# 1911 Encyclopædia Britannica/Rheumatism

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RHEUMATISM (from Gr. ῥεῦμα, flux), a general term for various forms of disease, now subdivided more accurately under separate names.
Acute Rheumatism or Rheumatic Fever is the name given to a disease having for its chief characteristics inflammatory affections of the joints, attended by severe constitutional disturbances and frequently associated with inflammation of the pericardium and valves of the heart. The acute rheumatism of childhood differs materially from that of adults in that the articular manifestations and constitutional disturbance are usually much less severe, whereas the heart and pericardium are especially liable to be attacked. It will be advisable, therefore, in discussing the symptoms, to deal separately with the rheumatism of adults and that of childhood. There are certain points of importance in connexion with its causation which are generally agreed upon. It is essentially a disease of childhood and early adult life, being most commonly met with between the ages of ten and twenty-five and comparatively rarely after forty. Heredity is unquestionably an important predisposing cause. Climate is also a factor of considerable importance, cold and damp with sudden and wide fluctuations of temperature being especially conducive to an attack. While perhaps more common in Great Britain than elsewhere, it is met with in most parts of the globe. Exposure to cold and wet, and especially a chill after free perspiration and fatigue, are among the most common exciting causes of an attack.
Of recent years much evidence has accumulated tending to show that rheumatism is a specific infective disease due to a micro-organism, and this is now generally recognized. There is still, however, some difference of opinion as to the nature of the micro-organism by which it is produced. In 1900 F. J. Poynton and Paine isolated from eight cases of acute rheumatism in children a minute diplococcus similar to that previously described by Triboulet and by A. Wasserman, which inoculated into rabbits produced lesions of the joints and of the heart indistinguishable from those met with in acute rheumatism. They have since obtained the same micro-organism from a further large number of cases of acute rheumatism, and their results have been confirmed by Walker, Beattie and others. They therefore claim that this micro-organism, to which they have given the name Diplococcus rheumaticus, is the specific cause of acute rheumatism. The objections which have been raised by other competent observers against this view are: (1) That this diplococcus is not found in all cases of acute rheumatism. (2) That certain other micro-organisms when inoculated into animals will produce joint and heart affections similar to those produced by the aforesaid Diplococcus rheumaticus. It would be out of place here to enter into the merits of this controversy; suffice it to say that the objections raised do not appear to be cogent enough to invalidate the conclusions arrived at by the authors of the germ theory. The matter is, however, still to a certain extent sub judice.
In adults the affection of the joints is the most striking feature. The attack is usually ushered in by a feeling of chilliness or malaise, with pain or stiffness in one or more joints, generally those of large or medium size, such as the knees, ankles, wrists or shoulders. At first the pain isSymptoms. confined to one or two joints, but others soon become affected, and there is a tendency to symmetry in the order in which they are attacked, the inflammation in one joint being followed by that of the same joint on the opposite side. The affected joints are swollen, hot and excessively tender, and the skin over them is somewhat flushed. The temperature is raised, ranging from about 101° to 103° F., the pulse rapid, full and soft; the face is flushed, the tongue coated with a thick white fur, and there is thirst, loss of appetite, and constipation. The body is bathed in a profuse perspiration, which has a characteristic sour, disagreeable odour. The urine is diminished, acid and loaded with urates. The attack is of variable duration, and may pass off in a few days or last for some weeks. Relapses are not uncommon when convalescence appears to have been established. Among the complications which may arise are hyperpyrexia, or rapid and extreme rise of temperature, which may run up as high as 110° F., when death will speedily ensue unless prompt and energetic treatment by cold baths or icepacks is resorted to. Affections of the heart, pericarditis (inflammation of the fibro-serous sac investing the heart) and endocarditis (inflammation of the lining membrane and the valves of the heart), which are so frequently associated with rheumatism, should be regarded as part of the disease, rather than as complications of rheumatism. They are far more common in children than in adults, and it is the damage to the valves of the heart in children by rheumatism which lays the foundation of much chronic heart disease in later life.
