Rheumatism, gout, and some allied disorders

Chapter III. Causes Of Rheumatism

Causes : Hereditary Predisposition, True and False Heredity ; Age, its Effects on the Various Forms ; Sex ; Connection with General Health and other Diseases ; Climate, Country, Race, and Change of Habitation ; Seasons, Atmospheric and Barometric Influences ; Occupation and Manner of Life ; Temperament and Constitution ; Injuries ; Sleep ; Former Attacks and their Effects ■ Drugs pp. 16-41

CHAPTER IY.

PATHOLOGY.

The Various Theories: The Local or Inflammatory; the Vascular; the Nervous,

comprising the Electric, the Spinal, and the Vaso-motor ; the Specific Poison, or

xctic Acid Theory ; the Physiological and Chemical Origin and Nature of the

Lactic Acids ; the Defects of this Theory ; the Infection Theory pp. 42-66

IV CONTENTS.

CIIAPTEE Y.

DESCRIPTION AND COURSE OF THE DISEASE.

Acute Rheumatism : the Prodromal Interval; Chill; Fever; Pain; Aspect of Face; General Bodily Condition ; Skin ; Pulse ; Temperature ; Digestive Functions ; Urine ; Sleep ; Delirium ; Menstrual Function ; Epistaxis ; Course, Duration, and Severity; Result. — Subacute Rheumatism: Its Distinction from other Grades and Forms .pp. 67-81

CHAPTER YL

CONSIDERATIONS OF THE INDIVIDUAL SYMPTOMS OF ACUTE RHEU- MATISM AND THEIR PECULIARITIES.

Of the Fever ; of the Chill ; Temperature Curve ; Modifications from Complications ' pp. 82-87

CHAPTER YIL

CONSIDERATIONS OF THE INDIVIDUAL SYMPTOMS OF ACUTE RHEUMA- TISM AND THEIR PECULIARITIES.— Continued.

Of the Joints : Development of the Articular Phenomena ; Reasons for the Involvement ; Attitude and Position of the Patient and of the Joints ; Cause, Seat, and Character of the Pain ; Redness ; Swelling- ; Subsidence of Inflammation ; Temperature of the Joints ; Comparison with Gout ; Numerical Frequency in the Different Joints ; Relation to Cardiac and other Complications ; Duration ; Metastasis pp. 88-94

CHAPTER YIII.

CONDITION OF THE SKIN AND ITS FUNCTIONS.

Excess of Function— Sweating and its Significance : Its Frequency ; Its Characteristics ; The Difference of the Sweats — The Eruptions : Sudamina ; Urticaria ; Medicinal Eruptions ; Hemorrhagic Eruptions ; Rheumatic Purpura ; Hemophilia or Scurvy ; Embolic Purpura -v . . .pp. 95-100

CHAPTER IX.

GENITO-URINARY APPARATUS.

Question of Rheumatic Localizations in the Kidneys — The Result of Contact with the Altered Urine — Comparison with Gout — Albumen, its Significance — Raver's Rheumatic Nephritis— Intercurrence of Bright's Disease and Rheumatism — Lan-

CONTENTS. V

cereaux's Interstitial Nephritis— Embolism, or Secondary Albuminuria — The Bladder, Affection of its Muscular Tissue— Urethra, Ovaries, Uterus, etc.— Rheumatic Orchitis pp. 101-100

OHAPTEE X.

THE URINE.

Causes of its Alterations — Its Amount — Its Color — Its Reaction — Its Density — Urea — Uric Acid — Other Solid Ingredients — Albumen — Sugar — " Fibrinous Urine." pp. 107-119

CHAPTER XL

COMPLICATIONS, OR EXTRA-ARTICULAR LOCALIZATIONS.

Their Importance in Rheumatism — The Point of View from which they are to be Regarded — The Order and Frequency of their Occurrence : Muscular ; Circulatory; Respiratory, Cerebro- Spinal, Digestive, and Urino-genital — Cardiac Localizations: Our Knowledge of them; Their Frequency; Various Forms of Cardiac Lesions Collectively ; Their Relative Frequency and Combination. Time of their Occurrence and Concurrence ; Symptoms of Endocarditis ; Symptoms of Pericarditis — Rheumatic Localizations in the Vascular System pp. 120-131

CHAPTER XII.

