A specific type not yet explained as to its nosological value, is represented by Still's disease. Here is found an almost painless chronic thickening and stiffening of the joints of little children, accompanied by fever, either continuous or periodical. The disease, begin ning with the knee-joint, wrists, or the cer vical portion of the vertebral column, gradu ally attacks the ankles, elbows and fingers, without leading to any destructive articular transformations. There is no endocarditis, but at the same time pericardial adhesions have been noticed. The most conspicuous manifestation is the hypertrophy of the spleen and the multiple swelling of the lymphatic glands. It yet remains an open question, or not these cases are possibly due to tuberculosis or to chronic sepsis.
Course and Termination.—The course of the affliction is chronic in the extreme, and may extend into years and eventually decades. At any rate the affec tion advances in children with greater rapidity than in adults. Long intermissions occur. Recovery or at least considerable improvement is seen especially in cases of the first group. Improvement is found also in very rare cases, of course, in children of the second group. Death is either the result of general exhaustion or of a secondary tuberculosis.
Diagnosis.—The differential diagnosis should present no difficul ties except to exclude syphilis and tuberculosis. Regarding the former we refer to its proper section. Multiple fungous joint disease may pro duce an appearance which is very similar to chronic rheumatism; here, however, tuberculous disease of the bones is often found, a fact which is proven by the X-ray pictures.
Since secondary tuberculosis occurs frequently in cases of real chronic articular rheumatism, it would not be reasonable to draw com prehensive conclusions, either from the tuberculosis of the internal organs, or from a positive tuberculin reaction. Greater weight should be attributed to a positive result from intra-peritoneal inoculation of a guinea-pig with the synovial fluid obtained by puncture, although even a secondary tubercular infection might have to be considered.
How far the presentation of this disease, "Rhumatisme tuberculeux " by the French (Berard and Dcstot, Barjon, Poneet, Maillard) is consistent with the facts, only further in vestigations will show. Further more, it may be mentioned that in connection with articular hwmorrhage may result in a chronic arthropathy, which might remind one of chronic rheumatism. Arthritis urica is so rare in children that we may forego discussing it here. Whether it will be possible to eliminate clinically from chronic articular rheumatism, synovitis chronica villosa, as described by Schuller (a disease which is said to originate from a special cone-shaped bacillus) will have to be determined only by further investigations.
only two really effective factors are known to us; namely, rhea- _ matic heredity and the influence of damp and cold habitations. The essential points to consider, therefore, against the further development of the disease in children afflicted with rheumatism are hygienic pre cautions in the dwelling and proper clothing, as well as appropriately guarding the child against inclement weather.
cases of the first group are amenable to treat ment with the salicylates, as aspirin, etc., and in cases of intercurrent acute attacks it will be well to return to these remedies.
If the salicylates, however, are ineffective in an attack of acute articular rheumatism, at its very outset, and the disease shows a tendency to assume a chronic course, then it is advisable to place the joints into a position of repose, and to use local applications of mesotan (see page 497).
Later it is well to start with what is paramount to all other treat ment, i.e., physical therapeutics; these procedures may sometimes be efficiently assisted by the quite persistent administration of iodide of sodium. After all, the most important mode of treatment, and one which must be adhered to with great patience, is gentle massage and careful passive motion. At the same time a local treatment with 10 per cent. ichthyol in vaseline may be useful. This is to be rubbed in at night and covered with wadding, next morning slight friction with French brandy.
Immobilizing bandages ought to be avoided as far as possible except in cases of acute exacerbations. In advanced stages of the disease the production of active or passive hypercemia proves use ful. Bier's process of producing con gestion (stasis), or preferably hot air or electric light baths may be considered.
Very favorable but of course only temporary results have been observed from the use of daily hot sand baths at 30-35° C. (S6-95° F.); for one half to one hour. Occasionally applications of fango (fango poultices) of 40° C. (104° F.) daily around the joints for six hours have attained some success. Frequent very warm applications of such poultices to the vertebral column occasionally lead to excellent results. As alter natives douches deserve consideration, if there is no tendency toward acute relapses. Sonic French authors have seen results with the galvanic current. In conjunction with external treatment, an internal or sub cutaneous treatment with arsenic may be tried. Occasionally rectal feeding may be necessary if there is a marked involvement of the tem poromaxillary articulation.
As to the success of hydrotherapy (as Nauheim, Teplitz, Wildbad, etc.) we can hardly judge, since almost without exception only children of the poorer, or the poorest, classes arc afflicted with the disease. If stiffness of the joints and contractures have already formed, then very beneficial functional results can be obtained by orthopedic and mechani cal treatment, reduction, tenotomy, plastic surgery of tendons, traction, and apparatus (Spit zy, Reiner).
Possibly thiosinamin could be used in these cases to great advan tage, although so far as I know, it has never been tried, in spite of its softening influence upon the cicatricial and connective tissues, especially as a transition from the chronic into an acute inflammation would be welcomed.
Menzer's serum has not as yet been tried. The hypnotic suggestive therapeutic endeavors of some authors (Bernheim, Grossmann) can be regarded only with skepticism especially with children.
A special surgical procedure, i.e., injection of iodoform guaiaco glycerin emulsion, or a free opening of the joints and excision of the villous coat, would have to be considered in a ease of Schiiller's synovitis chronica villosa.
Von Starck saw rapid improvement result from in unctions of Credo in a case presenting the picture of Still's disease. In cases attended with fever, the use of colloidal silver in the form of Credo's ointment or intravenous collargol injections would, at any rate, be worth a trial.