In childhood the affection of the joints is usually slight, and may be confined to a little pain or stiffness in one or two joints, and is sometimes attributed by parents to " growing pains." The constitutional symptoms are also ill-marked and there are no acid sweats, the temperature is not as a rule very high, the tongue not heavily coated, and the child does not appear to be very ill. The heart and pericardium are, however, especially liable to attack, and this may be so insidious in its onset that attention is not called to it till considerable damage has been done to the heart. It is of importance, therefore, that in children the heart should be frequently examined by a physician, when there is the slightest suspicion of an attack of rheumatism. Chorea or St Vitus's dance is a common manifestation of rheumatism in children. Subcutaneous fibrous nodules, attached to tendons or fibrous structures beneath the skin, are a special feature of the rheumatism of childhood. They are painless, and vary in size from one-eighth to half an inch in diameter. They are not very common, but when present indicate that the rheumatism has a firm hold and that cardiac complications are to be apprehended.
The patient should be placed in bed between blankets, and should wear a light flannel or woollen shirt. The affected joints should be kept at rest as far as possible, and enveloped in cotton-wool. Salicylate of soda or salicin, first suggested by Dr Maclagan in 1876, appear to exerciseTreatment. a specific influence in acute rheumatism. They have a powerful effect not only in reducing the temperature, but in relieving the pain and cutting short the attack. Frequent and fairly large doses of salicylate of soda should be administered for the first twenty-four hours: the dose and interval at which it is given should then be gradually reduced till the symptoms subside. In conjunction with this, alkalies such as bicarbonate or citrate of potash should also be administered. The effect of the salicylate should be carefully watched, and the dose reduced if toxic symptoms such as delirium, deafness, and noises in the ears occur. These drugs are of less service in the rheumatism of children than in that of adults, as they do not appear to exercise any specific influence in arresting the cardiac inflammation to which children are specially liable, though they have a marked effect on the joint affections. Aspirin has recently come into use as a substitute for salicylates, and may succeed when salicylates fail.
Subacute rheumatism. - This term is sometimes applied to attacks of the disease of a less severe type in which the symptoms, though milder in character, are usually of longer duration and more intractable than in the acute form. It is difficult, however, to draw a hard-and-fast line between the two, but the term may perhaps be most appropriately applied to the repeated and protracted attacks of cardiac rheumatism in children.
Chronic Rheumatism.—This term has been somewhat loosely applied to various chronic joint affections, sometimes of gouty origin or the result of rheumatoid arthritis. Strictly speaking, it may be applied to cases in which the joint lesions persist after an attack of rheumatism, and chronic inflammatory thickening of the tissues takes place, so that they become stiff and deformed. It is also appropriate to certain joint affections occurring in later life in rheumatic subjects, who are liable to repeated attacks of pain and stiffness in the joints, usually induced by exposure to cold and wet. This form of rheumatism is less migratory than the acute, and is commonly limited to one or two of the larger joints. After repeated attacks the affected joints may become permanently stiff and painful, and crackling or creaking may occur on movement. There is seldom any constitutional disturbance, and the heart is not liable to be affected.
Muscular Rheumatism.—By this is understood a painful affection of certain groups of muscles attributable to inflammation of their fibrous and tendinous attachments. It is commonly brought on by exposure to cold and wet, and especially by a chill after violent exercise and free perspiration when the clothes are not changed. Any movement of the affected muscles gives rise to severe and sharp pain which may induce a certain degree of spasm and rigidity at the time. The pain usually subsides and passes off completely while the patient is at rest, but occurs on the slightest movement of the affected muscles.
The chief varieties of muscular rheumatism are:—
    1. Lumbago, in which the muscles of the lower part of the back are affected so that stooping, particularly the attempt to rise again to the erect position, induces severe pain.
    2. Intercostal rheumatism, affecting the muscles between the ribs, so that taking a deep breath and certain movements of the arms give rise to pain.
    3. Torticollis or stiff neck, affecting the muscles of one side of the neck.
Treatment.—Salicylates, which are of service in acute rheumatism, are not so reliable in the chronic varieties, but are sometimes of service. Aspirin, salicin, quinine and iodide of potassium may be more successful, but other active treatment is usually required. The application of heat in the form of poultices or fomentations, counter irritation by mustard leaves or blisters, are indicated in some cases. In others massage, hot douches, or electricity may be required. Mineral waters and baths of various health resorts are often of great benefit in obstinate cases, such as those of Buxton, Bath, Harrogate, Woodhall Spa, &c., in England, or of Aix-les-Bains, Wiesbaden, Wildbad, &c., and many others on the continent of Europe. Wintering abroad in warm, dry and sunny climates may be advisable in some cases when this is practicable. (J. F. H. B.)