COMPLICATIONS, OR EXTRA- ARTICULAR LOCALIZATIONS. — Continued.

Respiratory Apparatus : The Parts Affected and the Frequency of their Involvement ; Pleurisy, its Character and Duration ; Pneumonia, its Relation to the Rheumatic Process ; its Type and Grade ; Mucous Membrane Inflammations, their Relationship to the Tissues Ordinarily Affected in Rheumatism ; Rheumatic Angina ; Bronchitis and Broncho-Pneumonia — Digestive Apparatus . .132-136

CHAPTER XIII.

NERVOUS COMPLICATIONS.

Symptoms— Acute Inflammatory, Cerebral, and Meningeal Lesions— Cerebral Rheumatism — Hyperpyrexia — Other Nervous Symptoms — Rheumatic Cephalalgia — Vertigo — Conditions which Tend to Produce Cerebral Symptoms and Lesions , ,. , .pp. 137-152

VI CONTENTS.

CHAPTER XIY.

MORBID ANATOMY.

Pathological Changes: Hyperinosis ; Condition of Joints; Changes in Cartilages ; In Tissues and Skin ; In the Blood — Hyperpyrexia — Cardiac Conditions — Endocarditis—Histological Process in Endocarditis— Embolism — Cardiac Murmur — Valvular Vegetations — Inflammatory Products : 1. Inflammatory Resolution ; 2. Infhmmatory Organization — Chronic Endocarditis — Pericarditis — Acute and Chronic Myocarditis pp. 153-175

CHAPTER XY.

DIAGNOSIS AND PROGNOSIS.

Diagnosis: Pyaemia; Gonorrhoeal Rheumatism ; Acute Rheumatoid Arthritis ; Acute Gout ; Pain ; Ag3 : D\iration of Attack — Prognosis — Death from Violence of the Fever ; Death from Cardiac or other Visceral Complications ; Disability from Joint Changes ; Liability to Second or Recurring Attacks, or to Chronic Rhenma- .tism — Predisposition to the Disease pp. 176-184

CHAPTER XYI.

TREATMENT.

Treatment of Rheumatism in the Past — General Remedies : Venesection ; Cupping and Leeching ; Purgatives ; Diuretics ; Sudorifics ; Woollen Applications ; Moist Applications ; Revulsives and Counterirrrtants ; Blister Treatment — Drugs Colchicum ; Guaiacum ; Cinchona Bark ; Quinine ; Opium ; Antimony and Mercury ; Veratria and Aconite — Alkaline Treatment : Nitrate of Potash ; Bicarbonate of Potash ; Citrate of Potash ; Lemon Juice : Bromide of Potash — Salicyl Treatment : Salicin ; Salicylic Acid ; Salicylate of Soda — Mode of Action of the Salicyl Treatment : Action of Salicin; Action of Salicylic Acid ; Action of Salicylate of Soda — Anaesthetic and other Topical Applications — Diet and Regimen pp. 185-221

CHAPTER XYIL

CHRONIC ARTICULAR RHEUMATISM.

Symptoms and Course. — Morbid Anatomy. — Diagnosis. — Treatment. —Local Applications f pp. 222-239

CONTENTS. Vll

CHAPTEE XVIII.

GONORRHCEAL RHEUMATISM.

Liability to, and Frequency of its Occurrence— Symptoms, Course, and Duration- Its Results— Treatment pp. 340-249

CHAPTER XIX.

GOUT.

Causes and Causal Factors. — Age, Sex, Heredity, Customs, and Nationality. — Varieties. — Symptoms, Course, and Duration. — Acute Gout, Chronic Gout. — Visceral Manifestations. — Pathology and Morbid Anatomy. — Diagnosis. — Prognosis. — Treatment. — Treatment of the Paroxysm. — Treatment of Chronic Gout pp. 250-270

EHEUMATISM, G-OUT,

AND

SOME ALLIED DISORDERS,

Chapter I. Introductory

Rheumatism — Some Considerations Concerning' its History, Nosology, and Etiology —

Synonyms — Definition.

