Rheumatologic Diseases

1. Acute/subacute - The attack is sudden, occurring generally between midnight and daylight. The first symptom is pain in the metatarsophalangeal joint of the great toe, oftener of the left than the right foot. The pain quickly becomes intense and often excruciating. It is compared by the patient to the pain supposed to be produced by the severest kind of local injury. It lasts for several hours, accompanied by fever, which is seldom very high, and then either abates or ceases, coincidently with more or less perspiration. After it ends, the affected joint remains reddened, glazed, swollen, hot, extremely tender to the touch; the subcutaneous veins notable dilated, and some oedema of the areolar tissue. The paroxysms are repeatedly nightly for a week or ten days. They diminish in severity after a few days, and become comparatively mild before disappearance. It is rare for an attack not to be followed by other attacks sooner or later. The small joints of the foot other than the metatarsophalangeal of the great toe, the joints of the fingers, the instep, the heel, and the large joints, may be primarily infected.

2. Chronic - As a rule, chronic gout is preceded by a greater or less number of acute attacks. The affected joints are persistently more or less swollen, tender, and painful. These symptoms, at different times, are increased and diminished. An abundant deposit of the urates around the joint, in a certain proportion of cases, gives rise to swellings which, for a time are soft to the touch. If these be opened, or if they open by ulceration, a mortar-like matter, or a thin liquid, in which white semi-solid masses are suspended, escapes. If the contents are not discharged, the swellings are diminished by absorption, and become hard. They now contain a chalk-like sub stance, which sometimes becomes exposed by ulceration. These tophaceous deposits, as they are termed, if numerous and large, produce stiffness, anchyloses, dislocations, and sometimes great deformity of the fingers and toes. The deposits abound in the urates, and are pathognomonic of gout, occurring in no other arthritic affection.

Flint, A. (1879). Clinical medicine: a systematic treatise on the diagnosis and treatment of diseases ; designed for the use of students and practitioners of medicine. London: Churchill. Pg. 771-773.

Entered by: Erin Choi, 06/16/2020

Heart-Specific Symptoms:

[...] we can recognize certain changes in the heart's condition, chiefly in an increase in the size and the presence of a murmur. These cardiac changes may go on with very little increase of temperature and little or no evidence of joint trouble. Sometimes in these milder cases I have detected evidence of involvement of the a.v. bundle by signs of interference with its power of conveying the stimulus from auricle to ventricle. With more serious involvement the dilatation of the heart may be extreme, and Lees and Poynton 110 particularly have called attention to the enlargement, and the ease with which it may be mistaken for pericardial effusion. At first, the full extent of the enlargement may not be realized, because it is partly masked by the lung. When the lung is pushed aside, the greatly enlarged heart can then be readily recognized. The rate of the heart is usually greatly increased beyond what might be expected from a mere rise in temperature. The pulse becomes soft and compressible, and sometimes shows irregularities whose nature in all cases I have not been able to make out. With subsidence of the fever, the patient enters on a long and slow convalescence. Other cases do not terminate so favourably, especially if the heart has been damaged by a previous attack. Complications, as pneumonia, are apt to arise. In severe cases there may be a considerable amount of praecordial distress. The breathing becomes shallow and rapid. The patient feels easiest with his shoulders well raised. The face becomes dusky, the lips dark red, sleep is broken and fitful, and the patient is continuously altering his position. The mind wanders and mental delusions arise. From such a state as this the young during their first attack may recover, but in the middle-aged the condition is very serious. Attacks of syncope may appear, and the patient may die in one. Frequently they gradually sink in spite of all treatment and die. In the recurring attacks of rheumatic fever this question of previous damage to the heart is a very important one. Patients with damaged aortic and mitral valves may pass scatheless through serious attacks of rheumatic fever, presumably where the heart is not involved in these later attacks. When, however, the process lays hold on the heart, the patient's life is in great danger, and after a period of extreme suffering the struggle frequently ends in death, While the foregoing description gives briefly the main points of the heart affection in rheumatic fever, it also holds good for the condition in other infectious diseases, apart from the recurrent attacks. As, however, the presence of other lesions has a modifying effect upon the course of the disease, it is necessary to refer to them. Unfortunately, the reference can only be brief and in the main unsatisfactory, the analysis of the symptoms in these cases having been very imperfectly carried out.

Mackenzie, J., Sir. (1908). Diseases of the Heart. (pp. 222-223). London: Henry Frowde; Hodder & Stoughton.

