Acute articular rheumatism is undoubtedly an infectious disease. It is so well defined that there is little danger of confusing it with other acute joint affections. We may say the same of the subacute form and of most of the milder grades of chronic rheumatism which are characterized by the attacks upon numerous joints in succession. Not infrequently, however, chronic rheumatism of sufficient duration and sufficient severity to produce deformed joints is confused with rheumatoid arthritis and other chronic deformities of joints. Necessarily, for successful treatment an accurate diagnosis must be made, and great care must therefore be taken in the examination of all chronic articular affections.

It is generally admitted to-day that acute articular rheumatism is an infectious malady, but through what channels infection takes place, and what is the exact nature of the infectious matter, is not known. Formerly it was thought that rheumatism, like gout, was dependent upon a chemical disturbance of the blood or nutritional fluids of the body. Richardson taught that an excess of lactic acid in the blood was its cause; but this has been completely disproved. Although it is now admitted that rheumatism is not due to any dietetic fault or fault in metabolism, it is a commonly observed fact that in a large proportion of cases the stomach is deranged prior to the onset of the rheumatism. Unquestionably, digestive disorders, particularly those which lead to the production of sour stomach, predispose to it. They exert a similar influence upon gouty disorders. It is evident, therefore, that indigestion, when it exists, must be corrected, and in those individuals who are particularly prone to rheumatism, must be prevented. Most frequently the indigestion which predisposes to rheumatism causes the formation of an excess of gas in the stomach, also an excess of abnormal acids, and coincidently constipation.

Rheumatism is frequently preceded by or its onset associated with tonsilitis usually of a mild type. It is also true that many who suffer from chronic rheumatism have chronically infected tonsils. It is generally believed that infection takes place through these tissues. The fact that removal of tonsils and pharyngeal adenoids sometimes stops subacute and chronic rheumatism increases the possibility of the truth of this supposition. Infection also at times occurs or is persistently maintained by chronic suppuration in other obscure places such as the sinuses about the face and the gall-bladder. To prevent attacks of rheumatism the possibility of infections from these places must be investigated. In the great majority of cases, however, the channel of infection cannot be found. Whether these suppurating disorders cause a true rheumatism or an arthritis which simulates it, has not been determined. Certainly these infections cannot be distinguished clinically from chronic rheumatism.

Treatment

Acute articular rheumatism is a febrile disease, and must be treated as the other fevers are. It is, however, necessary at the outset to cleanse the gastrointestinal tract as perfectly as possible because of the influence which imperfect digestion exerts upon the rheumatic trouble. This can be accomplished, in part by the administration of purges, preferably a saline; and in part by the prescription of proper food. It is equally necessary to wash from the blood any poisons that are provocative of the articular inflammations, which can be accomplished best by promoting as free elimination as possible by the kidneys, skin, and intestine. In the course of this trouble the skin usually acts freely, but an abundance of fluid should be furnished to the patient in order that diaphoresis may be made copious. Elimination by the intestine should be stimulated by the administration of cathartics, and the kidneys should be made to act more freely by liquid foods and copious drafts of water.

The best diet during the stage of fever is a strict milk diet. It is usual for those suffering from this sickness to feel a disinclination for food, and it is often necessary to urge nourishment upon them in order that they may get the requisite amount. Milk is usually taken with the least inconvenience by those who like it. Not infrequently, however, it causes a disagreeable taste in the mouth of patients with high temperatures. They crave acid drinks and cold water. The latter should be given them very freely. A little sodium bicarbonate may be added to it. This, however, although a useful medicine in the disease, is distasteful to most patients unless it is at least partly disguised, which can be done oftentimes by using a charged water, such as Seltzer or effervescent Lithia water. Sometimes a little sodium bicarbonate can be mixed with lemonade without its being detected. Lemonade and water acidulated slightly with phosphoric acid make palatable drinks for rheumatic patients.

Dr. Burney Yeo recommends that a nutritious beverage be prepared by mixing one pint of milk, one pint of boiled water, 8 to 12 teaspoons (30 to 40 grams) of sodium bicarbonate, 2 to 5 teaspoons (10 to 20 grams) of common salt; the whole to be cooled and a glassful to be administered every two hours during the day. This makes a beverage which combines nourishment with the alkali, so desirable for the patient suffering from this disease. Pateints who cannot take milk clear will often take it if it is diluted with a carbonized water.

During the period of the fever, milk is particularly suitable, for it is one of the foods least likely to ferment in the stomach and intestines, and therefore least likely to make those organs foul. By promoting free diuresis it aids in the elimination of toxins. If patients are met with, however, who cannot tolerate milk in sufficient quantities to maintain life and strength, other liquid foods must be used as a substitute. The best of these are broths which are entirely free from fat, and gruels. An egg may be broken into the broths to advantage, adding very much to their nutritive powers and also making them more agreeable to the taste. Neither gruels nor broths, however, are comparable to milk in these cases; for the gruels are apt to be slowly digested, and will often undergo fermentation, which causes a transformation of the sugar made from them into lactic acid, rendering the stomach unusually sour; and unless the broths are entirely free from fat they also are likely to be decomposed and to make the stomach sour. In broths alone there is not enough nutriment to maintain life. Many times, however, by a judicious combination of the two classes of food, and by the use of eggs in connection with them, and oftentimes by the employment of a little milk in addition, sufficient nourishment can be given to patients without deranging or overtaxing the digestive organs.