The term Rheumatism, in the sense in which it is now used, dates from about three centuries ago. Previous to this time writers comprehended under the term arthritis this disease with gout and all other inflammations of the joints, ligaments, and muscles. Anciently the words rheuma and rheumatism denoted all those diseases in which it was supposed that the blood became impregnated with acrid humors, phlegm, bile, or other noxious materials. Hippocrates states that the bile mingles with the blood in the veins and articulations, causing swelling of the joints, or extending to the whole body, producing acute pain. In this view, with some modifications, Hippocrates was followed by most of the later writers. From this group, these writers separated the diseases of the mucous membranes under the general head of catarrhs ; all the other members of the group retained the designation of rheumata. In 1610, William de Baillou published his thesis on rheumatism, in which he showed the distinction between this disease and gout. Sydenham, who lived fifty years later than Baillou, even more distinctly divided these two diseases. Cullen, Stoll, and Van Swieten in their teachings promoted these views and framed their treatment accordingly. The humoral pathology of that day

RHEUMATISM, GOUT, AND ALLIED DISORDERS.

,lv to {hv enforcement of these theories of the nature of

mtftam. Although the separation of these two maladies

BBtomed, nevertheless the meteorological theories of the

. m medical writers, assisted by the Nosologists, who at-

e ;lu knowledge of medical science into such bounds as

M* to give a name to, contributed to overturn the sound basis

$ lenham had given to the subject, so that early in the present

find the two diseases grouped under the same heading, and

1 upon by many as diverse manifestations of the same humor min-

iritfa the blood.

v x si mictions Concerning its History, Nosology, and Etiology,

In early times, but especially after the separation of rheumatism from - that the terms "rheumatism" and "rheumatic" were external diseases, or, rather, to maladies which affected the trta of the body ; however, it must be admitted that with rheum were confounded many ailments which were of wholly dissimilar • ; for example, phlebitis, pyaemia, neuralgia, coxalgia, certain scorand scrofulous diseases, and even some of the puerperal conditions, tli is, so to speak, external nature given to rheumatism, its cause •oked upon as of external origin, and the principal cause was con- 1 to be cold and such atmospheric variations as were connected with changes of temperature. This generally accepted theory of the caui of rheumatism led to the inclusion among the heterogeneous components of this malady other diseases, which formerly were not consid- ■ -longing to the same group, but which were due to the same supposed cause, viz., cold. Thus, all diseases, especially those accompa with pain, were counted as rheumatic, if not as being " rheumatism "" itself. Many of these newly included diseases were affections of internal organs. Rheumatism was, therefore, no longer a disease of the external alone, bat also a visceral affection. The brain, the lung and its 88, the heart, the kidneys, etc., were all supposed to be the f rheumatism, and not only the morbid changes which we now '■ ■ e organs as the results of rheumatic disease, but many ra were ascribed to this humoral poison. A rheumatic apoplexy, a •a of the intestines resulting in diarrhoea and dysentery, and others were added to this list. Through the advancement made in

"morbid anatomy, aided by greater accuracy in clinical studies, some of these diseases have been confirmed in their position as the results of the rheumatism poison, others have been thrust away, and still others, hitherto unknown, have been brought to light and arranged in a proper relation to this morbid cause.

The position which rheumatism now occupies, as a nosological entity, is that of a group of symptoms, not necessarily and essentially connected, having a common or supposed common cause, without, however, any, as yet discovered, anatomical basis. That this should be the position of rheumatism, is the necessary result of varied opinions held concerning it from the earliest times until the present. At first the word was used like catarrh, to signify a " defluxion of an acrid humor, generated in the brain, into various parts of the body," and later, after the catarrhal affections of the mucous membrane had been separated into a distinct group, denoted all diseases due to the circulation of acrid humors. Later still it was employed to denote the vague pains of the external parts, and afterward, when Ballonius distinguished it from gout, rheumatism was applied to the same group of symptoms to which it now appertains. It is no wonder, therefore, that the term, as handed down to us, has as vague a significance as some of the pain to which it has been and is at present applied.

While at the present time we may hold more definitely in mind what we comprehend under the heading of rheumatism than was done formerly, when unquestionably neuralgia, pyaemia, coxalgia, and certain syphilitic affections were included in this group, still it must be admitted that the acute and chronic forms of rheumatic articular disease and muscular rheumatism form a class which, if not pathologically dissimilar, are nevertheless joined together by only one common symptom, viz., pain, and one common cause, viz., cold. It is self-evident that these two bases are not sufficient grounds for founding either a pathological or an etiological group of disease.