Created by: Sara Ahmed, 06/16/2021

Entered by: Rachel Johnson, 07/09/2021

[…] The subjects of rheumatoid arthritis may have suffered for years of local syncopes and local asphyxias before their joint swellings appeared. Not uncommonly, also, we get a history in such patients of other paroxysmal neuroses, notably migraine and more rarely asthma. In other instances no such long interval exists between the onset of local syncopes and asphyxias and subsequent appearance of periarticular swellings. Not infrequently the vasomotor phenomena may develop almost suddenly in sequence to some infective or toxic condition such as influenza, sore-throat, and so on, to be followed a few days or weeks by the development of so-called spindle-shaped joints. […]

Muscular spasms occur very frequently in the course of rheumatoid arthritis […] These muscular spasms may be either continuous or paroxysmal, and like the vasomotor phenomena tend to be symmetrical. They are often intensely painful, and in severe cases may continue almost without remission for hours. […]

In the hands flexor spasm is more common ; the hand may be tightly clenched, so much so that the imprint of the nails can be seen on the palms. […]

In the lower extremities the same phenomena may present themselves : the toes may be painfully flexed and drawn to the fibular side, and the painful irregular contraction of the plantar may give the patient the sensation of “treading on marbles.” […]

Loss of muscular power, sudden in onset, fleeting in duration, is […] often a forerunner of rheumatoid disease. Such sudden, unaccountable weakness may betray itself by the unconscious slipping of articles from the grip, or may be by an oft-recurring, although transient, difficulty in picking up small objects. Such patients complain that their hands have no “use” in them, or that they will not “hold,” and are often haunted by the fear of oncoming paralysis. In some cases the “weakness” appears suddenly during performance of more highly specialized movements […], and the wrist is then regarded as the seat of trouble. Another frequent complaint made by such patients is that they cannot turn door-handles or taps, or take corks out of bottles. […]

Actual wasting of the muscles of a limb may precede the appearance of joint swellings. […] Although the arthritic mischief might be confined to one extremity, the muscular atrophy was quite as marked in the opposite and apparently unaffected limb. Again, even when trouble is localized, for example to one wrist joint, detailed examination not infrequently reveals the presence of marked wasting in muscles remote […]

Paresthesia of all sorts may precede by weeks or months the onset of rheumatoid changes in the joints of the limb, tingling and numbness, “pins and needles,” sensations of stinging and soreness, etc. Such sensory perversions are usually confined to the hands and feet, but in some cases they may ascend the limbs. […]

The joint swellings constitute the salient and most conspicuous feature of the affection around which the collateral phenomena group themselves.

The disease evinces a striking predilection for the smaller joints of the hands, its earliest manifestations being usually localized in the metacarpo-phalangeal or mid-phalangeal joints of the fingers.

The terminal phalangeal articulations may in very rare instances undergo enlargement. More commonly they become fixed in some abnormal position without enlargement.

If examined closely, however, they will often be found to exhibit signs of having undergone atrophy of the articular structures and overlying skin ; thus contrasting with the mid-phalangeal joints, in which the ultimate atrophy is preceded by a stage of fusiform swelling of these articulations. […]

While in the vast majority of the disease commences in the joints of the fingers, it may, on the other hand, begin in those of the toes, either the mid-phalangeal or the metatarso-phalangeal articulations. […]

[…] One of the most remarkable features of the affection is the symmetry with which the articular lesions are distributed. […] In the majority of cases at first the condition is asymmetrical, although ultimately by the spread of disease the same striking symmetry is arrived at. […]

The joint seat is fusiform, or spindle-shaped, enlargement, the skin over which is waxy white or semi-asphyxial in tint. Not infrequently the swelling shows a slight constriction at the line of articulation. On palpitation the swelling may feel remarkably tense and elastic, and in some instances apparently fluctuates. In others, however, the enlargement is softer and less resistant, giving more the impression of thickening in the synovial capsule ; but in no case at this stage can we detect nodular outgrowths at the line of articulation as in osteo-arthritis. Despite the suggestion of fluctuation conveyed to the fingers, there is rarely any great excess of fluid in the joint. […]

It is a polyarticular affection, occurring most commonly in young women. Its onset is more or less acute. It begins in the small joints, spreading centripetally, with a tendency to symmetry. The disease does not flit from joint to joint, the joint swellings being persistent, and nearly always leaving some residual thickening. The skin over the affected joint is semi-asphyxial in tint, or unnaturally white. Local pain and tenderness are slight or absent. The swelling is due to peri-articular thickening more than effusion. The temporo-maxillary and cervical articulations are almost always involved. Rapidly induced wasting of interossei and extensor groups of muscles ensue, with increased reflexes, while glandular enlargements are not infrequent. Pigmentation, vasomotor troubles, localized as well as general sweats, are additional features. Cardiac troubles are very rare. The temperatures are raised, but low compared with other arthritic diseases, especially considering the widespread affection of joints. The slight, though continuous pyrexia, a quickened pulse-rate, and the persistent nature of joint swellings, taken together, are very suggestive of rheumatoid arthritis. […]

Jones, R. (1909). Arthritis Deformans. (pp. 103-163). Bristol: John Wright & Sons LTD.

Created/Entered by: Rachel Johnson 07/22/2021