If the subacute exacerbation be due to the action of the rheumatic poison—to a fresh rheumatic attack—the salicyl treatment will do good for a time, but'will fail to cure because the irritable textures will take some time to regain their normal condition after the rheu matic poison has ceased to act, and because the lactic acid, formed as a result of their inflammation, tends to keep up disturbance in them. Such a case treated by salicin or salicylic acid would be, and with justice, instanced as one in which these drugs gave only partial and temporary relief.
It is in these cases in which the fibrous textures have been the seat of prior attacks of rheumatic inflammation that the alkaline treatment often does much good. The change resulting from the former attacks renders these textures more irritable and more liable to disturbance from the presence of lactic acid. As a consequence of this, the local symptoms are apt to persist for a time after the action of the rheumatic poison has ceased. They are kept up by the lactic acid, and anything which hastens the elimination of this from the system tends to shorten the duration of the attack. Hence in such cases the alkaline treatment should be combined with the salicyl. The latter puts a stop to the rheumatic process; the former aids in the elimination from the system of the lactic acid formed during that process.
As compared with the frequency, of the occurrence of the acute and subacute forms of rheumatism in which it originates, this chronic thickening of the fibrous textures is not common, at least in its fully developed form. For this there are two reasons : first, it is only in a minority of cases that the rheumatic constitution is so marked as to lead to attacks sufficiently frequent and long-continued for its production; and second, in a large number of those who possess this markedly rheumatic constitution, the heart suffers as well as the joints, and death ensues from the cardiac trouble, before there has been time for the development of permanent thickening of the fibrous textures.
Nowadays, treatment is so successful in shortening the duration of acute and subacute rheumatism that it may reasonably be hoped that this condition will year by year become less common.
This thickening of the fibrous textures is a condition over which drugs exercise little or no control. As one can never be sure that the pain at a given time may not be due to the action of the rheumatic poison, the salicyl compounds should always be given for a time, not with the idea of removing the chronic thickening, but with the object of relieving any purely rheumatic symptoms. For those who can
afford it the most useful treatment is such as is to be got at Bath, Buxton, Droitwich, Strathpeffer, and other baths in Great Britain; at Aix-les-Bains, Dax, in France; at Aix-la-Chapelle, Wildbad, Gas tein, Teplitz, Wiesbaden, Franzensbad, and other baths in Germany.
Chronic rheumatism is the ailment for which this chronic thick ening of the fibrous textures is most apt to be mistaken. Occurring as it does in those who have suffered from repeated attacks of acute or subacute rheumatism, and presenting many of the symptoms of rheumatism, it could scarcely fail to be mistaken for the chronic form. It is of great importance that the two conditions should not be confounded, for their prognosis and treatment are essentially dif ferent. Wherein chronic thickening of the fibrous textures consists, its name implies. Its pathology we have just considered. Chronic rheumatism, properly so-called, is a very different condition. It is due to the presence and direct action of the rheumatic poison, and is not necessarily, or even usually, accompanied by any perceptible change in the textures involved. It consists simply in rheumatic dis turbance of the affected tissue. It differs from the acute and sub acute forms not in nature but in degree, and sometimes in the special textures involved. It is a true rheumatic attack in which the morbid process and local disturbance are not sufficiently marked to raise the temperature or to lay the patient up. The textures involved are the same as those which suffer in the acute and subacute forms, with this difference, that the fibrous aponeuroses and muscles are more apt to be affected.
Chronic articular rheumatism usually affects the same joints as suffer in the acute and subacute forms. Seldom more than one or two joints are affected at the same time, and in none of them is the pain bad enough to lay the patient up. It may shift from joint to joint and last, off and on, for months or even for years, the patient during the whole time being never really ill and yet never quite well for more than a few weeks at a time.
The following two cases serve to illustrate this form of the disease.