The cause of this heterogeneous classification, so evidently the result of a survival from ancient times, is to be explained partly by the failure of post-mortem investigations to disclose any adequate explanation of the symptoms, and also by the infrequency of the opportunities to conduct such investigations, owing to the rarely fatal character of a vast majority of the cases belonging to this group of diseases. Although it is true that many patients die from rheumatism, the fatality occurs mostly from the after-results of the acute disease, and, therefore, at a period when the special manifestations and characteristic lesions have subsided and can no

4 RHEUMATISM, GOUT, AND ALL1KD DISORDERS.

« soon in the condition in which they present themselves during M the failure from this cause to study the special •Ism d068 not seem to cover the whole ground, or to ex- ..: ignormnoe of the special pathology of this affection, either in OX chronic form, or its manifestations as a muscular rheumatism. iiom the results obtained from the careful post-mortem examination of bodiee dying at the period of the disease most favorable for such lies, and the entire inadequacy of the lesions in explaining the morbid symptoms, it is not probable that more frequent opportunities for such examinations would contribute very greatly to our knowledge of its pathology. The true direction, it would seem, for us to seek enlightenment is from a study of the altered condition of the blood. Already some experimental studies have been made, and very many theories have been put forward in relation to the noxious ingredients present, but as yet nothing definite has been determined with sufficient positiveness to command the universal assent of investigators and the profession ha general. I cannot but think that if, at the present time, it were customary as formerly to bleed freely every patient suffering from acute rheumatism the amount of material thus so abundantly presented for examination would call up some one fully fitted to determine the problem. It is blood in the living state that is needed ; blood post-mortem, is not in a suitable condition for such an investigation. Even blood freshly drawn is so rapid in its alterations that the study of it is one of the most difficult tasks in the whole field of pathological investigation. Consequently to-day, our knowledge of the fluid, both in its normal and pathological conditions, is far behind that which we possess in regard to nearly every other organ of the body. Quite recently, however, more attention has been given to the study of the pathological states of the blood, especially in connection with infective disease, and this work has yielded abundant results, which are still to be held sub judice. In connection with syphilis and some of the exanthematous fevers, peculiar corpuscular elements of low forms of animal or vegetable life have been shown to be present with tolerably constant persistency. How far the presence of these morbid elements in the blood can be looked upon as the essential cause of the diseases with which they have been found remains to be proved, and is, in fact, the essence of thenpathological signification. In connection with malaria, a disease to which rheumatism bears a closer resemblance than to almost any other, except gout, in the whole nosological catalogue, a newly discovered fungoid growth1 has been shown to be present in the blood both of patients and infected animals, and a similar minute organism has been found in the soil and air of malarious districts.

It yet remains for us to find some agent or property which, newly formed in the blood under the influence of sufficiently exciting causes, leads to the outburst of that train of symptoms which we at present include under the head of rheumatism ; and also to show whether it is the same agent or product acting within the system that gives rise to both the acute and the chronic forms of the disease, as well as to the form included under muscular rheumatism.

The presence in excess of such an agent as lactic acid in the blood, which was at one time supposed to be the materies morbi in rheumatism, by no means proves that this material, or any other which may be discovered, is the essential cause giving rise to the disease. The presence of the morbid material may be due to the same cause as the disease itself — may, in fact, be only a symptom, may be a result and uot a cause.

Failing to find any efficient element or basis in the blood itself which may be regarded as the cause of the disease, the solid tissue remains as yet unsearched with the degree of care which can be called at all thorough. So far, we have only had the general statement made that the articular and fibrous tissues, which are specially implicated in the disease, show no evidences, or only very slight ones, of inflammatory or other changes. It is not improbable that this field of research, like so many other unsearched fields, may yield the most profitable return.

Finally, the results both of physiological and of pathological experiments have been as yet untried. As yet no one has suggested a clue to the line in which such examinations should be conducted ; but until the trial has been made in these various directions, the search for the pathological relationships of rheumatism must not be abandoned.

