§ 3. Muscular Rheumatism.—Pain and stiffness of rheumatic origin may also attack the muscular structures. It occurs with or without attendant fever ; but it cannot be supposed that in so slight a malady, the fever is symptomatic, the two are rather coincident affections ; and we must be careful to make out dis tinctly that such is the fact; for when the pyrexia arises from a local affection, tension and hardness will be observed as well as tenderness, indicating the presence of the products of inflamma tion, in the effusion of lymph or serum, and proving that the disease is not rheumatism. In the absence of fever, the disorder cannot be called " chronic," because of its short duration and transient nature ; but we may call it "slight" rheumatism. In a diagnostic point of view, we recognize the existence of pain, more or less constant, aggravated, or only called into existence by muscular movement ; passive motion not being attended with pain, as it is in rheumatism of the joints, except when, by anta gonism, some muscle is called into action.
This is one of the causes of lumbago, the most severe form of muscular rheumatism. Its diagnoses must not rest upon this one symptom, however prominent. Careful inquiry must also be made into the condition of the spine and the kidneys, which may each be the cause of pain in the loins. Muscular pains, uncon nected with rheumatism, will occupy our attention at a future period. (See Chap. X. § 1.) § 4. Chronic Rheumatism.—Pain and stiffness of the ligament ous structures, often of long duration, with or without thickening of parts, and increased by motion of the joints or handling of the limb, when unaccompanied by marked tenderness or febrile action, is to be classed under the denomination of chronic rheu matism.
It is not possible to specify, with any degree of accuracy, the exact element of this form of disease ; but it is very important that the practitioner should be able to distinguish painful affec tions dependent on other causes from those which, in the absence of positive indications to the contrary, must be regarded as rheu matic. In the subsequent recurrence of the disease, patients themselves are often able to discriminate very exactly between the pain of rheumatism and that of other disorders, but too much reliance must not be placed on such statements.
The early history generally points to pain as the fhst or the only indication, altered form or structure being a later or second ary effect,. Occasionally it occurs as the sequel of an acute attack which has not been followed b7 complete convalescence, but more frequently it has no such origin ; nor does it appear that the sub jects of chronic rheumatism have been, in any large proportion, affected with acute rheumatism at former periods. It is much
more common in advanced than in early life. Simultaneous affection of several joints, including the constitutional nature of the dise,ase, is not so frequently met with in this as in other forms of rheumatism; nor are there any general symptoms constantly associated with it. The inquiry into the condition of other organs often brings to light disordered functions or impaired nutrition, which have an indirect but important relation to the disease, and are even more essential to its correct treatment than perfect knowledge of the local condition.
When affecting the smaller joints, alterations of form are more frequently seen as its result than when the larger one,s are espe ciOy attacked, and, at all events, from their situation, the swelhng or distortion is more readily perceived ; but ita site is rather in the latter than in the former. The shoulders, the hips, and the ligamentous structures of the back are its common situations, and next in order, the knees, ankles, and elbows ; in the hands and feet, the disease is more likely to be of a gouty nature, or at least to correspond with what is called rheumatic gout.
With reference to diagnosis, we have to discriminate diseases accompanied by pain in eituations where chronic rheumatism is usually met with, and dis eases of the joints which are not rheumatic. The painful affections are chiefly neuralgic or sympathetic ; in the shoulder and upper part of the back, those connected with disorder of the liver and dyspepeis ; across the loins, those produced by affections of the kidney ; at the lower part of the back. in females, those associated with vaginal discharges and uterine disease ; while in the hip and thigh it is often very difficult to make out whether the pain is of the ordinary rheumatic character or is dependent on sciatica, which itself may be only a manifestation of rheumatism. In all of these cases we derive great aid from the consideration, that in rheumatic affections the pain is in creased by movement ; each, however, presents peculiar characters, which serve to confirm our diagnosis. In dieorders of digestion, the prominence of the symptoms bearing more directly upon the function itself ; m nephralgia and nephritis the pam described aa shootmg down to the groin, thigh, or tes ticle ; uterilie affections, the seat of pam corresponding to the satrum, where movement cannot be its exciting cause ; and in sciatica, the pain fol lowing the course of the nerve down the back and inside of the thigh, serves to discriminate it from one spoken of as extending from the hip to the ankle, simply because all the joints of the limb happen to be simultaneously affected.