired, unless the membranes of
the brain become involved in the inflammation. The patient’s
strength is usually well preserved, his chief suffering consisting in
the pain in the joints.

Although the local inflammation in the joints may result in some
permanent stiffness or deformity, yet the chief danger from the dis­
ease occurs, as has been stated, from the possible complication in
the heart, for the heart is lined by a membrane quite similar to that
of the joints, and is covered over with another such membrane ;
either one or both of these may become the seat of the inflamma­
tory process, a complication which may occur at any time in the
course of the disease, though most frequently in its first half.
The various structures in the lungs and bronchial tubes seem
also liable to the rheumatic inflammation, though these complica­
tions are somewhat rare. The brain, too, is enclosed in membranes
similar to those of the joints, and these membranes may undergo the
same inflammatory process. In such cases active delirium, convul­
sions, and, finally, stupor may occur, though delirium doubtless
often occurs without there being any inflammation of the membranes
in the brain.

The natural duration of the disease varies, within wTide limit,
from two weeks to two months, the average being perhaps about
four weeks. Its course can be considerably shortened by various
modes of treatment, and in the majority of cases can be stopped
abruptly within two days by means to be presently described. If,
however, the heart complications occur, the illness may be indefi­
nitely prolonged. The joints, it is true, recover, but the patient,
convalesces very slowly.

Another unpleasant feature in the disease is its liability to re­
commence when apparently about concluded ; that is to say, the
patient will sometimes, after weeks of illness, become quite free from
fever and pain, the joints are no longer swollen nor tender, and
complete recovery seems to be at hand, when suddenly the disease
begins again affecting perhaps the same joints as before, and mani­
festing the same intensity.

Cause.—The popular idea attributes rheumatism to exposure to
cold. There may be, and doubtless is, some truth in the idea that
such exposure promotes the development of the disease. Yet it is
none the less certain that there is a certain predisposition to it; that
the disease runs in certain families only as a rule. An individual
in whose family rheumatism has not occurred may, it is true, in the
course of time develop the disease ; but the majority of instances
occur in people who have a hereditary tendency to it. This is in-
dicated by the occurrence of rheumatism in childhood, and by the
repetition of the disease in the same individual. Age, too, seems
to have a decided effect upon the susceptibility to the disease ; for
it rarely occurs, even among those who have a constitutional tend­
ency to it, under the age of fifteen years — the great majority of
cases occurring between the ages of fifteen and thirty years. It is
very rare to find an individual more than thirty years old who is
suffering from the first attack of the disease. Hence, it appears,
that the liability to acute rheumatism decreases after this age, and
becomes very slight after fifty years of age.

Treatment.—Until a few years ago, the treatment of acute
rheumatism was not entirely satisfactory, as was proven by the
fact that many methods were in use. The best results had been
obtained by the use of alkalies, with or without colchicum. A
formula frequently used was the following:
Carbonate of potassium, 7 -~ , Æ            , , ir , ,
KT..           c 1                   \ bach two and a-nalf drachms
Nitrate of potassium. )
Water, eight ounces.
Dissolve and take a tablespoonful three times a day.

Much value seemed to be obtained also from the use of lemon-
juice in water, say a tablespoonful every three hours. Yet, since
1876, there has been but little resort to these measures, because
means have been found by which the disease can be promptly and
effectually checked. Under the use of the alkalies and lemon-juice,
the patient was usually ill for two or three weeks at least, and ran
the risk of complications in the heart, which might prolong the dis­
ease indefinitely.

At present, however, we are enabled to cut short
acute rheumatism usually within three days, sometimes within
twenty-four hours; and not the least valuable feature of this
treatment is the avoidance of the heart complications, which often
prove the most serious feature of the entire illness.

The measure employed for this purpose is the use of salicylic acid, or some of its
compounds. The best form for general use will be the compound
of the acid known as the salicylate of sodium, which is less disa­
greeable and more easily administered than the acid itself. Perhaps
the best way to take it is in powder, ten grains of which may be
taken every two hours until six doses have been swallowed. It may
then be desirable to discontinue the drug for six hours. If,
at the end of this time, the symptoms of the disease have not
materially subsided, the powder may be administered in the
same way and quantity for another twelve hours. In the ma­
jority of instances the remedy works like a charm, especially if
it be administered early in the disease, before complications have
arisen in other structures than the joints. The fever subsides, the
joints are less sore and not at all painful, the appetite returns, and
not infrequently the patient who a day previously was writhing in
agony upon the slightest movement, flushed and feverish, rises
from his bed and walks without pain. It must be said that this
result cannot always be depended upon. If the case has already
lasted one or two weeks, the drug does not always act so promptly
nor so efficiently, though even then it is usually the best treatment
that can be employed. Then again, there are cases in which the
disease is not very acute nor painful, in which the swelling of the
joints is moderate and the fever slight. These cases are apt to be
especially obstinate, and to resist the action of salicylic acid. It is
impossible to say in advance which of the cases will yield, and
which will resist this drug, although one may feel sure of the cases in
which the fever is high, and be somewhat doubtful in regard to those
in which the fever is very moderate. Yet in every case we should
begin the treatment — and the earlier the better — with the salicylic
acid. If this drug be efficient in controlling the case, the fact will
be evident within three days, at the outside, in the rapid diminu­
tion of the pain, swelling and fever. If, at the end of three days,
there be no evidence of improvement, it will be wise to resort to
the alkalies, as in the formula above given, and the lemon juice.

Local treatment may also be used for the swollen joints; these
may be enveloped in flannel or cotton wool, which may be sur­
rounded with oiled silk. Or the swollen joints may be wrapped up
in cloth saturated with chloroform liniment, as it is obtained in the
drug store. Much benefit is derived in some cases by gentle friction
of the joints with the dry hand or with chloroform liniment. The
choice of measures may be left largely to the selection of the
patient, since some individuals will prefer one and some another of
these local applications. In employing the friction, the pressure
must be at first, of course, extremely light, to avoid giving pain;
though many times the force employed can be gradually increased
with comfort to the patient until the attendant may use as much pres­
sure as he can conveniently employ. A method which has been
recently much employed consists in the application of fly blisters to
the affected joints, permitting them to remain until some blistering
occurs. This plan doubtless relieves temporarily the pain in the
particular joint which is blistered, but seems to have no effect upon
the progress or course of the disease. On the whole, it is an unde­
sirable measure, since the blisters may subsequently give trouble.

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