Kheumatism, in all its varieties, as at present classed, is a group of maladies founded on an etiological basis. Away from it' have been separated various diseases as rapidly as a firm pathological foundation has been discovered for them, and it is an old block from which many pieces have been hewn away. How far the remainder is a homogeneous mass can only be known when rheumatism itself has been shown to be a consistent pathological entity, and its pathogeny is discovered. The etiolo-

6 i:il BUM ATISM, GOUT, AND ALLIED DISORDERS.

gical foundation on which it rests at present is a chill, or some atmospheric influence of cold and moisture. Such influences may be a good and surticient 0OU96 for the disease, but it is not a valid reason for classing toh a variety of affections, having merely one factor in compain. The older nomenclature, from which the present one is a derivative, or, in truth, the remains, or a survival, was more nearly accurate, and certainly more consistent, for it included all the other disacknowledging the influence of cold as their cause, and likewise having the symptom, pain, as at least one of their principal phenomena. The separation of these various diseases and their classification under different pathological headings has not been altogether logical, and, so far as rheumatism is concerned, has not advantaged us. The class rheuma might well stand to-day with its subdivisions : pleuritis, pneumonitis, mucosae or catarrhalis, and the other "rheumata." All the latter of these diseases, as fast and so far as their pathologico-anatomical characteristics were known, have been put in proper and consistent groups, and by these discoveries our knowledge has been advanced ; but rheumatism still remains unknown and unclassified, as the residuum of former ignorance.

While, as has been shown, it is impossible to regard all the diseases now described as rheumatism as identical either in their causation or pathology, it by no means follows that the term is to be rejected from our nomenclature. In fact, any attempt to effect its displacement would be attended with failure. The efforts which have more recently been made by German authors, as well as others in our own language, to designate the disease by other titles, have met with but little success, and have not tended to advance our clearness of conception or knowledge of the essential factors of the malady. Clearly it has not been the change of name which has led up to the essential pathology of any of the diseases which have been separated from rheumatism. The steps in the process have been just the reverse, and a knowledge of their pathology has shown many of them to be so diverse from rheumatism, that a change of name became imperative. A name so familiar as rheumatism would be difficult, indeed, to displace from our language, even were its pathology most fully known. The word itself implies no pathological signification, and, therefore, like many terms similarly applied, may be usefully retained. The name, cirrhosis, as applied to the liver, formerly meant merely a tawny color ; now, however, it signifies the changes which lead in part to the production of that coloration, and is applied not only to the liver, but to various organs — the kidney, lung, etc. The same may be said of apoplexy. And while in respect to both apoplexy and cirrhosis, since their morbid anatomy has become fully known, so, in respect to rheumatism, the word still lingers in the language ; and, in spite of all discoveries in respect to its nature, will continue to remain, just as these other words nave so long done. Even in the new German nomenclature, the authors have been compelled to retain the word as an adjective ; thus, rheumatic polyarthritis or rheumarthritis, chronic rheumatic arthritis, and rheumatic myopathy or myalgia but partially displace the term commonly in use. This use of the word in its adjective form has, in their view, much to recommend it ; and whatever in the future may be discovered in relation to rheumatism and its pathology, or however much the term itself may be discarded, still the word "rheumatic" could always be maintained with advantage, or even extended in its use, as signifying that great group of •diseases having certain etiological features in common, and recognized as •dependent in their origin on certain external causes, as cold or atmospheric influences, until, at least, the other various causal factors have become known.

Synonyms.

The following names have been applied, by various authors, to rheumatism. Thus we find it called arthritis, rheumatismus, acute rheumatism, articular rheumatism, rheumatic fever, rheumatic polyarthritis, rheumariihritis, polyarthritis synovialis, febrile rheumatism of the joints.

Definition.

A definition does not add much to our knowledge of a disease, but it seems to be demanded, serving as a row of pins on which to attach our ideas.

Kheumatism is a constitutional disease, attended with febrile disturbance, and with inflammation of structures in and around the joint, and often ©f other organs of the body, especially of the connective-tissue group. The disease is not infectious. The inflammation does not lead to deposit of urate of soda, does not lead to suppuration, and is erratic or shifting in character ; by many is regarded as specific or peculiar, but its peculiarity is evidenced only by so violent an action leaving so little trace Ibehind it